Phase III CAQH CORE EFT & ERA Operating Rules

VII. CAQH CORE 382: ERA Enrollment Data Rule

  1. If we already offer ERA enrollment electronically, must we also implement a paper process?
  2. What are the requirements for presentation of the CORE-required Maximum ERA Enrollment Data Elements?
  3. What are the requirements for use of the CORE-required Maximum ERA Enrollment Data Elements Data Element Groups (DEGs)?
  4. Can additional data elements beyond the CORE-required Maximum ERA Enrollment Data Elements, be collected for ERA enrollment?
  5. Can my health plan use a single form for both EFT and ERA enrollment?
  6. My health plan currently uses one inclusive form to enroll providers to receive all healthcare electronic transactions. Can we use this same form to collect CORE-required Maximum ERA Enrollment Data Elements?
  7. Does the CAQH CORE 382 Rule, Section 4.4 requirement for health plans to offer an electronic safe harbor method for data collection mean health plans can only collect the ERA enrollment data elements electronically (i.e., cannot use paper-based enrollment forms)?
  8. The CAQH CORE 382 Rule, Section 4.3.1, Master Template for Manual Paper-Based Enrollment, requires the ERA enrollment form to include a section outlining how providers can access online instructions to determine their enrollment status. Does this mean health plans must also enable providers to view their enrollment status online?
  9. As a health plan, am I required to include only the Individual Data Elements within required Data Element Groups (DEGs) on my ERA Enrollment form?
  10. As a health plan, if I choose to include an optional Data Element Group (DEG) on my enrollment form, must I include all of the Individual Data Elements within the DEG?
  11. As a health plan, if I collect some of the data elements in the CAQH CORE Maximum ERA Enrollment Data Set as part of another enrollment process (e.g., provider credentialing), must I still include these data elements on my ERA enrollment form?
  12. What Individual Data Elements must be included in the electronic enrollment method required under Section 4.4 of the CAQH CORE 382 Rule?
  13. If a health plan or its agent uses a web-based enrollment method to fulfill the CORE Electronic Enrollment Safe Harbor required by Section 4.4 of the CAQH CORE 382 Rule do all of the ERA Enrollment Data Elements have to be included on a single webpage?
  14. Are the Assigning Authority and Trading Partner ID Individual Data Elements in the CORE-required Maximum ERA Enrollment Data Set the same as the Interchange ID Qualifier, Interchange Receiver ID, and Application Receiver's Code data elements identified in the X12 v5010 835 ISA and GS control segments?
  15. For health plans that use a web-based ERA enrollment method to fulfill the CAQH CORE Electronic Enrollment Safe Harbor, does CAQH CORE have an XML Schema Specification that can be used to create a web-based enrollment method?
  16. Are there available data file examples (e.g., DOC, XLS ,TXT, CSV, XML, etc.) of the CORE-required Maximum ERA Enrollment Data Set that health plans, their agents and/or vendors offering ERA Enrollment, can use to develop their enrollment form/utility?
  17. Does the reference to a “Safe Harbor” in Section 4.4 of the CAQH CORE 382 Rule mean that health plans must support data collection through the CAQH CORE 270: Connectivity Rule?
  18. Does the CAQH CORE 382 Rule require health plans to process a provider’s ERA enrollment within a specific time period?
  19. Per the CAQH CORE 350 Rule, health plans must support use of the CAQH CORE Connectivity Safe Harbor when conducting or processing the X12 v5010 835. As a provider, can I request to receive the X12 v5010 835 via the CAQH CORE Connectivity Safe Harbor during ERA Enrollment?
  20. By what date does my health plan, or agent or vendor offering ERA enrollment, need to convert our paper-based ERA enrollment forms to comply with the CORE-required Maximum ERA Enrollment Data Set, per the CAQH CORE 382 Rule?
  21. Does the CAQH CORE 382 Rule specify requirements for how health plans should verify the accuracy of the enrollment data submitted by providers?
  22. As a health plan, do we have to collect required Individual Data Elements for which we do not have a business need?
  23. As a health plan, do I conform to the CAQH CORE 382 Rule requirements for presentation of the CORE-required ERA Enrollment Data Elements if I use abbreviated Data Element Names on my electronic enrollment form and provide the full Data Element Names via a “mouse hover” function?
  24. As a health plan, do I conform to the CAQH CORE 382 Rule requirements for presentation of the CORE-required ERA Enrollment Data Elements if I use a “mouse hover” function to provide the descriptions of the enrollment data elements?
  25. Do the CAQH CORE EFT & ERA Enrollment Data Rules (CAQH CORE 380 & 382) specify requirements regarding whether a health plan can make provider EFT enrollment contingent upon the provider also enrolling to receive the X12 v5010 835 ERA?
  26. Section 4.3, CORE Master Template for Collecting ERA Enrollment Data, of the CAQH CORE 382 Rule requires a health plan ERA enrollment form to follow the “format, flow, and data set” specified in Table: 4.2-1. How are format, flow, and data set defined for this requirement?
  27. Does CAQH CORE have a glossary that defines the terms used in Table: 4.2-1, CORE-required Maximum ERA Enrollment Data Set of the CAQH CORE 382 Rule?
  28. Section 4.4 of the CAQH CORE 382 Rule requires health plans, or their agents/vendors offering ERA, to implement and offer an electronic method and process for collecting the CORE-required Maximum ERA Enrollment Data Set. What specific format(s) constitute an “electronic” method in accordance with the CAQH CORE 382 Rule requirement?
  29. If a health plan, or its agent or vendor offering EFT and ERA enrollment, chooses to use a single form for the purposes of both EFT and ERA enrollment, how should the EFT and ERA Enrollment Data Element Groups in the CAQH CORE Enrollment Data Rules (CAQH CORE 380 Rule and CAQH CORE 382 Rule) be presented on the form?
  30. My organization is a health plan. Do the CAQH CORE EFT & ERA Operating Rules specify requirements for how soon after we receive a provider EFT and/or ERA enrollment form that we must process the enrollment and implement a connection with the provider to deliver the transactions?
  31. Section 4.3.2 of the CAQH CORE 382 Rule requires that a health plan (or its agent or vendor offering ERA enrollment) offer an electronic way for providers to submit the CORE-required Maximum ERA Enrollment Data Set. What specific format(s) constitute an “electronic” submission method in accordance with the CAQH CORE 382 Rule requirement?
  32. Table 4.2-1 in the CAQH CORE 382 Rule includes “Provider Contact Name” as a required Data Element in Data Element Group (DEG) 3 with the Sub-element “Email Address”. The specified requirement for collection of “Email Address” is “Required; not all providers may have an email address”. Does the CAQH CORE 382 Rule define what data a health plan should collect when the provider does not have an email address?
  33. My organization is a clearinghouse that enrolls providers to receive the X12 v5010 835 from multiple health plan trading partners (i.e., conducts mass ERA enrollment). Can we continue to conduct mass enrollment using the CAQH CORE-required Maximum ERA Enrollment Data Set?
  34. Section 4.3.1 of the CAQH CORE 382 Rule requires health plans to “use the format, flow, and data set including data element descriptions of Table 4.2-1” when using a manual paper-based enrollment form. Does including the Data Element Descriptions in an Appendix to the paper-based enrollment form conform to the Section 4.3.1 requirements?
  35. The HIPAA provisions require use of a National Provider Identifier (NPI) only to identify HIPAA covered providers in a transaction standard. Why does the CAQH CORE 382 Rule require inclusion of both TIN and NPI as sub-elements for the “Provider Identifier” Data Element in DEG2 and “Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier)” Data Element in DEG7?
  36. Why does the CORE-required Maximum ERA Enrollment Data Set require health plans to collect a National Provider Identifier (NPI) and/or Taxpayer Identification Number (TIN) in both DEG2 and DEG7?
  37. The CORE-required Maximum ERA Enrollment Data Set requires health plans to collect a National Provider Identifier (NPI) and/or Taxpayer Identification Number (TIN) in both DEG2 and DEG7. Does the CAQH CORE 382 Rule require the identifier collected in DEG2 to be the same as the identifier collected in DEG7?
  38. Does the CAQH CORE 382 Rule specify requirements for how health plans must group X12 v5010 835 ERAs sent to providers (i.e., by NPI or TIN)?
  39. My organization is a health plan. As part of our ERA enrollment form/method, we currently ask providers to identify the service location for which they want to enroll to receive ERA via a proprietary location identifier. Can we continue to collect this location identifier using the CAQH CORE-required Maximum ERA Enrollment Data Set?
  40. The CORE-required Maximum ERA Enrollment Data Set specified in Table: 4.2-1 includes an optional Data Element Group, DEG4, to collect information about a “provider agent”. How is “provider agent” defined for this DEG?
  41. Does the CAQH CORE 382 Rule require health plans to include DEG numbers on their ERA enrollment method/form?
  42. Does the CAQH CORE 382 Rule require health plans to include the Column Headers in Table: 4.2-1 on their ERA enrollment method/form?
  43. Section 4.3.1 of the CAQH CORE 382 Rule specifies several items beyond the CORE-required Enrollment Data Elements that must be included on a paper-based ERA enrollment form. Does the CAQH CORE 382 Rule require all of these items to be included on a single page?
  44. The CAQH CORE 382 Rule requires health plans to collect a signature for the individual authorized to initiate, modify, or terminate the provider’s ERA enrollment. What data collection method should health plans use to obtain this signature (i.e., electronically or “wet”)?
  45. How are the CAQH CORE EFT & ERA Enrollment Data Sets maintained via the CAQH CORE EFT & ERA Enrollment Data Maintenance Process?
  46. What are the CAQH CORE Comprehensive and Limited Reviews of the CAQH CORE-required Maximum EFT & ERA Enrollment Data Sets? When do these reviews occur?
  47. What adjustments have been made to the CAQH CORE Maximum EFT & ERA Enrollment Data Sets to date?
  48. How can my organization submit potential substantive adjustments to the CORE-required Maximum EFT & ERA Enrollment Data Sets for consideration during the next Comprehensive Review?
  49. How will the CAQH CORE Enrollment Data Task Group evaluate potential substantive adjustments to the CORE-required Maximum EFT & ERA Enrollment Data Sets?
  50. How will organizations be notified about and access new versions of the CAQH CORE EFT & ERA Enrollment Data Rules?
  51. How long will my organization have to update our EFT and/or ERA enrollment system or forms after publication of substantive adjustments to the CAQH CORE EFT & ERA Enrollment Data Rules?
  52. What is the schedule for CAQH CORE to publish adjustments to CAQH CORE EFT & ERA Enrollment Data Rules?
  53. How can my organization get involved in the CAQH CORE EFT & ERA Enrollment Data Sets Maintenance Process?
  54. As a health plan, if my organization chooses to include an Individual Data Element that is designated as “optional” within the CORE-required Maximum ERA Enrollment Data Set, can we make completion of this data element mandatory for enrolling providers?
1. If we already offer ERA enrollment electronically, must we also implement a paper process?

No. The CAQH CORE 382 Rule, Section 4.5 specifies that “If a health plan or its agent does not use a paper-based manual method and process to collect the CORE-required Maximum ERA Enrollment Data Set as of the compliance date specified in any Federal regulation adopting this CORE Rule, it is not required by this rule to implement a paper-based manual process on or after the compliance date.

NOTE: The CAQH CORE 382 Rule addresses electronic and paper-based collection and submission of the enrollment data. It does not specify the health plan’s internal enrollment process.

2. What are the requirements for presentation of the CORE-required Maximum ERA Enrollment Data Elements?

Section 4.3.2 of the CAQH CORE 382 Rule requires that the CORE-required Maximum ERA Enrollment Data Set be used without revision or modification, and that the order of the data conforms to the flow, format, and data set (including data element descriptions) established in Table 4.2-1 of the rule. This requirement applies to both electronic enrollment data collection forms and manual paper-based forms, should a health plan or its agent offer a paper-based data collection process. In order to comply with the CAQH CORE 382 Rule requirements a health plan (or its agent or a vendor offering ERA) must not modify or vary the CORE ERA enrollment form template and ERA enrollment forms must follow the flow, format, and data set as specified in the rule.

3. What are the requirements for use of the CORE-required Maximum ERA Enrollment Data Elements Data Element Groups (DEGs)?

The CAQH CORE 382 Rule establishes a maximum set of data elements for both paper and electronic ERA enrollment data collection and submission. This maximum set of CORE-required ERA Enrollment Data Elements is specified in Table 4.2-1 of the rule, organized by categories of information referred to as “Data Element Groups”. CAQH CORE 382, Section 4.3 and its subsections specify the requirements for how the CORE-required Maximum ERA Enrollment Data Elements must be presented in both paper and electronic based ERA enrollment forms. Specifically, the rule requires that health plans (or their agents or vendors offering ERA) use the format, flow, and data set (including data element descriptions) as given in Table 4.2-1. Additionally, all CORE-required ERA Enrollment Data Elements (including DEGs) must appear in the same order as they appear in Table 4.2-1.

4. Can additional data elements beyond the CORE-required Maximum ERA Enrollment Data Elements, be collected for ERA enrollment?

The CAQH CORE 382 Rule establishes a maximum set of data elements for both paper and electronic ERA enrollment. This maximum set of CORE-required ERA Enrollment Data Elements is specified in Table 4.2-1 of the rule. Section 4.3 and its subsections describe how the CORE-required Maximum ERA Enrollment Data Elements must be presented.

Also, the CAQH CORE 382 Rule does not preclude health plans (or their agents) from collecting additional data elements in locations beyond the ERA enrollment form for other purposes beyond ERA enrollment. Additionally, the CAQH CORE 382 Rule does not prohibit health plans and their agents from adding capabilities to the electronic ERA enrollment method designed to improve functionality and ensure data integrity and comprehensiveness. Examples of functional and data improvements that may be added to the electronic submission tool include:

  • Use of drop-down selection lists and/or radio buttons to respond to each CORE-required Data Element or Sub-element
  • Requiring re-entry of key data to ensure accuracy
  • Inclusion of a context-specific “Help” button to display a window that provides a detailed description of the CORE-required Data Element or other guidance, e.g., data format, etc.
  • Enabling the end user to assign nicknames to certain data fields to more easily manage his/her data
  • Displaying all data entered to the end user for final review/correction prior to actual “submission”
5. Can my health plan use a single form for both EFT and ERA enrollment?

Yes. CAQH CORE 380: EFT Enrollment Data Rule and CAQH CORE 382: ERA Enrollment Data Rule establish a maximum set of data elements to be included on enrollment forms for EFT and ERA, as well as a required flow and format for presentation of the data elements on the form. The two rules were developed independent of each other as some health plans enroll providers separately for EFT and ERA while other combine the enrollments.

The CAQH CORE Enrollment Data Rules do not require or prohibit entities from creating a single form for the purposes of both EFT and ERA enrollment as long as the format, flow, and data set (including data element descriptions) are used as specified in CAQH CORE 380 Rule Table 4.2-1 and CAQH CORE 382 Rule Table 4.2-1. Sections 4.5 of the CAQH CORE 380 and 382 Rules specify the timeframe for converting existing paper-based EFT and ERA enrollment forms to comply with the rules.

6. My health plan currently uses one inclusive form to enroll providers to receive all healthcare electronic transactions. Can we use this same form to collect CORE-required Maximum ERA Enrollment Data Elements?

Yes. The CAQH CORE 382 Rule establishes a maximum set of data elements to be included on an ERA enrollment form, as well as a required flow and format for presentation of the data elements on the form. The CAQH CORE 382 Rule does not require or prohibit entities from using an inclusive form for the purposes of ERA Enrollment as long as the format, flow, and data set (including data element descriptions) are used as given in CAQH CORE 382 Rule, Table 4.2-1, CORE-required Maximum ERA Enrollment Data Set. Section 4.5 of the CAQH CORE 382 Rule specifies the timeframe for converting existing paper-based enrollment forms to comply with the rule.

NOTE: Section 4.4 of the CAQH CORE 382 Rule also requires all health plans, and their agents or vendors offering ERA enrollment, to “implement and offer to any trading partner (e.g., a healthcare provider) an electronic method (actual method to be determined by health plan or its agent) and process for collecting the CORE-required Maximum ERA Enrollment Data Set.

7. Does the CAQH CORE 382 Rule, Section 4.4 requirement for health plans to offer an electronic safe harbor method for data collection mean health plans can only collect the ERA enrollment data elements electronically (i.e., cannot use paper-based enrollment forms)?

No. Per the CAQH CORE 382 Rule, Section 4.4, CORE Electronic Safe Harbor for ERA Enrollment to Occur Electronically, all health plans must “implement and offer to any trading partner (e.g., a healthcare provider) an electronic method (actual method to be determined by health plan or its agent) and process for collecting the CORE-required Maximum ERA Enrollment Data Set.”

Rule Section 4.4 also notes that the rule “DOES NOT require health plans or their agents to use ONLY an electronic method and process for collecting the CORE-required Maximum ERA Enrollment Data Set.” Health plans must offer an electronic method for collection and submission of the CORE-required Maximum ERA Enrollment Data Set, but they may continue to also offer a paper-based method of enrollment, provided that the paper-based method of enrollment also meets all applicable rule requirements (see especially Section 4.3.1, Master Template for Manual Paper-Based Enrollment).

8. The CAQH CORE 382 Rule, Section 4.3.1, Master Template for Manual Paper-Based Enrollment, requires the ERA enrollment form to include a section outlining how providers can access online instructions to determine their enrollment status. Does this mean health plans must also enable providers to view their enrollment status online?

No. Section 4.3.1 of the CAQH CORE 382 Rule requires that health plans provide instructions online for how providers can determine the status of the enrollment. The ERA enrollment form must include a section outlining how to access these online instructions. The CAQH CORE 382 Rule does not require that that the status of enrollment must be able to be determined via online tool.

9. As a health plan, am I required to include only the Individual Data Elements within required Data Element Groups (DEGs) on my ERA Enrollment form?

The CORE-required Maximum ERA Enrollment Data Set includes ten Data Element Groups (DEGs). A DEG may be designated as required or optional for data collection. Additionally, within each DEG, Individual Data Elements may be designated as required or optional for data collection.

When a DEG is designated as required:

  • The health plan must collect all Individual Data Elements within the DEG that are designated as required.
  • The health plan may elect not to collect any Individual Data Elements within the DEG that are designated as optional.

When a DEG is designated as optional:

  • The health plan may elect not to include this optional DEG for collection on the ERA Enrollment Form.
  • However, if the health plan chooses to collect this optional DEG, the health plan must collect all Individual Data Elements within the DEG that are designated as required; the health plan may elect not to collect any Individual Data Elements within the optional DEG that are designated as optional.
10. As a health plan, if I choose to include an optional Data Element Group (DEG) on my enrollment form, must I include all of the Individual Data Elements within the DEG?

No. If a health plan chooses to collect an optional DEG:

  • The health plan must collect all Individual Data Elements within the optional DEG that are designated as required.
  • However, the health plan may elect not to collect any Individual Data Elements within the optional DEG that are designated as optional.
11. As a health plan, if I collect some of the data elements in the CAQH CORE Maximum ERA Enrollment Data Set as part of another enrollment process (e.g., provider credentialing), must I still include these data elements on my ERA enrollment form?

Not collecting an Individual Data Element identified as optional is not prohibited by the CAQH CORE 382 Rule requirements for the CORE-required Maximum ERA Enrollment Data Set. However, the CAQH CORE 382 Rule requires that the following Individual Data Elements must be collected during the ERA Enrollment process:

  • All required Individual Data Elements within required DEGs
  • All Individual Data Elements designated as required within optional DEGs, if the health plan chooses to collect the optional DEG.

NOTE: The CAQH CORE 382 Rule does not prevent a health plan from pre- or auto-populating the form with known data (for the provider to confirm or change), but the required Individual Data Elements must still be collected during the process.

12. What Individual Data Elements must be included in the electronic enrollment method required under Section 4.4 of the CAQH CORE 382 Rule?

Section 4.4 of the CAQH CORE 382 Rule requires all health plans to offer an “electronic safe harbor” enrollment method/process for collecting the CORE-required Maximum ERA Enrollment Data Set. The CAQH CORE 382 Rule requires that the following Individual Data Elements must be included in the electronic enrollment method:

  • All required Individual Data Elements within required DEGs
  • All Individual Data Elements designated as required within optional DEGs, if the health plan chooses to collect the optional DEG.
13. If a health plan or its agent uses a web-based enrollment method to fulfill the CORE Electronic Enrollment Safe Harbor required by Section 4.4 of the CAQH CORE 382 Rule do all of the ERA Enrollment Data Elements have to be included on a single webpage?

No. The CAQH CORE 382 Rule, Section 4.3.2, Master Template for Electronic Enrollment, requires that a web-based method of enrollment is restricted “only to the extent that the flow, format and data set including data element descriptions established by this rule must be followed.” The CAQH CORE 382 Rule does not include any language surrounding pagination or other contiguity of the data. Therefore, a web-based enrollment method with data elements on different pages would be compliant with the rule requirements.

14. Are the Assigning Authority and Trading Partner ID Individual Data Elements in the CORE-required Maximum ERA Enrollment Data Set the same as the Interchange ID Qualifier, Interchange Receiver ID, and Application Receiver's Code data elements identified in the X12 v5010 835 ISA and GS control segments?

No. The CAQH CORE 382 Rule establishes a maximum set of data elements to be collected by the health plan from the provider for ERA enrollment, as well as a required flow and format for the data elements on a web-based or paper-based enrollment form. It does not address data elements in the X12 v5010 835 ISA and GS control segments. These data elements are outside the scope of the CAQH CORE 382 Rule, and would need to be collected from the provider external to the ERA Enrollment process.

15. For health plans that use a web-based ERA enrollment method to fulfill the CAQH CORE Electronic Enrollment Safe Harbor, does CAQH CORE have an XML Schema Specification that can be used to create a web-based enrollment method?

No. There is no XML Schema Specification (.xsd file) for the CAQH CORE EFT & ERA Operating Rules, including the CAQH CORE 382 Rule. However, to assist implementers, CAQH CORE has published Excel-based versions of both the CORE-required Maximum EFT Data Set and CORE-required Maximum ERA Enrollment Data Set tables. The Excel Workbooks are available at the links below and on the CAQH CORE website:

NOTE: CAQH CORE 382 Rule, Section 4.3.2, Master Template for Electronic Enrollment, does specify that: When using an XML-based electronic approach, the Data Element Name and Sub-element Name must be used exactly as represented in the table enclosed in angle brackets (i.e., < >) for the standard XML element name and all spaces replaced with an underscore [ _ ] character e.g., <Provider_Address>.” There are no additional XML specifications for a web-based enrollment method beyond this requirement.

16. Are there available data file examples (e.g., DOC, XLS ,TXT, CSV, XML, etc.) of the CORE-required Maximum ERA Enrollment Data Set that health plans, their agents and/or vendors offering ERA Enrollment, can use to develop their enrollment form/utility?

Yes. As noted above, CAQH CORE has published an Excel-based version of Table 4.2-1, CORE-required Maximum ERA Enrollment Data Set. The Excel Workbooks are available at the links below and on the CAQH CORE website:

Beyond this Excel document and the table in the CAQH CORE 382 Rule, there are no other available data file examples of the CORE-required Maximum ERA Enrollment Data Set.

17. Does the reference to a “Safe Harbor” in Section 4.4 of the CAQH CORE 382 Rule mean that health plans must support data collection through the CAQH CORE 270: Connectivity Rule?

No. The reference in the CAQH CORE 382 Rule to a “safe harbor” does not mean that health plans must support the CAQH CORE Connectivity Safe Harbor for collection of the CORE-required Maximum ERA Enrollment Data Set.

Section 4.4, CAQH CORE Electronic Safe Harbor for ERA Enrollment, of the CAQH CORE 382 Rule requires all health plans to offer an “electronic safe harbor” enrollment method/process for collecting the CORE-required Maximum ERA Enrollment Data Set. The CAQH CORE 382 Rule does not specify the electronic method that health plans must use to fulfill the safe harbor requirement.

While the CAQH CORE 382 Rule does not require health plans to do so, health plans may choose to use the CAQH CORE 270 Connectivity Safe Harbor to fulfill the CAQH CORE Electronic Enrollment Safe Harbor. The CAQH CORE Connectivity Rule is payload agnostic and thus can carry both X12 and non-X12 administrative transaction payloads. Section 4.4.4 of the CAQH CORE 270 Rule specifies how to enumerate non-X12 payloads in the PayloadType field.

18. Does the CAQH CORE 382 Rule require health plans to process a provider’s ERA enrollment within a specific time period?

No. The CAQH CORE 382 Rule establishes a maximum set of data elements for both paper and electronic ERA enrollment as well as how the CORE-required Maximum ERA Enrollment Data Elements must be presented in both paper and electronic based ERA enrollment forms The CAQH CORE 382 Rule does not establish a required timeframe for processing a provider’s ERA Enrollment.

NOTE: Section 4.2, CORE-required Maximum ERA Enrollment Data Elements, of the CAQH CORE 382 Rule requires the health plan to “develop and make available to the healthcare provider (or its agent) specific written instructions and guidance for the healthcare provider (or its agent) when providing and submitting the data elements in Table 4.2-1.

The CAQH CORE 382 Rule does not specify the exact wording for the instructions and guidance that must be provided by the health plan. In anticipation of provider questions, the health plan could choose to describe its expected timeframe for processing enrollments in these instructions.

19. Per the CAQH CORE 350 Rule, health plans must support use of the CAQH CORE Connectivity Safe Harbor when conducting or processing the X12 v5010 835. As a provider, can I request to receive the X12 v5010 835 via the CAQH CORE Connectivity Safe Harbor during ERA Enrollment?

Yes. Data Element Group 7: Electronic Remittance Advice Information within the CORE-required Maximum ERA Enrollment Data Set includes as an Individual Data Element “Method of Retrieval”. “Method of Retrieval” is described in Table: 4.2-1, CORE-required Maximum ERA Enrollment Data Set, as the “the method in which the provider will receive the ERA from the health plan (e.g., download from health plan website, clearinghouse, etc.).”

As noted, the CAQH CORE 350: Health Care Claim Payment/Advice (835) Infrastructure Rule requires a health plan, or clearinghouse acting on behalf of a health plan, to support use of the CAQH CORE 270 Rule Connectivity Safe Harbor when conducting or processing the X12 v5010 835. Therefore, the CAQH CORE Connectivity Safe Harbor should be included as one of the ERA retrieval methods available to providers.

NOTE: When the provider is retrieving the X12 v5010 835 directly from a health plan (i.e., without an intermediary) this data element is required. However, when the provider is using an intermediary clearinghouse or vendor its use is optional.

20. By what date does my health plan, or agent or vendor offering ERA enrollment, need to convert our paper-based ERA enrollment forms to comply with the CORE-required Maximum ERA Enrollment Data Set, per the CAQH CORE 382 Rule?

Section 4.5 of the CAQH CORE 382 Rule specifies a time frame for health plans to convert all paper-based ERA enrollment forms relative to the compliance date for any Federal regulation that adopts the CAQH CORE 382 Rule for mandatory implementation. Specifically the rule states: “Not later than the date that is six months after the compliance date specified in any Federal regulation adopting this CORE Operating Rule, a health plan or its agent that uses a paper-based form to collect and submit the CORE-required Maximum ERA Enrollment Data Set must convert all its paper-based forms to comply with the data set specified in this rule.”

NOTE: The CAQH CORE 382 Rule requirement applies only if a health plan, or its agent or vendor offering ERA enrollment, has an existing paper-based enrollment form or chooses to use a paper-based form. The CAQH CORE 382 Rule does not require health plans to use a paper-based enrollment form if they do not currently do so. However, an electronic method for collecting and submitting the enrollment data elements is required.

In August 2012, HHS issued an Final Rule that adopts all of the CAQH CORE EFT & ERA Operating Rules to fulfill the Federal mandate under ACA Section 1104, with the exception of rule requirements pertaining to use of Acknowledgements. Per ACA Section 1104, the compliance date for the ACA-mandated EFT & ERA operating rules is January 1, 2014. Section 4.5 of the CAQH CORE 382 Rule requires health plans to modify their paper-based enrollment forms to conform to the CORE-required Maximum ERA Enrollment Data Set no later than six months after the January 1, 2014 Federal compliance date.

For more information on the ACA Section 1104 requirements for Federal operating rules, please see CAQH CORE FAQs Part B: ACA Section 1104 Mandate for Federal Operating Rules.

21. Does the CAQH CORE 382 Rule specify requirements for how health plans should verify the accuracy of the enrollment data submitted by providers?

No. Verifying the accuracy of the data collected from the provider during the ERA enrollment process is out of scope for the CAQH CORE EFT & ERA Operating Rules. The policies and methods that a health plan uses to verify accuracy of data are business decisions on the part of the health plan or its agent or vendor offering ERA enrollment.

22. As a health plan, do we have to collect required Individual Data Elements for which we do not have a business need?

Yes. A health plan (or its agent or vendor offering ERA enrollment) must collect all Individual Data Elements per the CAQH CORE 382 Rule requirements, including those for which the health plan has no business need.

The CORE-required Maximum ERA Enrollment Data Elements were identified after substantial industry research and analysis to compare ERA enrollment forms from across the industry. The CORE Participants agreed that these data elements represented the maximum set of data elements required for successful ERA enrollment. The CORE-required Maximum ERA Enrollment Data Set includes ten Data Element Groups (DEGs) designated as required or optional for data collection. Per Section 4.2, CORE-required Maximum ERA Enrollment Data Elements, of the CAQH CORE 382 Rule, the following Individual Data Elements must be included on either a paper-based or electronic enrollment form:

  • All required Individual Data Elements within required DEGs
  • All Individual Data Elements designated as required within optional DEGs, if the health plan chooses to collect the optional DEG.
23. As a health plan, do I conform to the CAQH CORE 382 Rule requirements for presentation of the CORE-required ERA Enrollment Data Elements if I use abbreviated Data Element Names on my electronic enrollment form and provide the full Data Element Names via a “mouse hover” function?

No. Section 4.3.2, Master Template for Electronic Enrollment, of the CAQH CORE 382 Rule specifies that health plans “must use the CORE Master ERA Enrollment Data Element Name and Sub-element Name as specified in Table 4.2-1 without revision or modification.” As described in Section 3.2, CORE-required Maximum ERA Enrollment Data Element Set, this requirement serves to provide consistency across health plans’ enrollment processes and promotes provider adoption of ERA.

To meet the requirements specified in Section 4.3.2, the Data Element Name must be used in full on the electronic enrollment form. Use of an abbreviated Data Element Name on an electronic enrollment form does not satisfy the rule requirement.

24. As a health plan, do I conform to the CAQH CORE 382 Rule requirements for presentation of the CORE-required ERA Enrollment Data Elements if I use a “mouse hover” function to provide the descriptions of the enrollment data elements?

Yes. Although a health plan (or its agent or vendor offering ERA enrollment) may not use a “mouse hover” function to provide the Data Element Names, the CAQH CORE 382 Rule does permit a health plan to use a “mouse hover” to display supplemental information about the enrollment data elements, such as the Data Element Description, or to provide further guidance to the provider on completing the enrollment form.

25. Do the CAQH CORE EFT & ERA Enrollment Data Rules (CAQH CORE 380 & 382) specify requirements regarding whether a health plan can make provider EFT enrollment contingent upon the provider also enrolling to receive the X12 v5010 835 ERA?

No. The CAQH CORE EFT & ERA Enrollment Data Rules (CAQH CORE 380 & 382 Rules) establish a maximum set of data elements to be included on an EFT and/or ERA enrollment form, as well as a required flow and format for presentation of the data elements on the form. The CAQH CORE EFT & ERA Enrollment Data Rules do not address whether or not health plans can make provider enrollment to receive healthcare EFT contingent on the provider also enrolling to receive the X12 v5010 835 ERA, or vice versa. Such a requirement is a health plan’s individual business decision.

26. Section 4.3, CORE Master Template for Collecting ERA Enrollment Data, of the CAQH CORE 382 Rule requires a health plan ERA enrollment form to follow the “format, flow, and data set” specified in Table: 4.2-1. How are format, flow, and data set defined for this requirement?

Section 4.3 of the CAQH CORE 382 Rule requires health plans “to use the format, flow and data set including data element descriptions in Table 4.2-1 as the CORE Master ERA Enrollment Submission form” for both paper-based and electronic ERA enrollment methods. The intent of the reference to “format, flow, and data set” is:

  • “Flow” means the order/sequence of the data elements in Table: 4.2-1
  • “Data Set” is the set of elements specified in Table: 4.2-1
  • “Format” refers to the Data Type and Format as specified in Table: 4.2-1 (e.g., alphanumeric, 15 characters for Zip Code).
27. Does CAQH CORE have a glossary that defines the terms used in Table: 4.2-1, CORE-required Maximum ERA Enrollment Data Set of the CAQH CORE 382 Rule?

CAQH CORE 382 Rule Table: 4.2-1 provides Data Element Descriptions and Data Types and Formats (when necessary) for the Individual Enrollment Data Elements in the CORE-required Maximum ERA Enrollment Data Set. Beyond the Data Element Descriptions and Data Types and Formats, further descriptive information (including citations) clarifying the terms used in Table 4.2-1 is provided via footnotes included for many of the Individual Data Elements. Beyond these references in the rule, there is not a separate glossary of terms.

28. Section 4.4 of the CAQH CORE 382 Rule requires health plans, or their agents/vendors offering ERA, to implement and offer an electronic method and process for collecting the CORE-required Maximum ERA Enrollment Data Set. What specific format(s) constitute an “electronic” method in accordance with the CAQH CORE 382 Rule requirement?

The CAQH CORE 382 Rule does not define a specific format(s) that constitutes an electronic method and process for collecting the CORE-required Maximum ERA Enrollment Data Set.

CAQH CORE does not provide a definition of “electronic” methods specific to implementation of the CAQH CORE Operating Rules. Rather, CAQH CORE has relied on various HIPAA regulations to do so for the industry. Currently, there are many ways entities can implement an “electronic” collection method. In the broader context of the mission and vision of CAQH CORE, the goal is to assist the industry to adopt uniform and consistent automated electronic processes to reduce costs and build efficiencies.

CMS is the HHS designated authority on any decisions regarding interpretation, implementation, and enforcement of the regulations adopting the HIPAA and ACA Administrative Simplification standards and provisions. As the regulatory authority, the determination of what constitutes an “electronic” method for collecting the CORE-required Maximum ERA Enrollment Data Set must be made by the CMS National Standards Group (NSG). The January 2013 HHS HIPAA Privacy and Security omnibus final rule includes a definition of “electronic media,” and CAQH CORE has asked CMS NSG to provide further guidance to the industry on the regulatory language, and what constitutes an “electronic” method. It is anticipated that a CMS NSG FAQ will be published shortly; thereafter CAQH CORE will provide detailed examples of the multiple ways to meet the requirements for both electronic collection and submission.

29. If a health plan, or its agent or vendor offering EFT and ERA enrollment, chooses to use a single form for the purposes of both EFT and ERA enrollment, how should the EFT and ERA Enrollment Data Element Groups in the CAQH CORE Enrollment Data Rules (CAQH CORE 380 Rule and CAQH CORE 382 Rule) be presented on the form?

The CAQH CORE Enrollment Data Rules do not prohibit entities from creating a single form for the purposes of both EFT and ERA enrollment. A combined EFT and ERA enrollment form must contain all of the required Data Element Groups (DEGs) and required Individual Data Elements from Table: 4.2-1, CORE-required Maximum EFT/ERA Enrollment Data Set in CAQH CORE 380 Rule and CAQH CORE 382 Rule. NOTE: Entities are not required to repeat DEGs that are identical in both enrollment data rules (e.g., DEG1).

Although the CAQH CORE Enrollment Data Rules do not explicitly outline the flow and format for a combined EFT and ERA enrollment form, DEGs unique to either of the CAQH CORE Enrollment Data Rules would need to be collected using the same general flow and format. For example, “Financial Institution Information” (DEG7 in the CAQH CORE 380 Rule) and “Electronic Remittance Advice Information” (DEG7 in the CAQH CORE 382 Rule) are both required for collection on a combined EFT and ERA enrollment form. Both DEGs would be collected after DEGs 1 through 6 in the CAQH CORE 380 and CAQH CORE 382 Rules, and before “Submission Information”, DEG 10 in the CAQH CORE 382 Rule.

30. My organization is a health plan. Do the CAQH CORE EFT & ERA Operating Rules specify requirements for how soon after we receive a provider EFT and/or ERA enrollment form that we must process the enrollment and implement a connection with the provider to deliver the transactions?

No. The CAQH CORE EFT & ERA Operating Rules do not specify timeframe requirements regarding how soon a health plan must process a provider’s EFT and/or ERA enrollment and/or implement a connection with the provider to deliver the transactions.

However, the CAQH CORE EFT & ERA Operating Rules do specify timeframe requirements that address exchange of the NACHA CCD+ and X12 v5010 835 transactions such as:

  • CAQH CORE 350: Health Care Claim Payment/Advice (835) Rule: Section 4.3, Dual Delivery of v5010 X12 835 and Proprietary Paper Claim Remittance Advices, requires health plans to support a dual or parallel processing period during which providers can continue to receive proprietary paper RAs while they test the use of the X12 v5010 835 standard and associated operating rules. The dual delivery period must be a period of 31 days or a minimum of 3 payments, whichever is longer.
    • NOTE: The dual delivery requirement applies only if the health plan currently delivers proprietary paper RAs. If a health plan does not currently deliver proprietary paper RAs, the CAQH CORE 350 Rule does not require a health plan to start doing so.
  • CAQH CORE 370: EFT & ERA Reassociation (CCD+/835) Rule: Section 4.2, Elapsed Time between Sending the X12 v5010 835 and the CCD+ Transactions, requires health plans to release the X12 v5010 835: “No sooner than three business days based on the time zone of the health plan prior to the CCD+ Effective Entry Date And No later than three business days after the CCD+ Effective Entry Date.”
    • The elapsed time requirement means that a health plan must not send the corresponding X12 v5010 835 earlier than three business days prior to the CCD+ Effective Entry Date or later than three business days after the CCD+ Effective Entry Date.
31. Section 4.3.2 of the CAQH CORE 382 Rule requires that a health plan (or its agent or vendor offering ERA enrollment) offer an electronic way for providers to submit the CORE-required Maximum ERA Enrollment Data Set. What specific format(s) constitute an “electronic” submission method in accordance with the CAQH CORE 382 Rule requirement?

The CAQH CORE 382 Rule does not define a specific format(s) that constitutes an electronic method and process for submitting the CORE-required Maximum ERA Enrollment Data Set.

CAQH CORE does not provide a definition of “electronic” methods specific to implementation of the CAQH CORE Operating Rules. Rather, CAQH CORE has relied on various HIPAA regulations to do so for the industry. Currently, there are many ways entities can implement “electronic” methods for data submission. In the broader context of the mission and vision of CAQH CORE, the goal is to assist the industry to adopt uniform and consistent automated electronic processes to reduce costs and build efficiencies.

CMS is the HHS designated authority on any decisions regarding interpretation, implementation, and enforcement of the regulations adopting the HIPAA and ACA Administrative Simplification standards and provisions. As the regulatory authority, the determination of what constitutes an “electronic” method for submitting the CORE-required Maximum ERA Enrollment Data Set must be made by the CMS National Standards Group (NSG). The January 2013 HHS HIPAA Privacy and Security omnibus final rule includes a definition of “electronic media,” and CAQH CORE has asked CMS NSG to provide further guidance to the industry on the regulatory language, and what constitutes an “electronic” method. It is anticipated that a CMS NSG FAQ will be published shortly; thereafter CAQH CORE will provide detailed examples of the multiple ways to meet the requirements for both electronic collection and submission.

32. Table 4.2-1 in the CAQH CORE 382 Rule includes “Provider Contact Name” as a required Data Element in Data Element Group (DEG) 3 with the Sub-element “Email Address”. The specified requirement for collection of “Email Address” is “Required; not all providers may have an email address”. Does the CAQH CORE 382 Rule define what data a health plan should collect when the provider does not have an email address?

No. The CAQH CORE 382 Rule does not explicitly define what a health plan must collect for the Sub-element “Email Address” when a provider does not have an email address. However, Section 4.2, CORE-required Maximum ERA Enrollment Data Elements, requires a health plan to “develop and make available to the healthcare provider (or its agent) specific written instructions and guidance for the healthcare provider (or its agent) when providing and submitting the data elements in Table 4.2-1.” The health plan could, in these instructions, describe what the provider should enter in the event that the provider does not have an email address (e.g., “If you do not have an email address, please leave the field blank,” or “If you do not have an email address, please enter ‘NONE’,” etc.)

33. My organization is a clearinghouse that enrolls providers to receive the X12 v5010 835 from multiple health plan trading partners (i.e., conducts mass ERA enrollment). Can we continue to conduct mass enrollment using the CAQH CORE-required Maximum ERA Enrollment Data Set?

Yes. The CAQH CORE 382 Rule provides a uniform and consistent maximum set of data elements that can be used by any health plan (or its agent/vendor offering ERA enrollment) for the purposes of enrolling any healthcare provider to receive remittance information electronically. This data set is the same for all providers and all health plans (or their agents/vendors); the CAQH CORE 382 Rule, therefore, can support approaches that are designed to enroll all providers with all plans (i.e., mass enrollment).

Section 4.2 of the CAQH CORE 382 Rule requires a health plan (or its agent/vendor offering ERA enrollment) to “develop and make available to the healthcare provider (or its agent) specific written instructions and guidance for the healthcare provider (or its agent) when providing and submitting the data elements”. A clearinghouse, or other intermediary, could include in these instructions guidance specific to the health plans for which it is authorized to collect enrollment data.

The CAQH CORE 382 Rule does not address the functionality or capability of an ERA enrollment system or process, which may include other data functions/capabilities beyond the collection of the CORE-required Maximum ERA Enrollment Data Set. A clearinghouse, or other intermediary, that conducts mass enrollment may include data fields in its enrollment process to collect information such as with which health plans providers want to enroll (specific to the health plans for which the clearinghouse is authorized to collect such provider enrollment data). Such a data field could be included in the enrollment process prior to or after collection of the CORE-required Maximum ERA Enrollment Data Set.

The CAQH CORE 382 Rule also permits clearinghouses, and other entities conducting ERA enrollment, to include other functionalities in the enrollment process (e.g., requiring a username/password to log on to the health plan’s website to begin the enrollment process, use of a mouse hover to display supplemental information about data elements, etc.). For further guidance, see “Can additional data elements beyond the CORE-required Maximum ERA Enrollment Data Elements be collected for ERA enrollment?)

34. Section 4.3.1 of the CAQH CORE 382 Rule requires health plans to “use the format, flow, and data set including data element descriptions of Table 4.2-1” when using a manual paper-based enrollment form. Does including the Data Element Descriptions in an Appendix to the paper-based enrollment form conform to the Section 4.3.1 requirements?

Section 4.3.1, Master Template for Manual Paper-Based Enrollment, of the CAQH CORE 382 Rule requires that a health plan (or its agent/vendor offering ERA enrollment) “use the format, flow and data set including data element descriptions in Table 4.2-1 as the CORE Master ERA Enrollment Submission form when using a manual paper-based enrollment method.” The CAQH CORE 382 Rule does not require that the Data Element Descriptions be included directly next to the Individual Data Element Name on the paper-based form. A health plan may include the Data Element Descriptions in an Appendix to the paper-based enrollment form provided that the health plan, as required by Section 4.3.1, “clearly label[s] any appendix describing its purpose as it relates to the provider enrolling in ERA.”

NOTE: The CAQH CORE 382 Rule does not require health plans to use a paper-based enrollment form if they do not currently do so. However, an electronic method for collecting and submitting the enrollment data elements is required. As with the paper-based form, the Data Element Descriptions are not required to be included directly next to the Individual Data Element Name on the electronic enrollment form. Health plans may use a function such as a “mouse hover” to display the Data Element Descriptions. (See FAQ “As a health plan, do I conform to the CAQH CORE 382 Rule requirements for presentation of the CORE-required ERA Enrollment Data Elements if I use a “mouse hover” function to provide the descriptions of the enrollment data elements?)

35. The HIPAA provisions require use of a National Provider Identifier (NPI) only to identify HIPAA covered providers in a transaction standard. Why does the CAQH CORE 382 Rule require inclusion of both TIN and NPI as sub-elements for the “Provider Identifier” Data Element in DEG2 and “Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier)” Data Element in DEG7?

Per the HIPAA Administrative Simplification provisions, as of May 2008, HIPAA-covered entities must use the National Provider Identifier (NPI) only to identify a group or individual as a HIPAA covered provider in the HIPAA transaction standards. A Taxpayer Identification Number (TIN), e.g., Social Security Number (SSN) or Employer Identification Number (EIN), can only be used when identifying a HIPAA covered provider as a tax payer.

These requirements do not apply to providers that are not HIPAA-covered as non-HIPAA covered providers are not required to obtain and use an NPI. Per CMS, a non-HIPAA covered provider that does not have an NPI should be identified in the HIPAA transaction standards by “its SSN or EIN as its Primary Identifier in standard transactions designed to capture a Primary and a Secondary Identifier for a health care provider [or] by one of the qualifiers (other than the qualifier for the NPI) listed in the Implementation Guides that are designed to capture a single identifier for a health care provider” (see CMS FAQ#1949).

The CAQH CORE 382 Rule requires inclusion of both NPI and TIN as “Provider Identifier” and “Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier) sub-elements to allow for enrollment of a non-HIPAA covered provider that does not have an NPI.

36. Why does the CORE-required Maximum ERA Enrollment Data Set require health plans to collect a National Provider Identifier (NPI) and/or Taxpayer Identification Number (TIN) in both DEG2 and DEG7?

Data Element Groups (DEGs) 2 and 7 represent two different sets of data elements that are necessary to enroll a provider to receive the X12 v5010 835:

  • DEG2: Provider Identifiers Information collects information related to the enrolling provider identified in DEG1: Provider Information. Within DEG2, health plans (or their agent/vendor offering ERA enrollment) are required to collect a Provider Identifier, which must be the identification number, NPI or TIN for non-HIPAA covered providers, for the legal entity reported under the “Provider Name” Data Element in DEG1.
  • DEG7: Electronic Remittance Advice Information collects information related to how the provider wishes to receive the X12 v5010 835 transaction. Within DEG7, health plans (or their agent/vendor offering ERA enrollment) are required to collect a “Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier)”. The X12 v5010 835 TR3 requires a single X12 v0510 835 transaction to correspond to a single EFT payment. Therefore, to identify the EFT payment corresponding to the X12 v5010 835 transaction, the identifier collected in DEG7 must be the identification number, NPI or TIN for non-HIPAA covered providers, linked to the provider’s Receiving Depository Financial Institution (RDFI) account.

The identification number linked to the provider’s RDFI account may differ from the identification number used to identify the legal entity. As such, the CAQH CORE 382 Rule requires health plans (or their agent/vendor offering ERA enrollment) to collect an identification number in both DEG2 and DEG7.

37. The CORE-required Maximum ERA Enrollment Data Set requires health plans to collect a National Provider Identifier (NPI) and/or Taxpayer Identification Number (TIN) in both DEG2 and DEG7. Does the CAQH CORE 382 Rule require the identifier collected in DEG2 to be the same as the identifier collected in DEG7?

No. While the identifier collected for DEG2: Provider Identifiers Information can be the same as the identifier collected for DEG7: Electronic Remittance Advice Information, the CAQH CORE 382 Rule does not require them to be the same.

Data Element Groups (DEGs) 2 and 7 represent two different sets of data elements that are necessary to enroll a provider to receive the X12 v5010 835:

  • DEG2: Provider Identifiers Information collects information related to the enrolling provider identified in DEG1: Provider Information. Within DEG2, health plans (or their agent/vendor offering ERA enrollment) are required to collect a Provider Identifier, which must be the identification number, NPI or TIN for non-HIPAA covered providers, for the legal entity reported under the “Provider Name” Data Element in DEG1: Provider Information.
  • DEG7: Electronic Remittance Advice Information collects information related to how the provider wishes to receive the X12 v5010 835 transaction. Within DEG7, health plans (or their agent/vendor offering ERA enrollment) are required to collect a “Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier)”. The X12 v5010 835 TR3 requires a single X12 v0510 835 transaction to correspond to a single EFT payment. Therefore, to identify the EFT payment corresponding to the X12 v5010 835 transaction, the identifier collected in DEG7 must be the identification number, NPI or TIN for non-HIPAA covered providers, linked to the provider’s Receiving Depository Financial Institution (RDFI) account.

Depending on how a provider has established its financial accounting structure, the provider’s RDFI account could be linked to an identification number that is different from the identification number used to identify the legal entity being enrolled for ERA. As shown in the figure below, a number of arrangements may exist:

  • A provider, individual or group, can have a single TIN that is linked to both a single NPI and a single RDFI account.
  • A provider group can have a single TIN that is linked to multiple NPIs, representing both individual provider subparts and the provider entity as a whole, with each NPI linked to a different RDFI account.
  • A provider individual can have a single NPI that is linked to multiple TINs, representing different provider

As the identification number linked to the provider’s RDFI account may differ from the identification number used to identify the legal entity, the CAQH CORE 382 Rule does not require the identification numbers collected within DEG2 and DEG7 to be the same.

Please note: As the X12 v5010 835 TR3 requires a single X12 v0510 835 to correspond to a single EFT payment, the CAQH CORE 382 Rule does require the identifier collected for “Preference for Aggregation of Remittance Data” during ERA enrollment to be the same as the identifier collected for “Account Number Linkage to Provider Identifier” during EFT enrollment (see CAQH CORE 380: EFT Enrollment Data Rule).

38. Does the CAQH CORE 382 Rule specify requirements for how health plans must group X12 v5010 835 ERAs sent to providers (i.e., by NPI or TIN)?

The CAQH CORE 382 Rule includes the following requirements for collection of National Provider Identifier (NPI) and Taxpayer Identification Number (TIN) within the CORE-required Maximum ERA Enrollment Data Set:

  • DEG2: Provider Identifiers Information requires health plans (or their agent/vendor offering ERA enrollment) to collect a “Provider Identifier” which must be the identification number, NPI or TIN for non-HIPAA covered providers, for the legal entity reported under the “Provider Name” Data Element in DEG1: Provider Information.
  • DEG7: Electronic Remittance Advice Information requires health plans (or their agent/vendor offering ERA enrollment) to collect a “Preference for Aggregation of Remittance Data (e.g., Account Number Linkage to Provider Identifier)” As the X12 v5010 835 TR3 requires a single X12 v0510 835 transaction to correspond to a single EFT payment, this identifier must be the identification number, NPI or TIN for non-HIPAA covered providers, linked to the provider’s Receiving Depository Financial Institution (RDFI) account to which claim payments should be deposited.

The CAQH CORE 382 Rule addresses the data to be collected during ERA enrollment; it does not specify requirements for health plans to implement a certain process after the data is collected. Beyond the data collection requirements, how a health plan groups X12 v5010 835 ERAs to providers is a business decision and contract issue to be negotiated between the health plan and its provider trading partners.

Section 4.2 of the CAQH CORE 382 Rule requires health plans to “develop and make available to the healthcare provider (or its agent) specific written instructions and guidance for the healthcare provider (or its agent) when providing and submitting the data elements”. The health plan could include in these instructions a description of its entity-specific process to reach agreement on grouping of the X12 v5010 835.

39. My organization is a health plan. As part of our ERA enrollment form/method, we currently ask providers to identify the service location for which they want to enroll to receive ERA via a proprietary location identifier. Can we continue to collect this location identifier using the CAQH CORE-required Maximum ERA Enrollment Data Set?

Yes. The CAQH CORE 382 Rule provides a uniform and consistent maximum set of data elements that can be used by any health plan (or its agent or vendor) for the purposes of enrolling any healthcare provider (or its agent) to receive claim payment via ERA. This maximum set of data elements is specified in Table 4.2-1 of the CAQH CORE 382 Rule, organized by categories of information referred to as “Data Element Groups” (DEGs).

As part of DEG2: Provider Identifiers Information (DEG2), a health plan (or its agent or vendor offering ERA enrollment) can choose to collect an optional Other Identifier(s). The Other Identifier(s) Individual Data Element allows a health plan to collect proprietary provider identifiers specific to its individual business needs. The CAQH CORE 382 Rule does not specify a data type or format for this identifier. Therefore, a health plan can use the Optional Identifier(s) data element to collect identification numbers for all service locations for which the enrolling provider wants to receive ERA.

Section 4.2, CORE-required Maximum ERA Enrollment Data Elements, in the CAQH CORE 382 Rule requires a health plan to “develop and make available to the healthcare provider (or its agent) specific written instructions and guidance for the healthcare provider (or its agent) when providing and submitting the data elements in Table 4.2-1.” A health plan can include guidance in these instructions for how providers should complete the Other Identifier(s) data element.

The CAQH CORE 382 Rule also permits health plans, and their agents or vendors offering ERA enrollment, to include other functionalities in the enrollment process improve functionality and ensure data integrity and comprehensiveness. For example, a health plan may use a drop down list to identify the optional service locations (via their proprietary identifiers) for which the providers can enroll to receive ERA. For further guidance, see “Can additional data elements beyond the CORE-required Maximum ERA Enrollment Data Elements be collected for ERA enrollment?)

40. The CORE-required Maximum ERA Enrollment Data Set specified in Table: 4.2-1 includes an optional Data Element Group, DEG4, to collect information about a “provider agent”. How is “provider agent” defined for this DEG?

As specified in Section 3.1, When the Rule Applies, the CAQH CORE 382 applies “when a health plan or its agent is enrolling a healthcare provider (or its agent)to receive the X12 v5010 835. As referenced, a “provider agent” is an entity that that has been designated and sufficiently authorized by the provider to receive ERA payments on the provider’s behalf. DEG4: Provider Agent Information in the CORE-required Maximum ERA Enrollment Data Set enables a health plan (or its agent/vendor offering ERA enrollment) to collect information about the provider’s designated agent.

41. Does the CAQH CORE 382 Rule require health plans to include DEG numbers on their ERA enrollment method/form?

No. The CAQH CORE 382 Rule does not require a health plan, or its agent/vendor offering ERA enrollment, to include the DEG number on its electronic or paper-based ERA enrollment form/method. NOTE: Use of paper-based method is optional.

Section 4.3, CORE Master Template for Collecting ERA Enrollment Data, of the CAQH CORE 382 Rule requires health plans “to use the format, flow and data set including data element descriptions in Table 4.2-1 as the CORE Master ERA Enrollment Submission form” for both paper-based and electronic ERA enrollment methods. To conform to the flow, format, and data content requirements, a health plan, or its agent/vendor offering ERA enrollment, must include the data element name and data element description, without revision or modification, on its ERA enrollment form/method and follow the order/sequence as given in Table: 4.2-1.

NOTE: The CAQH CORE 382 Rule does not require health plans to offer a paper-based enrollment form. However, an electronic method for collection and submission of the CORE-required Maximum ERA Enrollment Data Set must be offered. If a health plan chooses to also offer a paper-based enrollment form it must conform to all applicable CAQH CORE 382 Rule requirements.

42. Does the CAQH CORE 382 Rule require health plans to include the Column Headers in Table: 4.2-1 on their ERA enrollment method/form?

No. The CAQH CORE 382 Rule does not require a health plan, or its agent/vendor offering ERA enrollment, to include the column header labels in Table 4.2-1 (e.g., “Individual Data Element”, “Sub-Element name”, “Data Element Description”, “Data Element Requirement for Health Plan Collection”, etc.) on its electronic or paper-based ERA enrollment form/method. NOTE: Use of a paper-based method is optional.

Section 4.3, CORE Master Template for Collecting ERA Enrollment Data, of the CAQH CORE 382 Rule requires health plans “to use the format, flow and data set including data element descriptions in Table 4.2-1 as the CORE Master ERA Enrollment Submission form” for both paper-based and electronic ERA enrollment methods. To conform to the flow, format, and data content requirements, a health plan, or its agent/vendor offering ERA enrollment, must include the data element name and data element description, without revision or modification, on its ERA enrollment form/method and follow the order/sequence as given in Table 4.2-1.

NOTE: The CAQH CORE 382 Rule does not require health plans to offer a paper-based enrollment form. However, an electronic method for collection and submission of the CORE-required Maximum ERA Enrollment Data Set must be offered. If a health plan chooses to also offer a paper-based enrollment form it must conform to all applicable CAQH CORE 382 Rule requirements.

43. Section 4.3.1 of the CAQH CORE 382 Rule specifies several items beyond the CORE-required Enrollment Data Elements that must be included on a paper-based ERA enrollment form. Does the CAQH CORE 382 Rule require all of these items to be included on a single page?

No. Section 4.3.1, Master Template for Manual Paper-Based Enrollment, of the CAQH CORE 382 Rule requires a health plan (or its agent/vendor offering ERA enrollment) to include the following items on its paper-based ERA enrollment form:

  • Specific written instructions and guidance for completing and submitting the enrollment form
  • A number to fax and/or a U.S. Postal Service or email address to send the completed form
  • Contact information for the health plan, specifically a telephone number and/or email address to send questions
  • Authorization language for the provider to read and consider
  • A section that outlines how the provider can access online instructions for how to determine the status of the ERA enrollment
  • Clear labels for any appendix describing its purpose as it relates to the provider enrolling in ERA

The CAQH CORE 382 Rule does not specify any requirements regarding pagination. A health plan may choose to include the above additional items on a single page of the enrollment form or on a separate page at the health plan’s discretion. NOTE: To conform to the flow and format requirements specified in Section 4.3 of the CAQH CORE 382 Rule, the above items cannot appear within or between the Maximum Enrollment Data Elements.

NOTE: The CAQH CORE 382 Rule does not require health plans to offer a paper-based enrollment form. However, an electronic method for collection and submission of the CORE-required Maximum ERA Enrollment Data Set must be offered. If a health plan chooses to also offer a paper-based enrollment form it must conform to all applicable CAQH CORE 382 Rule requirements.

44. The CAQH CORE 382 Rule requires health plans to collect a signature for the individual authorized to initiate, modify, or terminate the provider’s ERA enrollment. What data collection method should health plans use to obtain this signature (i.e., electronically or “wet”)?

Data Element Group (DEG) 8: Submission Information in the CORE-required Maximum ERA Enrollment Data Set includes as a required Individual Data Element “Authorized Signature”. This data element allows a health plan (or its agent/vendor offering ERA enrollment) to collect the “signature of an individual authorized by the provider or its agent to initiate, modify or terminate an enrollment”. As specified in Table: 4.2-1, a health plan (or its agent/vendor offering ERA enrollment) can require this signature to be submitted either electronically or written (i.e., “wet”). It is the health plan’s individual business decision what method it chooses to use to obtain the authorizing signature.

Section 4.2 in the CAQH CORE 382 Rule requires a health plan to “develop and make available to the healthcare provider (or its agent) specific written instructions and guidance for the healthcare provider (or its agent) when providing and submitting the data elements in Table 4.2-1.” Depending on what method the health plan chooses to obtain the authorized signature, the health plan could provide guidance to the provider in the instructions for how providers should submit the signature (e.g., if the health plan chooses to include “Written Signature of Person Submitting Enrollment” in its electronic enrollment method, the health plan could instruct the provider how to deliver the required wet signature prior to/along with/after completion of the electronic enrollment in ERA).

45. How are the CAQH CORE EFT & ERA Enrollment Data Sets maintained via the CAQH CORE EFT & ERA Enrollment Data Maintenance Process?

As specified in Section 3.4, CORE Process for Maintaining CORE-required Maximum EFT Enrollment Data Set, of the Phase III CAQH CORE 380: EFT Enrollment Data Rule and Phase III CAQH CORE 382 ERA Enrollment Data Rule, the CAQH CORE-required Maximum EFT & ERA Enrollment Data Sets are reviewed and updated on an annual basis. Section 3.4 in the CAQH CORE 380 and CAQH CORE 382 Rules requires that the first review of the enrollment data sets commence one year after the rules were adopted into federal regulation. This first review occurred in 2014.

  • Limited Reviews: Occur biennially and consider only non-substantive adjustments to the Enrollment Data Sets; occur on an alternating schedule with Comprehensive Reviews (next Limited Review is in 2016)
  • Comprehensive Reviews: Occur biennially and consider both substantive and non-substantive adjustments to the Enrollment Data Sets; occur on an alternating schedule with Limited Reviews (next Comprehensive Review is in 2017)

NOTE: Adjustments pertaining to rule language and requirements beyond the CAQH CORE-required Maximum EFT & ERA Enrollment Data Sets are out of scope for the CAQH CORE EFT & ERA Enrollment Data Maintenance Process.

In keeping with the CAQH CORE multi-stakeholder, collaborative and transparent rule development process, participation in the CAQH CORE Enrollment Data Task Group is open to representatives from any CORE Participating Organization. There is no limit to the number of representatives that a CORE Participating Organization can assign to the Task Group. Individuals with knowledge of the business processes and work flows for EFT and ERA enrollments are strongly encouraged to join the Task Group. Interested participants can send their name, title, organization name, email address, and telephone number to core@caqh.org.

46. What are the CAQH CORE Comprehensive and Limited Reviews of the CAQH CORE-required Maximum EFT & ERA Enrollment Data Sets? When do these reviews occur?

Per the CAQH CORE EFT & ERA Enrollment Data Sets Maintenance Process, the CAQH CORE Enrollment Data Task Group conducts two types of review of the CAQH CORE-required Maximum EFT & ERA Enrollment Data Sets:

  • Comprehensive Reviews consider both potential substantive and non-substantive adjustments to the CORE-required Maximum EFT & ERA Enrollment Data Sets.
  • Limited Reviews consider potential non-substantive adjustments to the CORE-required Maximum EFT & ERA Enrollment Data Sets.

Comprehensive and Limited Reviews occur biennially on alternating years; i.e., if a Comprehensive Review occurs one year, a Limited Review will occur the following year.

As defined in the CAQH CORE EFT & ERA Enrollment Data Sets Maintenance Process, substantive adjustments address addition of new data elements/Data Element Groups (DEGs) to address emerging, new, or changing industry needs. Non-substantive adjustments improve usability of the enrollment data set but do not change the name, position, or collection requirements for the CORE-required EFT & ERA Enrollment data elements, sub-elements, or DEGs.

Once the CAQH CORE Enrollment Data Task Group approves a set of substantive and/or non-substantive adjustments to the CAQH CORE EFT & ERA Enrollment Data Sets, updated CAQH CORE EFT & ERA Enrollment Data Rules will be published. HIPAA-covered entities will need to update their EFT and ERA enrollment forms/systems to ensure conformance with any substantive adjustments applied to the data sets as a result of a Comprehensive Review. NOTE: HIPAA-covered entities will not need to update their EFT and ERA enrollment forms/systems as a result of a Limited Review.

47. What adjustments have been made to the CAQH CORE Maximum EFT & ERA Enrollment Data Sets to date?

2014 Review

In Q2 2014, the CAQH CORE Enrollment Data Task Group conducted the first Limited Review of the CORE-required Maximum EFT & ERA Enrollment Data Sets.

In this Limited Review, Task Group members identified and addressed non-substantive adjustments in the CORE-required Maximum EFT & ERA Enrollment Data Sets to improve implementer usability of the Enrollment Data Sets, including formatting inconsistencies and typographical errors, consistency between data elements, and improving clarity on data elements that generated questions from implementers. These non-substantive updates did not require HIPAA-covered entities to update their enrollment forms/systems.

Versions 3.0.1 of the Phase III CAQH CORE 380: EFT Enrollment Data Rule and Phase III CAQH CORE 382: ERA Enrollment Data Rule were distributed to the industry in September 2014.

2015 Review

The CAQH CORE Enrollment Data Task Group convened in Q4 2015 to conduct its first scheduled Comprehensive Review of the CORE-required Maximum EFT & ERA Enrollment Data Sets. During the Task Group's 2015 Review, Task Group members reviewed the rationale for and against conducting a Comprehensive Review. Upon consideration, the Task Group elected NOT to conduct a Comprehensive Review. This decision was based on several factors, which included:

  • Industry resources better spent on higher-priority items such as ICD-10, completing implementations of mandated operating rules, and preparing for Phase IV CAQH CORE Operating Rules implementation
  • Lack of an industry-wide call to action for adjustments to the Enrollment Data Sets, i.e. CAQH CORE did not receive any Requests related to the Data Sets in 2015
  • Current Data Sets are successfully implemented in the market, i.e. more than 30 organizations are Phase III CORE-certified and in conformance with the Data Sets

Additionally, the Task Group sought to collect non-substantive adjustments as part of a Limited Review. As no non-substantive adjustments were proposed, the Task Group did not update the Enrollment Data Sets in 2015.

48. How can my organization submit potential substantive adjustments to the CORE-required Maximum EFT & ERA Enrollment Data Sets for consideration during the next Comprehensive Review?

The next Comprehensive Review of the CORE-required Maximum EFT & ERA Enrollment Data Sets is schedule to occur in 2017. Per the CAQH CORE EFT & ERA Enrollment Data Sets Maintenance Process, the Comprehensive Reviews consider both substantive and non-substantive adjustments to the CORE-required Maximum EFT & ERA Enrollment Data Sets. More information on the 2017 Comprehensive Review will be shared later in 2017.

49. How will the CAQH CORE Enrollment Data Task Group evaluate potential substantive adjustments to the CORE-required Maximum EFT & ERA Enrollment Data Sets?

The CAQH CORE Enrollment Data Task Group uses a set of Enrollment Data Evaluation Criteria to evaluate potential substantive adjustments to the CORE-required Maximum EFT & ERA Enrollment Data Sets. When submitting potential substantive adjustments for Task Group consideration, stakeholder entities will be required to confirm that their submission meets at least four of the seven criteria listed below:

  1. Supports the vision of the CAQH CORE Enrollment Data Rules to move the industry toward a uniform, standard maximum set of required EFT and ERA enrollment data elements
  2. Promotes EFT and ERA enrollment efficiency (e.g., reduction in staff time and resources required to complete enrollment) and increases provider adoption by reducing the range of enrollment information requested and variation in terms used to collect the same/similar information
  3. Does not result in addition of data elements that are semantic variations of existing data elements; i.e., data elements must collect unique and distinctly separate information
  4. Meets a demonstrated, new or current industry-wide multi-stakeholder business need not addressed by the existing Enrollment Data Set
  5. Ensures collection of key items needed to fully automate both claims payment and remittance advice posting processes
  6. Balances return on investment (ROI) and industry-wide benefit against the significant lift required for health plans or agents to revise enrollment systems and paper-based forms and for providers to provide the data
  7. Consistent with Phase III CAQH CORE Guiding Principles

In addition to alignment with the above Evaluation Criteria, the Enrollment Data Task Group’s policy is to collect Supporting Information including a Business Case and any applicable Supporting Data for each submitted potential substantive adjustment to the CORE-required Maximum EFT & ERA Enrollment Data Sets.

For more information on the CAQH CORE EFT & ERA Enrollment Data Sets Maintenance Process, see the CAQH CORE EFT & ERA Enrollment Data Set Maintenance Process webpage.

50. How will organizations be notified about and access new versions of the CAQH CORE EFT & ERA Enrollment Data Rules?

Once the CAQH CORE Enrollment Data Task Group approves a set of substantive and/or non-substantive adjustments to the CORE-required Maximum EFT & ERA Enrollment Data Sets, an updated version of the CAQH CORE EFT & ERA Enrollment Data Rules will be published. Publication of updated versions of the CAQH CORE EFT & ERA Enrollment Data Rules will be announced on the CAQH CORE webpage and via an industry-wide email notification.

51. How long will my organization have to update our EFT and/or ERA enrollment system or forms after publication of substantive adjustments to the CAQH CORE EFT & ERA Enrollment Data Rules?

HIPAA-covered entities will need to update their EFT and ERA enrollment forms/systems to ensure conformance with any substantive adjustments applied to the data sets as a result of a Comprehensive Review. Per the CAQH CORE EFT & ERA Enrollment Data Sets Maintenance Process, a health plan, or its agent offering EFT and/or ERA enrollment, will have:

  • NINE calendar months to update their electronic EFT and/or ERA enrollment systems or forms and
  • TWELVE calendar months to update their paper-based EFT and/or ERA enrollment forms.

The compliance timeframe for HIPAA-covered entities to adjust their systems and/or forms begins on the date of publication of the updated versions of the CORE-required Maximum EFT & ERA Enrollment Data Sets.

52. What is the schedule for CAQH CORE to publish adjustments to CAQH CORE EFT & ERA Enrollment Data Rules?

Per the CAQH CORE EFT & ERA Enrollment Data Sets Maintenance Process, Comprehensive and Limited Reviews of the CORE-required Maximum EFT & ERA Enrollment Data Sets occur biennially on alternating years (i.e., if a Comprehensive Review occurs one year, a Limited Review will occur the following year). The 2016 Review is scheduled to be a Limited Review followed by a Comprehensive Review in 2017.

53. How can my organization get involved in the CAQH CORE EFT & ERA Enrollment Data Sets Maintenance Process?

Entities are encouraged to join CAQH CORE as a CORE Participating Organization to contribute to the evolution of the CORE-required Maximum EFT & ERA Enrollment Data Sets via the CAQH CORE Enrollment Data Task Group. Participation in CAQH CORE also enables industry entities to have a say in the development of operating rules, and be part of a solution that diminishes the cost and complexity within the healthcare system. CAQH CORE welcomes Participating Organizations representing a range of stakeholder groups.

The CAQH CORE EFT & ERA Enrollment Data Sets Task Group is open to representatives from any CORE Participating Organization. There is no limit to the number of representatives that a CORE Participating Organization can assign to the Task Group. Individuals with knowledge of the business processes and work flows for EFT and ERA enrollments are strongly encouraged to join the Task Group. Interested participants can send their name, title, organization name, email address, and telephone number to core@caqh.org.

Entities can also contribute a number of other ways, including attendance on bimonthly CAQH CORE Town Hall Calls. Interested entities should email core@caqh.org for further information.

54. As a health plan, if my organization chooses to include an Individual Data Element that is designated as “optional” within the CORE-required Maximum ERA Enrollment Data Set, can we make completion of this data element mandatory for enrolling providers?

The CORE-required Maximum ERA Enrollment Data Set includes ten Data Element Groups (DEGs). For each DEG, Table 4.2-1, CORE-required Maximum ERA Enrollment Data Set, specifies whether the DEG is “required” or “optional” for data collection. Additionally, within each DEG, Individual Data Elements or Sub-elements may be designated as “required” or “optional” for data collection. This designation is provided in the “Data Element Requirement for Health Plan Collectioncolumn in Table 4.2-1.

The “required” or “optional” designation identified in Table 4.2-1 is specific to whether a health plan, or its agent, must include the DEG or Individual Data Element/Sub-element on its ERA enrollment form/method. The CAQH CORE 382 Rule does not address requirements for provider completion of the elements included on the ERA enrollment form/method. As such, if a health plan chooses to include an “optional” Individual Data Element or Sub-element on its ERA enrollment method, it is permitted by the CAQH CORE 382 Rule to make completion of this “optional” data element mandatory for enrolling providers.