HIPAA covered entities, including providers, clearinghouses and payers, are required to comply with the Affordable Care Act (ACA) requirements to implement the CORE Phase I, Phase II, and Phase III Operating Rules:
- Phase I & II Eligibility and Claim Status Transactions (270/271)
- Phase III Electronic Fund Transfer (EFT) & Electronic Remittance Advice (ERA) (835)
Notifications to Providers and Trading Partners
New enrollment forms for EFT and ERA were created to conform to standard data elements, flow and format of data collection required by CORE Operating Rules 380 and 382. The processes for providers to follow to report a missing/late EFT or ERA were also published. See Provider Bulletin No. 14-28 for details.
The new forms and procedures apply only to Medicaid providers who submit transactions and receive payment through the MMIS.
Nebraska Medicaid is implementing HIPAA operating rules in two Administrative Simplification (AS) projects:
- AS Eligibility and Claims Status (Phase I & II): AS-ECS
- Track 1: Data Content changes required under Operating Rules for HIPAA 5010 Eligibility for a Health Plan 270/271 transactions were implemented July 28, 2013. See Provider Bulletin No. 13-51 for more details.
- Track 2: Nebraska Medicaid has contracted with Edifecs, Inc., to provide the technical solution for connectivity and real-time response operating rule requirements. Implementation of these capabilities is currently scheduled for November 2014.
- AS EFT/ Electronic Remittance Advice (Phase III): AS-EFT/ERA
- Track 1: Data Content changes affect the Uniform Use of Claims Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC) that are returned on the 835. Infrastructure changes affect EFT and ERA Enrollment data, and the reassociation of EFT and ERA using the NACHA CCD+ standard for EFT delivery. Dual delivery of remittance advices will also be part of this implementation. These changes were implemented June 18, 2014.
- Track 2: Connectivity operating rule requirements will be implemented after AS-ECS Track 2, as completing this is dependent on the infrastructure implemented in AS-ECS Track 2.
To assist in delivery of information, a dedicated email address has been created for questions and answers specific to the Administrative Simplification projects. This email address is: DHHS.ACAEDIAdminSimp@Nebraska.gov
Operating Rules Background
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.”
Operating rules build on existing standards to make electronic transactions more predictable and consistent, regardless of the technology. Rights and responsibilities of all parties, security, transmission standards and formats, response time standards, liabilities, exception processing, error resolution and more must be clearly defined in order to facilitate successful interoperability. Beyond reducing cost and administrative hassles, operating rules foster trust among all participants.
CMS under ACA, required adoption of the Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange® (CORE) Operating Rules. All CORE rules will build on applicable HIPAA requirements and other related standards.