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New Rules for Electronic HIPAA Transactions Approved by CAQH CORE

Last week, the CAQH® Committee on Operating Rules for Information Exchange (CORE®) approved a new set of national rules for electronic HIPAA transactions, as part of Phase IV of the CAQH® CORE® Operating Rules.

The new rules for electronic HIPAA transactions cover four groups of healthcare business transactions – prior authorizations, employee premium payment, enrollment/disenrollment in health plans, and healthcare claims. The aim of the new rules is to facilitate the exchange of healthcare information, as mandated by the Affordable Care Act (ACA). The new rules will augment 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 times. Rules covering data content of transactions are due to be added to the Operating Rules at a later date.

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

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The completion of Phase IV is the result of 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 will be required to meet a number of basic expectations when exchanging data. Covered entities will be required to acknowledge that a transaction has been received, and will be required 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 amount of time of system availability to send and receive data. The new infrastructure requirements for data exchange also require a common format to be used when providing information about proprietary data exchange systems (via companion guides).

The new rules only introduce a set of minimum standards that must be adhered to. HIPAA-covered entities 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 benefits of electronic information exchange to their trading partners and help create a highly efficient system of healthcare data exchange.

The new rules will ensure that transactions take place quickly, 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 inevitable when these HIPAA transactions take place via phone or fax.

Phase IV has taken three years to complete, 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 are expected to be federally mandated for all HIPAA-covered entities (as has happened with phase I, II and III). Once the HHS mandates the rules, all HIPAA-covered entities – health plans, healthcare clearinghouses, healthcare providers and their Business Associates – will be required to comply with the new standards when conducting any of the above business transactions.

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

In a recent press release, 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 went on to say, “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 downloaded here

Author: Steve Alder is the editor-in-chief of HIPAA Journal. Steve is responsible for editorial policy regarding the topics covered on HIPAA Journal. He is a specialist on healthcare industry legal and regulatory affairs, and has several years of experience writing about HIPAA and other related legal topics. Steve has developed a deep understanding of regulatory issues surrounding the use of information technology in the healthcare industry and has written hundreds of articles on HIPAA-related topics.