1. As a health plan, is collecting information about the bank account owner as a component of our fraud prevention measures conformant with the CORE-required Maximum EFT Enrollment Data Set?

Since the CAQH CORE Payment & Remittance EFT Enrollment Data Rule was initially developed, many organizations have identified the need to improve their fraud prevention measures. Per the rule, verifying the accuracy of the data collected from the provider is outside the scope of the rule and entities are permitted to include policies and methods to minimize fraud in their enrollment process.

2. As a health plan, our EFT enrollment process is used for new enrollments only. Do we still need to include the “Reason for Submission” Data Element if this is the case?

If an entity’s EFT enrollment process defaults to new enrollments only, there is no need to include the Reason for Submission Data Element. The data element is required only when there is more than one option for selection. The health plan or its agent must clarify in its instructions and guidance that the process is for new enrollments only.

3. As a vendor, we use a single enrollment process for EFT/ERA and have a business need for providers to indicate payer/services they are enrolling with before Preference for Aggregation of Remittance Data. Is this conformant with the Enrollment Rules?

The EFT Enrollment Rule allows for use of a single inclusive enrollment form for both EFT and ERA. Clarifying the payer and EFT and/or ERA enrollment selection is considered necessary for verifying the accuracy of the data collected from the provider and is out of scope per the CAQH CORE EFT and ERA Enrollment Data Operating Rules.

4. While the EFT Enrollment Data Set includes “Street” as a Sub-element to Address Data Elements, it does not specify a secondary address field or “Address 2” line. As a health plan, can I collect this information to ensure accuracy and prevent fraud?

The EFT Enrollment Data Set does not define the field length for “Street.” During initial rule development, CAQH CORE Participants purposefully maintained flexibility with this field given the potential for updates to address formats from USPS.

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

The CAQH CORE Payment & Remittance Operating Rules support the healthcare industry's transition to electronic payment and remittance advice. Two of the five CAQH CORE Payment & Remittance Operating Rules address the barriers to greater provider EFT and/or ERA enrollment due to the variance in the required processes and data elements.

6. Why does the CAQH CORE Payment & Remittance EFT Enrollment Data Rule require inclusion of both TIN and NPI as sub-elements for the “Provider Identifier” Data Element in DEG2 and “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.

7. If a health plan offering EFT and ERA enrollment chooses to use a single form, how should the EFT and ERA Enrollment Data Element Groups in the CAQH CORE Enrollment Data Rules 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.

8. 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 EFT enrollment) must collect all Individual Data Elements per the CAQH CORE Payment & Remittance EFT Enrollment Data Rule requirements, including those for which the health plan has no business need.

9. Are there available data file examples of the CORE-required Maximum EFT Enrollment Data Set that health plans, their agents and/or vendors offering EFT Enrollment, can use to develop their enrollment form/utility?

Yes. CAQH CORE has published an Excel-based version of Table 4.2-1, CORE-required Maximum EFT Enrollment Data Set. The Excel Workbooks are available on the CAQH CORE website. Beyond this Excel document and the table in the CAQH CORE Payment & Remittance EFT Enrollment Data Rule, there are no other available data file examples of the CORE-required Maximum EFT Enrollment Data Set.

10. If a health plan uses a web-based enrollment method to fulfill the CORE Electronic Enrollment Safe Harbor required by the CAQH CORE Payment & Remittance EFT Enrollment Data Rule, do the data elements have to be included on a single webpage?

No. The CAQH CORE Payment & Remittance EFT Enrollment Data 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 Payment & Remittance EFT Enrollment Data Rule does not include any language surrounding pagination or other contiguity of the data.

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