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Billing and insurance related tasks account for a significant portion of administrative costs for providers and hospitals. This number will only increase with the growth in healthcare claims due to an aging population that will require more healthcare services.

The federally mandated CAQH CORE EFT & ERA Operating Rules simplify and streamline

provider payment and claim reconciliation so you can reduce costs and spend more time caring for patients.

Reaping the benefits of the federally mandated EFT & ERA Operating Rules is easy, and CAQH CORE can assist you in the process.

 

Federally-Mandated CAQH CORE EFT & ERA Operating Rules

Deadline: January 1, 2014

How to Comply

No matter where your organization is in the process, CAQH CORE offers numerous free tools and resources to assist with implementation. Follow the steps below to ensure your organization is gaining the benefits of the EFT & ERA Operating Rules.

Providers must be proactive in order to obtain the full range of benefits of the EFT & ERA Operating Rules. If your organization is just getting started, follow the steps below:

  • Determine if your organization is conducting the applicable electronic transactions, as providers are only required to comply if they conduct electronic transactions.
  • Determine if your organization is a HIPAA covered entity. ACA Section 1104 requires all HIPAA covered entities to comply with the HIPAA-mandated EFT and ERA operating rules. If you are unsure whether your organization is a HIPAA covered entity, click here
  • Review the high-level overview of the CAQH CORE EFT & ERA Operating Rules to ensure you are familiar with the rules and what they require.
  • Contact your health plans to request payment via EFT. CAQH CORE has developed a sample letter for providers to send to the health plans with which they work, given all HIPAA covered health plans are required to offer payment via EFT as of January 1, 2014.
  • Contact your bank(s) to ensure they are aware of the CAQH CORE EFT & ERA Operating Rules and arrange for the delivery of the CORE-required Minimum CCD+ Data Elements necessary for successful reassociation of the EFT payment with the ERA.CAQH CORE has developed a sample letter for providers that can make this process easier.
  • Contact your vendor(s) to ensure they are aware of the CAQH CORE EFT & ERA Operating Rules and encourage them to become CORE-certified.
  • Download and review the Phase III CAQH CORE EFT & ERA Operating Rules
  • Review our Frequently Asked Questions

If your organization conducts the applicable electronic transactions, the next step is to create a high-level systems impact analysis and develop a detailed project plan for adopting the EFT & ERA Operating Rule requirements.

If you have successfully assessed your organization's readiness, you are ready to move forward with adoption and testing to ensure the proper systems are in place.

  • Communicate your readiness for testing conformance with trading partners.
  • Test and certify your systems using an independent testing platform developed by a CORE-authorized testing vendor.
  • Become CORE-certified
For more information, review our FAQs or access the CAQH CORE education session archive.
Implementation Resources

About CAQH CORE

CAQH CORE

The Committee on Operating Rules for Information Exchange (CORE) is a multi-stakeholder initiative of CAQH. CAQH CORE was established in 2005 with the mission to build consensus among healthcare industry stakeholders on a set of operating rules that facilitate administrative interoperability between providers and health plans and drive adoption of the operating rules and the affiliated standards. The CAQH CORE vision is for streamlined, robust, efficient, and trusted administrative data exchange based on a set of Guiding Principles such as alignment of clinical and administrative, and use of Federally mandated standards.

The CAQH CORE Operating Rules:

  • Enable providers to submit transactions using the system of their choice (i.e., vendor agnostic) and quickly receive a standardized response
  • Facilitate administrative and clinical data integration.

CAQH CORE is the HHS designated author of the ACA-mandated Federal healthcare operating rules.

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CAQH

CAQH is a non-profit that serves as a catalyst for industry collaboration on initiatives that simplify healthcare administration by:

  • Promoting quality interactions between plans, providers and other stakeholders
  • Reducing costs and frustrations associated with healthcare administration
  • Facilitating administrative healthcare information exchange
  • Encouraging administrative and clinical data integration
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After reviewing these tools & resources, please email CORE@caqh.org with any general questions or for additional clarification.
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