The Affordable Care Act mandated better standardization of the electronic HIPAA administrative and financial transactions that providers and insurers commonly exchange as part of the reimbursement process.

In 2012-2013, the first revamped transactions were released; covering eligibility, claim status, electronic funds transfer and remittance advice transactions. Now, four additional transaction sets—made more uniform and including a higher emphasis on data exchange than previously—have received approval.

Initial tests will start soon followed by beta testing in the second quarter of 2016, and availability expected in the summer. Work on the transactions is being done by the CAQH Committee on Operating Rules; CAQH is an industry stakeholder collaborative.

The new transactions, in what is called the Phase IV CAQH CORE Operating Rules, are claims and encounters, prior authorization, employee premium payment, and enrollment and disenrollment in a health plan. CAQH has some vendors and health plans lined up to test but is accepting additional volunteers. The testing will be done with electronic data interchange testing firm Edifecs and other testing vendors are welcome to the table, says Gwen Lohse, CORE managing director.

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Congress in the ACA mandated adoption of CORE operating rules for HIPAA transactions as they are made available. The first four in 2013-2014 were mandated following a rulemaking process, although industry compliance has been spotty. Under congressional intent, the new transactions also are to be mandated, but no final rules have been published because the National Committee on Vital and Health Statistics, a federal advisory body, has not yet made a recommendation on mandating. Consequently, the transaction sets may be voluntary at the start, but could later be mandated, Lohse says.

Already, the four new operating rules are available on paper and CAQH has comprehensive guidance on its website here. Data exchange enhancements include a common, Internet-based method to connect with trading partners in additional to proprietary data exchange processes that may already be in use. There also are new performance requirements governing uptime on insurance websites and the payers also must track downtime and have the ability to communicate to stakeholders if they will be down longer than expected, according to Lohse.

Other performance requirements include acknowledging receipt of transactions from providers and specific response times expected for real-time and batch transactions. Further, a common format for payer and vendor CORE documentation will make it easier for providers to know where certain information is in a document because specific sets of information will be in the same area of all payer and vendor documentation.

Two other transactions—coordination of benefits and claims attachments—are among those that are to be made more uniform, but there is not yet enough industry consensus on the processes.

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