CMS Adopts Two EDI Operating Rules

The Centers for Medicare and Medicaid Services has issued an interim final rule to adopt the first two in a series of "operating rules" that will tighten and make more uniform the HIPAA standards for electronic administrative/financial transactions.

Adoption of operating rules between 2013 and 2016 is mandated under the Affordable Care Act. Under the interim final rule, available here and being officially published on July 8, CMS adopts the CORE operating rules for the insurance eligibility verification/benefit determination and claim status transactions.

CORE is the Committee on Operating Rules for Information Exchange within CAQH, an alliance of industry stakeholders. The initiative also is working with the Electronic Payments Association, a banking group, to develop operating rules for electronic remittance advice and electronic funds transfer transactions covering non-retail pharmacy transactions.

The goal of CORE is to make electronic HIPAA transactions as easy to conduct as an ATM transaction and to provide far more information to providers than payers currently provide. Many eligibility inquiries today result in a provider getting a yes/no answer as to whether a patient has insurance coverage. Under the CORE rules, the payer will provide additional information, including benefit levels, co-pays and deductibles, to enable the provider to know the patient's payment responsibility at the point of service.

Under the Affordable Care Act, CMS must adopt rules for eligibility and claims status transactions by July 1, 2011, effective Jan. 1, 2013. Rules for electronic funds transfer and payment/remittance advice transactions must be adopted by July 1, 2012, effective Jan. 1, 2014. CMS must adopt rules for claims/encounters, enrollment/disenrollment, health plan premium payments, and referral certification /authorization by July 1, 2014, effective Jan. 1, 2016.

CMS through the interim final rule now is adopting the eligibility and claim status rules in their entirety--with the exception of acknowledgement functions, for which no current standards exist.

CMS will accept public comment on the interim final rule through the business day on Sept. 6. More information on CORE is available at


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