Committee on Operating Rules For Information Exchange (CORE®) Understanding the Value of the ACA Mandated CAQH CORE Operating Rules Central Ohio HFMA Spring Conference March 14, 2013 Additional information/resources available at www.caqh.org Agenda • Introduction to CAQH CORE • Operating Rules and Affordable Care Act (ACA) Section 1104 • Overview of ACA Mandated CAQH CORE Operating Rules – First Set: Eligibility & Claim Status Operating Rules – Second Set: EFT & ERA Operating Rules – Third Set: Attachments, Prior Authorization, Enrollment, etc. • Reaping the Benefits of Operating Rules – Engaging Practice Management System (PMS) Vendors – Measures of Success – Action Items for Providers • 2 Q&A © 2013 CORE. All rights reserved. Objectives 3 • Understand what operating rules are and their role in the broader healthcare context • Understand status of the ACA mandates and what they mean for providers • Consider the role of PMS vendors and impact on provide receipt of compliance transactions • Learn about tracking and potential ROI associated with Operating Rules • Review a list of immediate action steps for providers to ensure ROI from operating rules © 2013 CORE. All rights reserved. Introduction to CAQH CORE 4 © 2013 CORE. All rights reserved. CAQH: Current Initiatives Industry-wide stakeholder collaboration to facilitate development and adoption of industry-wide operating rules for administrative transactions. Over 130 participating organizations. Service that replaces multiple paper processes for collecting provider data with a single, electronic, uniform data-collection system (e.g., credentialing). • 85% of Ohio physicians (MD/DO) are registered in UPD Service that enables providers to enroll in electronic payments with multiple payers and manage their electronic payment information in one location, automatically sharing updates with their selected payer partners. Objective industry forum for tracking progress and savings associated with adopting electronic solutions for administrative transactions across the industry. 5 © 2013 CORE. All rights reserved. CAQH CORE Background • • A multi-stakeholder collaboration established in 2005 Mission: To build consensus among healthcare industry stakeholders on a set of operating rules that facilitate administrative interoperability between providers and health plans – Enable providers to submit transactions from the system of their choice (vendor agnostic) and quickly receive a standardized response – Facilitate administrative and clinical data integration • Recognized healthcare operating rule author by NCVHS and HHS Research and Develop Rules (based on key criteria) Maintain and Update Track Progress, ROI and Report Build Awareness and Educate Promote Adoption 6 © 2013 CORE. All rights reserved. Design Testing and Offer Certification Provide Technical Assistance, e.g., free tools, access to Early Adopters Base Examples of CORE Participants The more than 130 CORE Participants represent all key stakeholders including providers, health plans, vendors, clearinghouses, government agencies, Medicaids, standard development organizations, banks, etc. Providers Health Plans (Strong presence in Ohio markets) 7 © 2013 CORE. All rights reserved. Vendors Overview of ACA Mandated CAQH CORE Operating Rules 8 © 2013 CORE. All rights reserved. Industry Context: Federally Mandated Operating Rules • Today, operating rules support existing standards in many high-volume industries, e.g. cellular phones, financial services ...Consider the ATM • Prior to 2005, national operating rules for medical administrative transactions did not exist in healthcare outside of individual trading partner relationships • In 2005 CAQH CORE began facilitating voluntary development of industrywide healthcare operating rules • In 2010, Section 1104 of the Patient Protection and Affordable Care Act (ACA) required that all HIPAA covered entities be compliant with applicable HIPAA standards and associated operating rules The effective date for the first set of ACA mandated operating rules was January 2013; additional deadlines follow through 2016. 9 © 2013 CORE. All rights reserved. Industry Context: A Spectrum of Change For Providers • Goal: Generate a responsive, and adaptive, system-wide approach to administrative IT adoption that aligns with other U.S. healthcare strategic initiatives • Each major transaction in the revenue cycle was addressed by HIPAA in 1996; standards alone did not go far enough to reach Administrative Simplification – therefore, ACA amended HIPAA • Due to ACA and other pressures, during the next several years the entire revenue cycle process will experience significant transformation as the industry adopts operating rules – The exchange of data critical to a provider’s revenue cycle, e.g. patient financials – The infrastructure requirements that drive interoperability and ROI Health Plan 820 Premium Payment Provider 270 Eligibility Inquiry Membership 271 Eligibility Response Charge Capture Clinical O/E, Utilization Review 278 Referral Response Billing 837 Claim/Encounter 277 Request for Info 278 Referral Request 275 Claim Attachment A/R and Treasury 277 Status Response 835 Remittance (EOB) Bank © 2013 CORE. All rights reserved. Claim Adjudication 276 Status Inquiry CCD+ (EFT) 10 Pre-Adjudication A/P Enrollment 834 Enrollment Sponsor Purpose of Operating Rules • • The Patient Protection and Affordable Care Act (ACA) defines operating rules as “the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications” They address gaps in standards, help refine the infrastructure that supports electronic data exchange and recognize interdependencies among transactions; they do not duplicate standards Rights and responsibilities of all parties Security Exception processing 11 © 2013 CORE. All rights reserved. Operating Rules: Key Components Transmission standards and formats Response timing standards Liabilities Error resolution ACA Mandated Operating Rules Compliance Dates: Required for all HIPAA Covered Entities Operating rules encourage an interoperable network and, thereby, are vendor agnostic Compliance in Effect as of January 1, 2013 HIPAA covered entities conduct these transactions using the CAQH CORE Operating Rules Implement by January 1, 2014 • Electronic funds transfer (EFT) transactions • Health care payment and remittance advice (ERA) transactions Implement by January 1, 2016 • • • • • Rule requirements available. 12 • Eligibility for health plan • Claims status transactions © 2013 CORE. All rights reserved. Health claims or equivalent encounter information Enrollment and disenrollment in a health plan Health plan premium payments Referral certification and authorization Health claims attachments ACA Mandated Healthcare Operating Rules: First Set - Eligibility & Claim Status 13 © 2013 CORE. All rights reserved. Mandated Eligibility & Claim Status Operating Rules: Scope –Effective as of January 1, 2013 Enforcement Action Begins March 31, 2013 Mandated Eligibility & Claim Status Operating Rules Compliance date January 1, 2013 Type of Rule Addresses Data Content: Eligibility Need to drive further industry value in transaction processing Infrastructure: Eligibility and Claim Status Voluntary Eligibility & Claim Status Operating Rule CAQH CORE Eligibility & Claim Status Operating Rules More Robust Eligibility Verification Plus Financials Enhanced Error Reporting and Patient Identification Industry needs for common/ accessible documentation Companion Guides System Availability Industry-wide goals for architecture/ performance/ connectivity Response Times Connectivity and Security “We are addressing the important role acknowledgements play in EDI by strongly encouraging the industry to implement the acknowledgement requirements in the CAQH CORE rules we are adopting herein.” HHS Interim Final Rule Acknowledgements* *Please Note: In the Final Rule for Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transaction, CORE 150 and CORE 151 are not included for adoption. HHS is not requiring compliance with any operating rules related to acknowledgement, the Interim Final Rule. 14 © 2013 CORE. All rights reserved. ACA Federal Compliance Requirement Highlights: Eligibility and Claim Status Three dates are critical for implementation of the first set of ACA mandated Operating Rules There are two types of penalties related to compliance1 Key Area HIPAA Mandated Implementation Dates First Date January 1, 2013 Compliance Date Enforcement Date Extension March 31, 20134 Applicable Penalties Second Date December 31, 2013 Health Plan Certification Date Third Date No Later than April 1, 2014 Health Plan Penalty Date Who: Health plans Who: Health plans Action: Implement CAQH CORE Eligibility & Claim Status Operating Rules Action: File statement with HHS certifying that data and information systems are in compliance with the standards and operating rules2 Action: HHS will assess penalties against health plans that have failed to meet the ACA compliance requirements for certification and documentation2 Amount: Due to HITECH, penalties for HIPAA non-compliance have increased, now up to $1.5 million per entity per year Amount: Fee amount equals $1 per covered life3 until certification is complete; penalties for failure to comply cannot exceed on an annual basis an amount equal to $20 per covered life or $40 per covered life for deliberate misrepresentation Who: All HIPAA covered entities Description ACA-required Health Plan Certification 1 CMS OESS is the authority on the HIPAA and ACA Administrative Simplification provisions and requirements for compliance and enforcement. The CMS website provides information on the ACA compliance, certification, and penalties and enforcement process. 2 According to CMS, regulation detailing the health plan certification process is under development, and they will release details surrounding this process later this year; CAQH CORE will continue to offer its voluntary CORE Certification program and will share lessons learned with CMS as the Federal process is developed. 3 Covered life for which the plan’s data systems are not in compliance; shall be imposed for each day the plan is not in compliance 4 Per the Jan 2, 2013 CMS OESS announcement of the 90-day Period of enforcement extension Discretion for Compliance with Eligibility and Claim Status Operating Rules 15 © 2013 CORE. All rights reserved. Compliance with Eligibility & Claim Status Operating Rules: 90-Day Period of Enforcement Discretion • • • On January 2, 2013, CMS OESS* announced a 90-Day Period of Enforcement Discretion to reduce the potential of significant disruption to the healthcare industry Enforcement action will begin March 31, 2013 with respect to HIPAA covered entities (including health plans, health care providers, and clearinghouses, as applicable) that are not in compliance with the ACA mandated Eligibility and Claim Status Operating Rules OESS began accepting complaints associated with compliance with the operating rules on January 1, 2013 – If requested by OESS, covered entities that are the subject of complaints (known as “filed-against entities”) must produce evidence of either compliance or a good faith effort to become compliant with the operating rules during the 90-day period • For more information review CMS’s Administrative Simplification Enforcement Tool (ASET), which is a web-based application where entities may file a complaint against a covered entity for potential non-compliance related to Transactions and Code Sets and Unique Identifiers * CMS Office of E-Health Standards and Services (OESS) is the U.S. Department of Health and Human Services’ (HHS) component that enforces compliance with HIPAA transaction and code set standards, including operating rules, identifiers and other standards required under HIPAA by the Affordable Care Act. 16 © 2013 CORE. All rights reserved. Checkpoint #1: What do the Eligibility & Claim Status Operating Rules Mean for Providers? The ACA mandated Eligibility & Claim Status Operating Rules ensure realtime access to robust eligibility and claim status data for providers – How do providers benefit from the Eligibility and Claim Status Operating Rules? • More accurate patient eligibility verification: Real-time information on health plan eligibility and benefit coverage before or at the time of service – • • Improved point of service collections: Real-time provider access to key patient financials including YTD deductibles, co-pays, coinsurance, in/out of network variances via the ASC X12 v5010 270/271 transactions Decrease in claim denials: Real-time claim status data ensures provider is aware of status in billing process – – Providers experienced a 24% increase in electronic eligibility verifications* Providers experienced a 10-12% reduction in denials related to eligibility* How can my provider organization ensure we benefit from the Eligibility and Claim Status Operating Rules? • • Identify all systems and vendors that touch the ASC X12 v5010 270/271 and ASC X12 v5010 276/277 transactions Conduct internal gap analyses using the CAQH CORE Eligibility & Claim Status Operating Rules Analysis & Planning Guide and/or reach out to your vendors to ensure compliance * Based on the CAQH CORE Phase I Measures of Success Study when working with Phase I CORE Certified health plans. 17 © 2013 CORE. All rights reserved. Mandated Healthcare Operating Rules: Second Set - EFT & ERA 18 © 2013 CORE. All rights reserved. Mandated EFT & ERA Operating Rules: Required for All HIPAA Covered Entities • Healthcare EFT Standard: July 2012 CMS announces CMS-0024-IFC is in effect adopting the NACHA ACH CCD plus Addenda Record (CCD+) and the X12 835 TR3 TRN Segment as the HIPAA mandated healthcare EFT standard • EFT & ERA Operating Rules: August 2012: CMS published an Interim Final Rule with Comment, CMS-0028-IFC; adopts Phase III CAQH CORE Operating Rules for the Electronic Funds Transfer (EFT) and Health Care Payment and Remittance Advice (ERA) transactions except for rule requirements pertaining to Acknowledgements* Compliance date for both the Healthcare EFT Standard and EFT & ERA Operating Rules is January 1, 2014 * CMS-0028-IFC excludes requirements pertaining to acknowledgements. 19 © 2013 CORE. All rights reserved. CAQH CORE EFT & ERA Operating Rules in Action Indicates where a CAQH CORE EFT/ERA Rule comes into play Pre- Payment: Provider Enrollment EFT Enrollment Data Rule ERA Enrollment Data Rule Provider first enrolls in EFT and ERA with Health Plan(s) and works with bank to ensure receipt of the CORE-required Minimum ACH CCD+ Data Elements for reassociation Claims Payment Process Health Plan Health Care Claim Payment/Advice (835) Infrastructure Rule Claims Processing Payment/Advice (835) © 2013 CORE. All rights reserved. Provider Billing & Collections Electronic Funds Transfer (CCD+/TRN) Treasury Bank Stage 1: Initiate EFT 20 Uniform Use of CARCs & RARCs Rule Bank EFT & ERA Reassociation (CCD+/835) Rule Treasury Checkpoint #2: What do the EFT & ERA Operating Rules Mean for Providers? The ACA mandated EFT & ERA Operating Rules ensure more streamlined provider enrollment and processing of the EFT & ERA transactions – How will providers benefit from the EFT & ERA Operating Rules? • • • – Standardized electronic enrollment for EFT/ERA: Providers will be able to enroll in both EFT and ERA electronically with all health plans using a consistent set of data elements Potential reduction in manual claim rework: With health plans more consistently using denial and adjustments codes per the CORE-defined Business Scenarios, providers will have less rework Reduction in A/R days: Automated and timely re-association of EFT and ERA leading to efficiencies and reduced errors for payment posting How can my provider organization ensure we benefit from the EFT & ERA Operating Rules? • • Identify all systems and vendors that touch the ASC X12 v5010 835 and the Healthcare EFT Standard transactions Conduct internal gap analyses using the CAQH CORE EFT & ERA Operating Rules Analysis & Planning Guide and/or reach out to your vendors to ensure compliance * Based on the CAQH CORE Phase I Measures of Success Study when working with Phase I CORE Certified health plans. 21 © 2013 CORE. All rights reserved. Example: CAQH CORE Uniform Use of CARCs and RARCs Rule - Four Business Scenarios Pre CORE Rule 360 300+ RARCs 800+ CARCs 4 CAGCs Inconsistent Use of Tens of Thousands of Potential Code Combinations Four Common Business Scenarios Post CORE Rule 360 CORE Business Scenario #1: Additional Information Required – Missing/Invalid/ Incomplete Documentation (≈470 code combos) CORE Business Scenario #2: Additional Information Required – Missing/Invalid/ Incomplete Data from Submitted Claim CORE Business Scenario #3: Billed Service Not Covered by Health Plan CORE Business Scenario #4: Benefit for Billed Service Not Separately Payable (≈330 code combos) (≈30 code combos) (≈300 code combos) Code Combinations not included in the CORE-defined Business Scenarios may be used with other non-CORE Business Scenarios 22 © 2013 CORE. All rights reserved. Mandated Healthcare Operating Rules: Third Set – Attachments, Prior Authorization, Enrollment, etc. 23 © 2013 CORE. All rights reserved. Mandated Attachments, Prior Auths, Enrollment, etc.: Third Set • • 24 Remaining operating rule mandate, effective January 1, 2016, will address the following transactions: – Health claims or equivalent encounter information – Enrollment and disenrollment in a health plan – Health plan premium payments – Referral certification and authorization – Claims attachments Secretary of HHS recommended CAQH CORE as author for the remaining ACA mandated operating rules – Q1 2013: Key opportunities/out of scope areas being identified via research, survey findings, and call discussions – Q2 2013: Potential rule options will be developed, reviewed, and agreed upon by CORE Subgroups and Work Groups – Q3 2013: CORE Subgroup and Work Group discussion and straw polling will be conducted – Q4 2013: Detailed documentation of draft rule requirements by CORE Participants © 2013 CORE. All rights reserved. How to Contribute to Development of Third Set • Entities are encouraged to join CAQH CORE to directly contribute: – The most effective way for individual organizations to assure they have direct input on the mandated and voluntary operating rules is by becoming a CORE Participating Organization; any entity may join. Cost is extremely low or free. Benefits include: • Participation on Subgroup/Work Group rules-writing calls, surveys, straw polls, and ballots; eligibility to Co-Chair • Entity vote on CAQH CORE Operating Rules at Work Group and Full CORE Membership voting levels • Access to CAQH CORE Education Sessions specific to CORE Participating Organizations • Entities unable to join CAQH CORE can contribute via: – CAQH CORE Town Hall Calls • CAQH CORE holds bi-monthly Town Hall calls which provide attendees an update on recent activities including status of rule development; email email@example.com to be added to the distribution list – CAQH CORE Industry Surveys • CAQH CORE periodically conducts industry-wide surveys for directional feedback on operating rule opportunities; email firstname.lastname@example.org to be added to the distribution list 25 © 2013 CORE. All rights reserved. Engaging Vendors 26 © 2013 CORE. All rights reserved. The Importance of Industry Collaboration STREAMLINED ADMINISTRATIVE DATA EXCHANGE Health Plans CORERequired Data & Infrastructure Vendors/Clearinghouses (Vendors may not be HIPAA covered entities) V e n d o r - A g n o s t i c 27 CORERequired Data & Infrastructure Providers R u l e s • HIPAA-covered entities work together to exchange transaction data in a variety of ways • Vendors, often acting as business associates that provide services or process transactions on a provider’s behalf, play a crucial role in enabling provider clients to realize the benefits of industry adoption of CAQH CORE Operating Rules • Key steps to ensuring streamlined administrative data exchange: – Assess impacted systems/vendors: Understand which systems/vendors touch the administrative transactions – Engage with your vendors: Confirm with vendors compliance/ability to support ACA mandated operating rules as certain vendors, including PMSs, third-party billing companies, etc. are not considered HIPAA-covered entities rather they act as the provider’s business associate – Encourage voluntary CORE Certification: Work with your vendors to publicly confirm systems are conformant with applicable operating rules © 2013 CORE. All rights reserved. Analysis & Planning Guides Assist in Understanding Applicability of Rules to Various Trading Partners • • CAQH CORE offers two Analysis & Planning Guides (for Eligibility & Claim Status and EFT & ERA) which provide guidance for Project Managers, Business Analysts, System Analysts, Architects, and other project staff to complete systems analysis and planning for implementation of the CAQH CORE Operating Rules Guide should be used by project staff to: – Understand applicability of the CAQH CORE Operating Rule requirements to organization’s systems and processes that conduct the transactions – Identify all impacted external and internal systems and outsourced vendors that process the transactions – Conduct detailed rule requirements gap analysis to identify system(s) that may require remediation and business processes which may be impacted • The guides include three tools to assist entities in completing analysis and planning: – – – 28 Stakeholder & Business Type Evaluation Systems Inventory & Impact Assessment Worksheet Gap Analysis Worksheet © 2013 CORE. All rights reserved. Voluntary CORE Certification 29 © 2013 CORE. All rights reserved. Voluntary CORE Certification • Since its inception, CAQH CORE has offered a voluntary CORE Certification to health plans, vendors, clearinghouses, and providers – – Learn more about voluntary CORE Certification here Voluntary CORE Certification provides verification that your IT systems or product operates in accordance with the federally mandated operating rules • Certification and testing are separate activities – – Testing is completed by CORE-authorized testing entities and occurs on-line based on stakeholder-specific test scripts; test scripts developed by CORE participants Cost of testing and certification is extremely low or free • CORE Certification is a 4-step process: 1. Pre-certification Planning and Systems Evaluation: – – 2. Sign and Submit the CORE Pledge: – 3. Comprised of three phases: Pre-testing, Testing and Post-testing Testing is by stakeholder-specific test scripts by rule Apply for the CORE Certification Seal: – 30 Formally communicate your intent to pursue CORE Certification CORE Certification Testing: – – 4. Understand requirements of the CORE Operating Rules and scope your internal efforts to adopt rules CORE has free gap analysis tool; email CORE@CAQH.org Entities successfully achieving CORE Certification will receive a CORE “Seal” from CAQH that corresponds with the CORE Phase and stakeholder-type © 2013 CORE. All rights reserved. Measures of Success 31 © 2013 CORE. All rights reserved. CORE Measures of Success: Tracking ROI • CORE made an early commitment to track Measures of Success • Health Plans, vendors and providers that are pursuing voluntary CORE Certification are invited to participate in the ROI study – Also need participation from providers that are not CORE-certified, but trading data with CORE-certified entities • CAQH CORE contracted with IBM to conduct tracking and analysis – Analyze two 3-month measurement periods; volunteers asked to record expenses and then impact one year later • Outcomes available from health plans covering 33 million lives and their vendor and provider partners – Provider groups working with CORE-certified health plans saw 10-12% fewer claim denials and a 20% increase of patients verified prior to a visit – The time needed by vendors and clearinghouses to connect to trading partners significantly reduces with a common approach to connectivity 32 © 2013 CORE. All rights reserved. The Business Case: All Stakeholders • More robust and accessible data has and will continue to enhance the flow of information between providers and health plans • CAQH CORE Operating Rules help stakeholders leverage investments – Common infrastructure supports multiple methods and future transaction types – Solutions reusable with new partners • Streamlined implementation with CAQH CORE partners – Better technical skill and resources – Less customization, reduced testing – Lower cost connectivity using the public internet • Costs to implement CAQH CORE Operating Rules vary widely, depending on how much technology change is required * IBM assessed results achieved by Phase I CAQH CORE Operating Rules early adopters (represents 33 million covered lives and 1.2 million providers) 33 © 2013 CORE. All rights reserved. Checkpoint #3: Key Action Items for Providers Determine if your organization is conducting the applicable electronic transactions: – The ACA mandated operating rules only apply to providers if they are conducting the associated electronic transactions If you conduct the transactions, assess your organization’s readiness/compliance: Use the CAQH CORE Analysis & Planning Guides (for Eligibility & Claim Status and EFT & ERA) to help you assess impacted systems/vendors Speak with your PMS vendor* about their compliance/ability to support your practice Ask your clearinghouse(s) if the product(s) your practice uses is compliant (clearinghouses are HIPAA covered, and thus should already be compliant) If not already, encourage your vendors/clearinghouses to become voluntarily CORE-Certified to test conformance * REMINDER: PMSs are not HIPAA-covered entities, and thus are not mandated to be compliant - so provider requests are critical! 34 © 2013 CORE. All rights reserved. Additional CAQH CORE Resources • • Become a CORE Participant Join us for these free CAQH CORE Education Events held jointly with: – CMS OESS: “The Basics of Mandated Operating Rules for Providers” • – ASC X12: “Eligibility and Claims Status Transactions: A Deep Dive” • – Tuesday, March 26, 2013 from 2:00 pm to 3:30 pm ET NACHA: “Save the Date” for an in-depth look at the EFT Standard and EFT & ERA Operating Rules • 35 Wednesday, March 20, 2013 from 2:00pm-3:00pm ET Tuesday, April 10, 2013 from 2:00 - 3:00 pm ET • Review the CAQH CORE Operating Rules for free • Access general FAQs regarding the ACA operating rules mandate • Submit your questions to the CAQH CORE Request Process by emailing email@example.com © 2013 CORE. All rights reserved. Appendix 36 © 2013 CORE. All rights reserved. ACA Mandated Eligibility & Claim Status Operating Rules Infrastructure Data Content Rules Eligibility & Benefits Eligibility, Benefits & Claims Status High-Level CAQH CORE Requirements Respond to generic and explicit inquiries for a defined set of 50+ high volume services with: • Health plan name and coverage dates • Static financials (co-pay, co-insurance, base deductibles) • Benefit-specific and base deductible for individual and family • In/Out of network variances • Remaining deductible amounts • Enhanced Patient Identification and Error Reporting requirements • • • • • Companion Guide – common flow/format System Availability service levels – minimum 86% availability per calendar week Real-time and batch turnaround times (e.g., 20 seconds or less for real time and next day for batch) Connectivity via Internet and aligned with NHIN direction, e.g., supports plug and play method (SOAP and digital certificates and clinical/administrative alignment). Acknowledgements (transactional)* *NOTE: In the Final Rule for Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transaction, requirements pertaining to use of Acknowledgements are NOT included for adoption. Although HHS is not requiring compliance with any operating rule requirements related to Acknowledgements, the Final Rule does note “we are addressing the important role acknowledgements play in EDI by strongly encouraging the industry to implement the acknowledgement requirements in the CAQH CORE rules we are adopting herein.” 37 © 2013 CORE. All rights reserved. ACA Mandated EFT & ERA Operating Rules Data Content Rule Uniform Use of CARCs and RARCs (835) Rule • Identifies a minimum set of four CAQH CORE-defined Business Scenarios with a maximum set of CAQH CORE-required code combinations that can be applied to convey details of the claim denial or payment to the provider • • • Identifies a maximum set of standard data elements for EFT enrollment Outlines a flow and format for paper and electronic collection of the data elements Requires health plan to offer electronic EFT enrollment • Similar to EFT Enrollment Data Rule • Addresses provider receipt of the CAQH CORE-required Minimum ACH CCD+ Data Elements required for re-association Addresses elapsed time between the sending of the v5010 835 and the CCD+ transactions Requirements for resolving late/missing EFT and ERA transactions Recognition of the role of NACHA Operating Rules for financial institutions Claim Adjustment Reason Code (CARC) Remittance Advice Remark Code (RARC) Rule 360 EFT Enrollment Data Rule Rule 380 ERA Enrollment Data Rule Rule 382 Infrastructure High-Level Requirements EFT & ERA Reassociation (CCD+/835) Rule Rule 370 • • • • Health Care Claim Payment/Advice (835) Infrastructure Rule Rule 350 • • • Specifies use of the CAQH CORE Master Companion Guide Template for the flow and format of such guides Requires entities to support the Phase II CAQH CORE Connectivity Rule. Includes batch Acknowledgement requirements* Defines a dual-delivery (paper/electronic) to facilitate provider transition to electronic remits * CMS-0028-IFC excludes requirements pertaining to acknowledgements. 38 © 2013 CORE. All rights reserved.