Electronic HIPAA Transactions: New Rules Approved by CAQH CORE

by | Sep 30, 2015

As part of Phase IV of the CAQH® CORE® Operating Rules, the CAQH® Committee on Operating Rules for Information Exchange (CORE®) recently approved new national rules for electronic HIPAA transactions.

These new rules for electronic HIPAA transactions govern four groups of healthcare business transactions – prior authorizations, employee premium payment, enrollment/disenrollment from health plans, and healthcare claims. The aim of the new rules is to allow the exchange of healthcare information, as mandated by the Affordable Care Act (ACA). The new rules will reinforce existing HIPAA administrative standards to ensure uniform transmission of electronic healthcare data.

Phase IV of the CAQH® CORE® Operating Rules address infrastructure requirements such as connectivity, system availability and response reaction times. Rules governing data content of transactions are due to be added to the Operating Rules later.

The approval process involves a vote on the proposed new rules by the subgroups and work groups charged with preparing the draft version of the Operating Rules. If the new rules pass the voting stage, they go before the AQH CORE Board for a final review and approval. Over 90% of participating groups took part in the vote, with 88% approving the new rules. The final board approval was passed unanimously.

The completion of Phase IV happened following three years of hard work by more than 140 participating organizations, which have given their input during the development process. Under the new rules, participants must meet a number of basic expectations when exchanging data. Covered bodies will be required to acknowledge that a transaction has been received, and will have to respond within a set time frame for both real-time and large scale record submissions. They must also offer a minimum of one common method of connectivity, and guarantee a minimal duration of time of system availability to send and receive data. The new infrastructure requirements for data exchange also require a common format to be implemented when providing information about proprietary data exchange systems (via companion guides).

The new rules only establish a set of minimum standards that must be complied with. HIPAA-covered bodies are expected to go further than the basic set of standards to ensure that electronic HIPAA transactions run smoothly. They are also expected to extend the advantages of electronic information exchange to their trading partners and help put in place a highly efficient system of healthcare data exchange.

The new rules will ensure that transactions take place speedily, eliminating the delays that are caused by lost healthcare claims and should reduce the number of errors made with prior authorization requests and enrollment/disenrollment transactions. These delays and errors are unavoidable when these HIPAA transactions take place via phone or fax.

Phase IV has taken three years to finish, and now it has received full board approval, the new rules will go to the Department of Health and Human Services’ Office for Civil Rights, where they should be federally mandated for all HIPAA-covered bodies (as has happened with phase I, II and III). Once the HHS mandates the rules, all HIPAA-covered bodies – health plans, healthcare clearinghouses, healthcare providers and their Business Associates – will have to comply with the new standards when conducting any of the above business transactions.

Now that the rules have been passed, CAQH® CORE® will get to work on formulating a set of implementation tools and educational resources to help HIPAA-covered bodies comply with the new standards. CAQH® CORE® is also offering a Certification Test Suite to permit HIPAA-covered bodies to demonstrate compliance. The voluntary certification program is under development and is due to be finalized in the coming months. The final certification program will be made available mid-2016.

In a recent press announcement, CAQH CORE Board Chair, George S. Conklin, explained the need for the new rules: “These operating rules are an important step in moving the healthcare system from manual to electronic business transactions.” He added, “When each entity in the process follows the operating rules, everyone benefits from reductions in costs, time and confusion.”

Full details of Phase IV of the CAQH® CORE® Operating Rules can be viewed here

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Patrick Kennedy

Patrick Kennedy is a highly accomplished journalist and editor with nearly two decades of experience in the field. With expertise in writing and editing content, Patrick has made significant contributions to various publications and organizations. Over the course of his career, Patrick has successfully managed teams of writers, overseeing the production of high-quality content and ensuring its adherence to professional standards. His exceptional leadership skills, combined with his deep understanding of journalistic principles, have allowed him to create cohesive and engaging narratives that resonate with readers. A notable area of specialization for Patrick lies in compliance, particularly in relation to HIPAA (Health Insurance Portability and Accountability Act). He has authored numerous articles delving into the complexities of compliance and its implications for various industries. Patrick's comprehensive understanding of HIPAA regulations has positioned him as a go-to expert, sought after for his insights and expertise in this field. Patrick's bachelors degree is from the University of Limerick and his master's degree in journalism is from Dublin City University. You can contact Patrick through his LinkedIn profile:

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