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All providers of commercial health insurance benefits must comply with the Committee on Operating Rules for Information Exchange (CORE), which was proposed by the Council for Affordable Quality Healthcare (CAQH). CORE operating rules were created as an initiative to develop a solution that enables consistent provider access to healthcare administrative information before or at the time of service, using their choice of electronic system.

 

What is ACA?

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."

 

ACA Section 1104 applies to HIPAA-covered entities and business associates engaging in

HIPAA standard transactions on behalf of covered entities. ACA Section 1104 also mandates a certification process for health plans only. The legislation requires that the standards and associated operating rules adopted by the Secretary will:

oEnable the determination of an individual’s eligibility and financial responsibility for specific services before or at the point of care;

oBe comprehensive, requiring minimal augmentation by paper or other communications;

oProvide for timely acknowledgment, response, and status reporting that supports transparent claims and denial management process (including adjudication and appeals); and

oDescribe all data elements (including reason and remark codes) in unambiguous terms, require that such data elements be required or conditioned upon set values in other fields, and prohibit additional conditions (except where necessary to implement State or Federal law, or to protect against fraud and abuse.)

 

Per the ACA, health plans must file a statement with the Department of Health & Human Services (HHS), in such form as the Secretary may require, certifying that their data and information systems comply with any applicable transaction standards and associated operating rules; financial penalties for health plans are significant.

 

The adoption deadline for Eligibility and Claim Status EDI transactions (included in Phase I and II of the CORE Operating Rules) was January 1, 2013. So far, the HHS has not enforced this deadline with penalties, and affected entities are still in the implementation phase.

 

On December 31, 2013, HHS issued a Notice of Proposed Rulemaking (NPRM) on the ACA-mandated health plan certification, and accepted public comments on the NPRM through April 3, 2014 (previously March 3, 2014).