Eligibility, Claim Status Transactions Rule Finalized

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  • December 15, 2011
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In a surprise move, the U.S. Department of Health & Human Services (HHS) announced Dec. 7 that, after considering public comment, policies established in the “Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transactions” interim final rule would be finalized as is.

But don’t panic just yet. HIPAA-covered entities are not expected to comply with the full set of rules, which were developed by the Council for Affordable Quality Health Care – Committee on Operating Rules for Information Exchange (CAQH CORE).
“We emphasize that CMS-0032-IFC is a final rule that is in effect now, which means industry implementation efforts should be underway for the January 1, 2013 compliance date,” HHS said.  HHS says in their announcement, “We also reiterate, as discussed in the IFC, that we do not require compliance with certain rules within the full set of operating rules for eligibility and claim status transactions. Specifically, we do not require covered entities to comply with the CORE requirements for use of the acknowledgment standards, and we do not require covered entities to secure CORE certification or comply with any of the CORE certification policies. Any references in the adopted CORE operating rules that pertain to CORE certification and use of the acknowledgement standards may be accommodated voluntarily by covered entities and between willing trading partners, but are not required under HIPAA, nor subject to HIPAA enforcement actions.”
The Administrative Simplification provisions under the Affordable Care Act of 2010 require the secretary to adopt operating rules based on recommendations from NCVHS and consultation with providers. The compliance dates for use of the operating rules are:
Jan. 1, 2013 for:

  • eligibility for a health plan
  • health claim status

Jan. 1, 2014 for:

  • electronic funds transfers (EFT)
  • health care payment and remittance advice (ERA)

Jan. 1, 2016 for:

  • health care claims or equivalent encounter information
  • coordination of benefits
  • health plan enrollment/disenrollment
  • health plan premium payment
  • referral certification and authorization transactions

New standards must be adopted for:

  • EFT – compliance date is Jan. 1, 2014
  • Health care claims attachments – compliance date is Jan. 1, 2016
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