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Customer Experience and Design

Are you ready for the Mandated (ACA) Healthcare Operating Rules?

The 2010 passage of the Patient Protection and Affordable Care Act (ACA) and its Section 1104 establishes a national healthcare operating rule mandate in support of the industry’s ongoing administrative simplification efforts. The first healthcare operating rule set, issued by CMS in July 2011, mandates the adoption of CAQH CORE Operating Rules for Eligibility and Claim Status transactions. This mandate applies to all HIPAA covered entities and is effective January 1, 2013. Subsequently, on January 1, 2014, operating rule regulations will become effective for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) transactions.

What is a HIPAA covered entity? A HIPAA covered entity is any organization or corporation that directly handles Personal Health Information (PHI) or Personal Health Records (PHR). The most common examples of covered entities include hospitals, doctors’ offices and health insurance providers.

If you haven’t started yet, better get a move on. There is quite a bit of information to sift through, and you need to determine if you are compliant. The best source of information for these rules is the CAQH CORE Phase I and Phase II documents which can be found on the CAQH website You don’t have to get the certification, but the documentation found on this site is extremely helpful in determining your compliancy.

The transaction sets that need to be compliant by the end of this year are the 270/271 and 276/277. Other items covered that must be compliant by the end of the year: mandated times your systems must be available for receiving and sending, “safe harbor” connectivity requirements, normalizing patient last name, “standardized” companion guides, and response times.

Let’s start with the transaction sets. The biggest changes here are to the EB (CAQH Phase I CORE 154 rule and Phase II CORE 260 rule) and AAA (CAQH Phase II CORE 259 rule) segments. Review these carefully as there are very explicit rules as to what data should be sent and when.

Next big one is the ruling on connectivity (CAQH Phase I CORE rule 153, 155, 156, 157, CAQH Phase II CORE rule 250, 270), system availability (CAQH Phase I CORE rule 157 and Phase II CORE rule 250), and companion guides (CAQH Phase I CORE rule 152). Once again there are very explicit rules on each of these subjects.

Hopefully everyone is already working on this compliancy and have it well in hand. Don’t be dismayed, it’s really not as bad as it looks!

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Deborah O'Rear, Sr. Technical Consultant

Deborah O’Rear is a business-focused, outcomes-driven consultant with more than 15 years of healthcare industry experience. She has a vast depth of EDI and BSA knowledge to support healthcare clients. Deborah is well versed in articulating, clarifying, and writing business requirements, establishing implementation strategies, QA, user stories, and testing.

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