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American Association of Oral and Maxillofacial Surgeons

Practice Management & Allied Staff News & Materials

HIPAA Transaction Operating Rules

April 29th, 2013

The Affordable Care Act (ACA) requires all HIPAA covered entities to be compliant with the applicable HIPAA standards and associated operating rules. The ACA defines the operating rules for the HIPAA transaction standards as "the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications". There are three sets of operating rules that were created by the Committee on Operating Rules for Information Exchange (CORE). CORE is an initiative implemented by the Council for Affordable Quality Healthcare (CAQH). The CAQH describes the operating rules as an addition to existing standards to make electronic transactions more predictable and consistent, regardless of the changing technology. Beyond reducing cost and administrative hassles, operating rules foster trust among all participants.

The CAQH CORE operating rules will offer physician practices the ability to determine a patient's eligibility and financial responsibility for specific services prior to or while the patient is still in the office so they may accept payment from patients at the time of service. Electronic eligibility verification will now provide the patient's co-payment, co-insurance and remaining deductible amounts, while the claim status feature will provide for timely acknowledgment and status reporting, including error and remark codes.

The first set of operating rules (Phase I and Phase II), implemented on January 1, 2013 were enforced March 31, 2013. Phase I and Phase II specify eligibility and claim status for HIPAA covered entities. More information on the first two phases can be found below:

The second set of operating rules (Phase III) has a compliance date of January 1, 2014 for all HIPAA covered entities. Phase III is for the implementation of the national operating rules for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA). More information on Phase II can be found below:

The third and final set of HIPAA operating rules effective as of January 1, 2016, will mandate health claims or equivalent encounter information, enrollment and disenrollment in a health plan, health plan premium payments, referral certification and authorization, and claims attachment. The third set of HIPAA operating rules is not categorized as a specific phase. More information on the third set of rules that will be implemented in 2016 can be found on the CAQH Timeline at http://www.caqh.org/ORMandate_timeline.php.

The CORE Phase descriptions can be found at on the Operating Rules page of the CAQH website at http://www.caqh.org/CORE_operat_rules.php. Those providers that electronically check patient eligibility or claims status are encouraged to work with their software vendors and/or clearinghouses to determine readiness.