Payer Obligations

All providers of commercial health insurance benefits must comply with the CORE operating rules. The Committee on Operating Rules for Information Exchange (CORE) was proposed by CAQH(the Council for Affordable Quality Healthcare) 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. At has become law with the introduction of the Affordable Care Act (Obama Care)

CORE 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."

ACA Section 1104 applies to HIPAA covered entities and business associates engaging in HIPAA standard transactions on behalf of covered entities. The legislation requires that the standards and associated operating rules adopted by the Secretary will:

•	Enable the determination of an individual’s eligibility and financial responsibility for specific services prior to or at the point of care;

•	Be comprehensive, requiring minimal augmentation by paper or other communications;

•	Provide for timely acknowledgement, response, and status reporting that supports a transparent claims and denial management process (including adjudication and appeals);

•

Describe 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).

Section 1104 of the Patient Protection and Affordable Care Act (ACA) mandates a certification process for health plans only.

Per the ACA, health plans must file a statement with HHS, in such form as the Secretary may require, certifying that their data and information systems are in compliance 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 Phase II of the CORE Operating Rules) was 1/1/2013, 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 (MPRM) on the ACA-mandated health plan certification. The Department of Health and Human Services (HHS) accepted public comments on the NPRM through April 3, 2014 (previously March 3, 2014). The NPRM includes health plan certification requirements for the eligibility, claim status, electronic funds transfers (EFT), and electronic remittance advice (ERA) transactions.