1. My health plan provides the X12 v5010 835 via an online application only, do the CAQH CORE Payment & Remittance (835) Infrastructure Rule requirements apply?

​​​​​​The CAQH CORE Operating Rules apply to HIPAA transactions, which are healthcare electronic data interchanges (EDI); as such, the CAQH CORE Payment & Remittance (835) Infrastructure Rule does not apply when the X12 v5010 835 is provided via Direct Data Entry.

4. My entity is a provider organization. Can we be charged a fee by health plans to receive claims reimbursement via the HIPAA-mandated Healthcare EFT Standards?

ACA Section 1104 added Electronic Funds Transfer (EFT) to the list of electronic healthcare transactions for which the HHS Secretary must adopt a HIPAA standard. In July 2012, HHS adopted the NACHA CCD+ and ASC X12N/005010X221 Health Care Claim Payment/Advice (835) and associated errata (hereafter referenced as ASC X12N v5010 835) TR3 TRN Segment together as the HIPAA-mandated Healthcare EFT Standards.

5. My entity is a provider organization. We currently cannot access EFT and/or ERA from some of the health plans we work with but would like to begin using the transactions. Does CAQH CORE have any tools to assist with this?

Yes. As of January 1, 2014 all HIPAA covered health plans must offer to providers an electronic payment option via the newly mandated Healthcare EFT Standard (e.g. NACHA CCD+). Health plans have been required to offer payment via the X12 v5010 835 HIPAA standard for ERA for many years. Additionally, health plans must be compliant with the ACA mandated Payment & Remittance Operating Rules which support more efficient provider use of both EFT and ERA.

6. My organization is a provider office. We currently receive claim payment via paper with accompanying electronic remittance. Do the CAQH CORE Payment & Remittance Operating Rules require us to receive claim payment electronically?

The CAQH CORE Payment & Remittance Operating Rules do not require any provider to accept claim payment or remittance information via the HIPAA-mandated X12 v5010 835 and Healthcare EFT Standards (CCD+ and X12 v5010 835 TR3 TRN Segment).

7. My organization is a provider office. We currently do not receive electronic claim payment and remittance information from all health plan trading partners. Do the CAQH CORE Operating Rules require us to accept an 835 from all health plans?

The CAQH CORE Payment & Remittance Operating Rules do not require any provider to accept claim payment and remittance information via the HIPAA-mandated X12 v5010 835 and Healthcare EFT Standards (CCD+ and X12 v5010 835 TR3 TRN Segment).

8. My organization is a health plan. We currently do not support claim payments via the HIPAA-mandated Healthcare EFT Standards. As we do not use the transaction standards, are we exempt from conformance with the CAQH CORE Operating Rules?

ACA Section 1104 requires all HIPAA covered entities, including health plans, to comply with the mandated standards and applicable operating rules. ACA Section 1104 adds Electronic Funds Transfer (EFT) to the list of electronic health care transactions for which the HHS Secretary must adopt a HIPAA standard.

My organization is a health plan. We currently deliver both a proprietary paper Remittance Advice (RA) and the X12 v5010 835. Do the CAQH CORE Operating Rules addressing the X12 v5010 835 require us to only provide remittance information via the X12 835?

The CAQH CORE Payment & Remittance Operating Rules do not require any health plan to send remittance information via the X12 v5010 835 only.

10. My organization is a health plan. We currently send a paper Remittance Advice (RA) and do not support the X12 v5010 835. As we do not use the X12 v5010 835, are we exempt from conformance with the CAQH CORE Operating Rules?

ACA Section 1104 requires all HIPAA covered entities, including health plans, to comply with the mandated standards and applicable operating rules. ACA Section 1104 adds Electronic Funds Transfer (EFT) to the list of electronic health care transactions for which the HHS Secretary must adopt a HIPAA standard. In January 2012, HHS issued an IFC adopting the NACHA CCD+ and X12 v5010 835 TR3 TRN Segment together as the HIPAA-mandated Healthcare EFT Standards.

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