Industry Survey: Potential Operating Rule Opportunity Areas for ACA Section 1104 Third Set

Background

 
CAQH CORE has been developing operating rules on a voluntary basis since 2005, with broad stakeholder engagement in a transparent and consensus-driven process. To date, the Secretary of HHS has adopted CAQH CORE Operating Rules to address the first and second sets of operating rules mandated under ACA Section 1104.

• Per ACA Section 1104, HIPAA covered entities must comply with the first set of Federally mandated operating rules addressing the eligibility and claim status transactions by January 1, 2013.

• Compliance with the second set of Federally mandated rules addressing the electronic funds transfer (EFT) and electronic remittance advice (ERA) transactions is required by January 1, 2014.

In September 2012, the HHS Secretary recommended CAQH CORE as the authoring entity for the third set of operating rules mandated under ACA Section 1104. The third set of Federally mandated operating rules addresses the following transactions:

• Health claims or equivalent encounter information

• Health plan enrollment/disenrollment

• Health plan premium payments

• Referral certification and authorization

• Claim attachments

Per the legislation, HHS must adopt operating rules to address these transactions by July 1, 2014. By January 1, 2016, HIPAA covered entities must be in compliance with the Federally mandated operating rules.
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