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.
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)
Nebraska Medicaid is pleased to announce that it has received a CAQH CORE® health plan certification seal and exchanges electronic administrative data in compliance with the CORE rules.
CAQH CORE®, the CORE-certification/Endorser Seals and logo are registered trademarks of CAQH® Copyright 2010, Council For Affordable Quality Healthcare®. All rights reserved.
Nebraska Medicaid mplemented 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: The technical solution for connectivity and real-time response based on Operating Rule requirements was implemented
March 9, 2015. See Provider Bulletin No. 15-10 for more details.
- AS EFT/ Electronic Remittance Advice (Phase III): AS-EFT/ERA
- Track 1: Data Content changes affected the Uniform Use of Claims Adjustment Reason Codes (CARC) and Remittance Advice Remark Codes (RARC) that are returned on the 835. Infrastructure changes affected 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 were also a part of this implementation. These changes were implemented June 18, 2014. See Provider Bulletin No. 14-24.
- Track 2: The technical solution for connectivity based on Operating Rule requirements was implemented May 18, 2015. See Provider Bulletin No. 15-16 for more details.
A dedicated email address is avaliable for questions and answers specific to the Administrative Simplification projects. This email address is: DHHS.ACAEDIAdminSimp@Nebraska.gov