Operating Rules for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) for Payments and Reconciliation (Phase III)


CAQH CORE Comments on 2018 Interoperability Standards Advisory

  • “Operating Rules” should be included as one of the structures under “Type,” which presently only includes “Standard” or “Implementation Specification.” Although there are other utilities referenced in the ISA (e.g. Integrating the Healthcare Enterprise (IHE)’s Integration Profiles) that also technically do not meet the definition of either a standard or implementation specification, operating rules are distinct in this regard. The Centers for Medicare and Medicaid Services (CMS) notes, in its , that they are “the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications” (emphasis added).
  • The should be included given the inclusion of other non-mandated standards and implementation guides in the ISA. The Phase IV CAQH CORE Operating Rules, approved September 2015, include:
  • These operating rules build on the foundation established by previous CAQH CORE Operating Rules and expand the Phase I-III CAQH CORE infrastructure requirements to four additional transactions upgrade connectivity requirements. On July 6, 2016, the National Committee on Vital and Health Statistics (NCVHS), the statutory public advisory body to the HHS Secretary on health information policy, that the Secretary of HHS strongly support voluntary industry adoption and use of the Phase IV CAQH CORE Operating Rules.

  • CAQH CORE anticipates publication of the Phase V CAQH CORE Prior Authorization Operating Rules in Q2 of 2019. The purpose of these rules is to promote adoption of electronic prior authorizations ultimately resulting in timelier patient care. The new Phase V Rules should be included in the ISA once available.

(Above content is an except of the full CAQH CORE Comment Letter).