CAQH CORE Operating Rules for Electronic Funds Transfer (EFT) & Electronic Remittance Advice (ERA)

Updates to the CORE EFT/ERA page

CORE recommends several substantive content and clarifying changes to the CAQH CORE Operating Rules for Electronic Funds Transfer (EFT) and Electronic Remittance Advise (ERA) website. The changes are outlined on Page 11-12 of the letter found at this link: CORE Submission for the 2024 ISA Open Comment Period.

CAQH CORE Operating Rules for EFT and ERA Updates

Updates to the CAQH CORE Operating Rules for EFT and ERA are on pages 8-10 in the attached document. CAQH CORE has proposed a substantive change of increasing the adoption level of these Operating Rules from three to four. Upwards of 67% of insured lives are covered under health plans that are currently CORE-certified on the CAQH CORE Operating Rules for EFT and ERA. Given that these rules are federally mandated it can be assumed that overall industry adoption is even higher. Therefore, CAQH CORE believes that is justified to increase the adoption level reflected in the 2023 ISA Reference Edition and web version. Other non-substantive changes have been accommodated for consistency, conciseness, and grammar and syntax. Changes are highlighted in gray with proposed deletions shown as strikethrough text.

CAQH CORE ISA Letter 2022_2.pdf

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CAQH CORE Comments to ONC ISA - Phase III

Aligning ISA with New Operating Rule Structure: In Spring 2020, CAQH CORE restructured its operating rules from phase-based rule sets to rule sets based on the business processes supported by the rules. No substantive changes were made to existing rule requirements. As a result of the restructuring, CAQH CORE recommends updates to the following sections of the ISA:

Operating Rules for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) for Payments and Remittance (Phase III) -- Payments & Remittance Operating Rules

ISA Comments from CAQH CORE 11.1.20 FINAL_2.pdf

CAQH CORE Comments to ONC ISA 2020 Reference Edition - Phase III

Statutory References for Operating Rules for Electronic Funds Transfer and Electronic Remittance Advice for Payments and Reconciliation (Phase III) 

CAQH CORE recommends ONC include the statutory reference in the subpage titled “Operating Rules for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA)” to enhance ease of use. Such reference would be (Incorporated by reference in § 162.920) after each of the five bullets. This would be consistent with language currently included in the ISA for Operating Rules to Support Eligibility Transactions (Phase I) and Operating Rules to Support Eligibility and Claim Status Transactions (Phase II). 
For example: 
 
Phase III Operating Rules for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) for Payments and Reconciliation include:  
(1) Phase III CORE 350: Healthcare Claim Payment/Advice (835) Infrastructure Rule (Incorporated by reference in § 162.920)

(2) Phase III CORE 360: Uniform Use of CARCs and RARCs (835) Rule (Incorporated by reference in § 162.920)

(3) Phase III CORE 370: EFT and ERA Reassociation (CCD+/835) Rule (Incorporated by reference in § 162.920)

(4) Phase III CORE 380: EFT Enrollment Data Rule (Incorporated by reference in § 162.920)

(5) Phase III CORE 382: ERA Enrollment Data Rule (Incorporated by reference in § 162.920)

CAQH CORE Comment Letter to ONC ISA_1.pdf

CAQH CORE Comments on 2018 Interoperability Standards Advisory

• “Operating Rules” should be included as one of the structures under “Type,” which presently only includes “Standard” or “Implementation Specification.” Although there are other utilities referenced in the ISA (e.g. Integrating the Healthcare Enterprise (IHE)’s Integration Profiles) that also technically do not meet the definition of either a standard or implementation specification, operating rules are distinct in this regard. The Centers for Medicare and Medicaid Services (CMS) notes, in its definition of operating rules, that they are “the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications” (emphasis added).

• The Phase IV CAQH CORE Operating Rules should be included given the inclusion of other non-mandated standards and implementation guides in the ISA. The Phase IV CAQH CORE Operating Rules, approved September 2015, include:
  • Phase IV CAQH CORE 450: Health Care Claim (837) Infrastructure Rule
  • Phase IV CAQH CORE 452: Health Care Services Review – Request for Review and Response (278) Infrastructure Rule
  • Phase IV CAQH CORE 454: Benefit Enrollment and Maintenance (834) Infrastructure Rule
  • Phase IV CAQH CORE 456: Payroll Deducted and Other Group Premium Payment for Insurance Products (820) Infrastructure Rule
  • Phase IV CAQH CORE 470: Connectivity Rule

• These operating rules build on the foundation established by previous CAQH CORE Operating Rules and expand the Phase I-III CAQH CORE infrastructure requirements to four additional transactions plus upgrade connectivity requirements. On July 6, 2016, the National Committee on Vital and Health Statistics (NCVHS), the statutory public advisory body to the HHS Secretary on health information policy, recommended that the Secretary of HHS strongly support voluntary industry adoption and use of the Phase IV CAQH CORE Operating Rules.

• CAQH CORE anticipates publication of the Phase V CAQH CORE Prior Authorization Operating Rules in Q2 of 2019. The purpose of these rules is to promote adoption of electronic prior authorizations ultimately resulting in timelier patient care. The new Phase V Rules should be included in the ISA once available.

(Above content is an except of the full CAQH CORE Comment Letter).