Operating Rules for HIPAA Transactions

The Administrative Simplification provisions under the Affordable Care Act of 2010 require the Secretary to adopt operating rules based on recommendations from NCVHS, and with consultation with providers. The compliance dates for use of the operating rules are :

January 1, 2013 for
• eligibility for a health plan
• health claim status

January 1, 2014
• electronic funds transfers (EFT)
• health care payment and remittance advice (ERA)

January 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
• Electronic funds transfers (EFT) - compliance date is January 1, 2014
• Health care claims attachments – compliance date is January 1, 2016

CMS-0028-IFC:  HHS adopts operating rules for health care electronic funds transfers (EFT) and remittance advice August 07, 2012.  You can view the press release, and more information is available in this fact sheet.

A new FAQ on the applicability of Eligibility and Claim Status Operating Rules on e-prescribing has been posted.  

CMS-0032-IFC Notice to Industry Wednesday, December 7, 2011: The Interim Final Rule that adopts operating rules for the eligibility for a health plan and health care claim transactions is a final rule that is in effect now.  Plans to implement the operating rules should be underway.  You can view the full announcement.

CMS-0032-IFC:  HHS adopts operating rules for eligibility for a health plan and health care claim status transactions, June 30, 2011.  You can view the press release for more information.