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Operating Rules

Background

In March 2010, HIPAA Administrative Simplification provisions were amended through the enactment of the Patient Protection and Affordable Care Act (ACA). Section 1104 of the ACA establishes new requirements for administrative transactions that will improve the utility of the existing HIPAA transactions and reduce administrative costs.

Specifically, in section 1104(b)(2) of the ACA, Congress required the adoption of operating rules for the health care industry and directed the Secretary of Health and Human Services to ‘‘adopt a single set of operating rules for each transaction with the goal of creating as much uniformity in the implementation of the electronic standards as possible.’’

The ACA called for the release of three sets of operating rules:

  • Eligibility and claim status (compliance date January 1, 2013)
  • Electronic funds transfer and claims payment/remittance advice (compliance date January 1, 2014)
  • Health claims, health plan enrollment/disenrollment, health plan premium payment, referral certification, and authorizations (compliance date January 2016)

 

The Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) has been selected as the authoring entity for operating rules.

The Federal Government releases the final regulations related to operating rules.

Impacts

DHCS Health Plan trading partners and internal DHCS program areas.

Resources

Below are external links that will lead you away from the Department of Health Care Services.

Affordable Care Act

Federal Register:  Operating Rules Eligibility and Claims Status

Federal Register:  Operating Rules Electronic Funds Transfers and Remittance Advice

CAQH CORE

 

 
Last modified on: 3/12/2015 2:17 PM