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Operating Rules

The Patient Protection and Affordable Care Act (ACA) refers to  operating rules as  necessary business rules and guidelines for the electronic exchange of information. It further clarifies that these rules are not defined by a standard or its implementation specifications

Operating rules make electronic transactions more predictable and consistent, regardless of the technology behind them. More than a cost saver, operating rules lend themselves to increased administrative efficiencies and foster commonality among participants.

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

Corresponding SWGs: EFT, 835, 27x

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