Operating Rules for EFT/ERA on the Horizon

The Centers for Medicare and Medicaid Services plans to soon publish an interim final rule to require adoption of standards and "operating rules" for electronic funds transfer and remittance advice HIPAA transactions.

CMS has sent the rule to the Office of Management and Budget for review, which is one of the last steps before publication. Operating rules are designed to 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.

CMS in July 2011 published an interim final rule adopting operating rules for the insurance eligibility verification/benefit determination and claim status transactions. The Committee on Operating Rules for Information Exchange within CAQH, an alliance of industry stakeholders is developing many of the operating rules. CORE is working with the Electronic Payments Association, a banking group, to develop the 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. For instance, many eligibility inquiries sent today to insurers 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.