In the August 10, 2012 Federal Register, the Department of Health and Human Services (HHS) and its Center for Medicare & Medicaid Services (CMS) announced the HIPAA/ACA interim final rule with comment period (IFC) entitled “Administrative Simplification:  Adoption of Operating Rules for Health Care Electronic Funds Transfers (EFT) and Remittance Advice Transactions.” The operating rules build upon industry-wide health care electronic fund transfer standards that HHS adopted in January of this year. HHS estimates that when implemented by health plans, this rule is estimated to save the industry, primarily physician practices, between $300 million and $3.3 billion over the next ten years.

This is the third IFC in a series of rules that Section 1104 of the Affordable Care Act (ACA) requires HHS to issue over the course of several years to foster efficiencies in health care. The prior two IFCs dealt with:

  1. Operating rules electronic health care transaction related to eligibility and claim status. These were designed to make it easier for physician practices and hospitals to determine whether a patient is eligible for coverage and to ascertain the status of claim submitted to a health plan.  There are a number of infrastructure rules that are part of these operating rules as well, including connectivity, availability and real time requirements.  This rule is finalized and effective for covered entities beginning January 1, 2013.
  2. The standard for electronic health care claim payments made via EFT and for electronic remittance advice (ERA). This rule is finalized and effective January 1, 2014. The EFT standard applies to EFT transactions made through the ACH Network.

Under the IFC, operating rules include best business practices on how electronic transactions are transmitted and often target obstacles that physician practices and health insurers have with using electronic transactions. For instance, the IFC requires insurers to offer a standardized, online enrollment for EFT and ERA so that physicians and hospitals can more easily enroll with multiple health plans to receive those transactions electronically.  The IFC also requires health plans to send the EFT within a certain amount of days of the ERA, which helps providers reconcile their accounts more quickly.

Specifically, HHS is adopting the Phase III Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) EFT & ERA Operating Rule Set, including the CORE v5010 Master Companion Guide Template, for the health care EFT and remittance advice transaction (hereinafter referred to as the EFT & ERA Operating Rule Set), with one exception: HHS is not adopting Requirement 4.2, titled "Health Care Claim Payment/Advice Batch Acknowledgement Requirements," of the Phase III CORE 350 Health Care Claim Payment/Advice (835) Infrastructure Rule because that requirement requires the use of the Accredited Standards Committee (ASC) X12 999 acknowledgement standard, which has not been adopted by the Secretary as the HIPAA standard for electronic acknowledgement transactions.  There are several other key “rules” included in this set of operating rules, and CMS encourages industry to review these in depth from the links in the regulation.

The IFC is effective August 10, 2012. It may be viewed at https://www.federalregister.gov/articles/2012/08/10/2012-19557/administrative-simplification-adoption-of-operating-rules-for-health-care-electronic-funds-transfers. The comment period closes on Oct. 9, 2012. 

A fact sheet with technical information on the rule is found at http://www.cms.gov/apps/media/fact_sheets.asp.