Mandated for adoption by the Administrative Simplification provisions of the Patient Protection and Affordable Care Act of 2010 (ACA), operating rules are defined as “the necessary business rules and guidelines for the electronic exchange of information that are not defined in a standard or its implementation specifications.”
Operating rules support the standards that streamline electronic administrative transactions. For example, an operating rule may require that health or dental plans respond to a provider inquiry in real-time.
The Department of Health and Human Services (HHS) is required to adopt an operating rule for each adopted transaction standard. HHS is also required to identify organizations to develop and maintain the operating rules for the transactions, and in 2011 designated the Council for Affordable Quality Health Care Committee on Operating Rules (CAQH CORE) to develop operating rules for the adopted administrative transaction standards, but not those for retail pharmacy. To date, HHS has adopted operating rules for four transactions:
- Eligibility for a health plan (Phase I)
- Health care claim status (Phase II)
- Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) (Phase III)
Who Must Comply with Operating Rules?
All HIPAA-covered entities, including covered health care providers, health plans (including medical and dental plans) and health care clearinghouses, must comply with the operating rules. Trading partners and business associates must comply with mandated operating rules when they engage in the transactions, including with or on behalf of the covered entities.
Why Do We Need Operating Rules?
Operating rules support and complement standards to make electronic transactions consistent and predictable. Operating rules are intended to make transactions more efficient and require less manual work, like fewer phone calls and faxes—saving time and money for providers as well as for health and dental plans. With less time required for administrative tasks, providers can have more time for patient care.
Find Out More
Look for our next message on Phase I operating rules.
See our animated video short explaining operating rules from the provider perspective.
Check out the video short, CMS Compliance Review Program.
Visit the website at go.cms.gov/AdminSimp.