1. Do the CAQH CORE Payment & Remittance Operating Rules apply when entities make electronic healthcare payments via other Electronic Funds Transfer (EFT) standards instead of the HIPAA-mandated Healthcare EFT Standards?

No. The CAQH CORE Payment & Remittance Operating Rules apply only when entities are using the HIPAA-mandated EFT and ERA standards. While the HHS Final Rule permits entities to use EFT transaction standards beyond the HIPAA-mandated Healthcare EFT Standards (the NACHA CCD+ and the ASC X12N v5010 835 TR3 TRN Segment), these other standards are outside the scope of the CAQH CORE Payment & Remittance Operating Rules.

2. What entities are required to comply with the ACA-mandated Payment & Remittance Operating Rules?

The ACA Administrative Simplification provisions require all HIPAA-covered entities to comply with the ACA mandated standards and applicable operating rules by their compliance dates. The compliance date for the ACA mandated CAQH CORE Payment & Remittance Operating Rules was January 1, 2014.

3. What are the HIPAA-mandated Healthcare EFT Standards?

ACA Subsection 1104(c)(2) adds the Electronic Funds Transfer (EFT) transaction to the list of electronic health care transactions for which the HHS Secretary must adopt a HIPAA standard. Specifically, ACA Section 1104 requires the HHS Secretary to promulgate a final rule to establish a HIPAA transaction standard for healthcare EFT no later than January 1, 2012, with the rule effective January 1, 2014.

4. What transactions are addressed by the ACA-mandated CAQH CORE Payment & Remittance Operating Rules?

The CAQH CORE Payment & Remittance Operating Rules apply to the use, conduct, or processing of the ASC X12N/005010X221 Health Care Claim Payment/Advice (835) and associated errata (hereafter referenced as ASC X12N v5010 835) transaction and the HIPAA-mandated Healthcare EFT Standards (the NACHA ACH CCD+ and the ASC X12N v5010 835 TR3 TRN Segment).

6. What CAQH CORE Payment & Remittance Operating Rules have been adopted to fulfill the ACA Section 1104 mandate?

The August 2012 HHS Final Rule adopts all the CAQH CORE Payment & Remittance Operating Rules to fulfill the ACA mandate, with the exception of rule requirements pertaining to use of Acknowledgements. Specifically, the Final Rule adopts the following CAQH CORE Payment & Remittance Operating Rules:

7. What do the CAQH CORE Payment & Remittance Operating Rules address?

Payment and remittance advice processing are faster when a provider receives payment via Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) instead of via paper check and corresponding paper remittance advice. The CAQH Index estimates the proportion of these transactions conducted electronically. Several key barriers exist to achieving rapid, industry-wide adoption of EFT and ERA including:

Subscribe to III. Requirements for Federal Operating Rules Addressing the EFT & ERA Transactions