Frequently Asked Questions - I. Development of Remaining ACA-Mandated Operating Rules

ACA Section 1104 requires the Secretary of the Department of Health and Human Services (HHS) to adopt and regularly update operating rules for each of the HIPAA-mandated healthcare administrative transactions. HHS has not adopted operating rules for the following HIPAA-mandated administrative transactions:

• Health claims or equivalent encounter information
• Health plan enrollment/disenrollment
• Health plan premium payments
• Referral certification and authorization
• Health claims attachments

On September 12, 2012, the Secretary of HHS concurred with the recommendation from the National Committee on Vital and Health Statistics (NCVHS) that CAQH CORE be designated the authoring entity for the remaining operating rules mandated under ACA Section 1104.

From December 2013 – June 2015, CAQH CORE Participants used the open CAQH CORE rules-making process to produce a set of operating rules for the following transactions: health claims or equivalent encounter information, health plan enrollment/disenrollment, health plan premium payments and referral certification and authorization. These CAQH CORE Operating Rules was approved per the formal CAQH CORE voting process in September 2015 and include:

• CAQH CORE Health Care Claims Operating Rules
• CAQH CORE Prior Authorization & Referrals Operating Rules
• CAQH CORE Benefit Enrollment Operating Rules
• CAQH CORE Premium Payment Operating Rules

NOTE: Currently, the CAQH CORE Operating Rules for Health Care Claims, Prior Authorization & Referrals, Benefit Enrollment and Premium Payment are voluntary and have not been adopted by HHS for mandatory use by HIPAA-covered entities. HHS will determine if these Operating Rules will be included in any regulatory mandates. Any such considerations will include an HHS public comment period.

ACA Section 1104 requires HHS to adopt a standard, and applicable operating rules, for the health claims attachments transaction. To date, HHS has not adopted a standard for health claims attachments or indicated what standard(s) it might consider for the transaction.

Through its HHS designation as the Operating Rule Authoring Entity for HIPAA-mandated administrative transactions including attachments, a key goal of CAQH CORE is to accelerate the adoption of electronic transactions and streamline communication of clinical information through the development of operating rules. CAQH CORE has engaged in a variety of work efforts to survey industry utilization and barriers to identify opportunities for greater uniformity and to educate and promote industry adoption of electronic attachments. In 2019, CAQH CORE launched operating rule development for attachments given the industry clamor for adoption and uniformity. A CAQH CORE Attachments Subgroup is developing operating rules to improve automation of the exchange of attachments, with an initial focus on the prior authorization use case. Work will be completed in Q1 2021. The Subgroup will then address the healthcare claims use case.