Operating Rules: Key Takeaways

Operating Rules: Key Requirements and Getting to Compliance

To wrap up Operating Rules Week, today’s message summarizes Phase I, Phase II, and Phase III operating rule use requirements for electronic transactions—and provides tips for getting to compliance.

Key Requirements

Operating rules require health and dental plans to:

• Offer providers the option to enroll electronically for EFT and ERA (electronic funds transfer and remittance advice)
• Limit the amount of data required from providers enrolling in EFT or ERA
• Make uniform use of CARC and RARC codes to explain payment adjustments or denials
• Furnish data that allow providers to readily reassociate EFT and ERA transactions and facilitate auto-posting to accounts receivable
• Support real-time processing of eligibility and claims status transactions (for example, real-time responses to providers’ eligibility inquiries with coverage information about a specific service, including patient financial responsibility)
• Conform to batch processing requirements outlined in the eligibility and claimsstatus rules—if the entity offers batch processing
• Follow the format and flow of the CAQH CORE Master Companion Guide Template for any companion guides for EFT and ERA, claims status, and eligibility transactions
  

Resolving Compliance Issues

Health and dental plans experiencing challenges with operating rule compliance may want to:

• Engage a clearinghouse to assist with transactions
• Consult with their software vendor/IT team about system solutions
  

Covered entities have the option to file a complaint about compliance issues. CMS will investigate the complaint as delegated by HHS.