CMS issed new regulation that adopts operating rules for making health care claim payments electronically and describing adjustments to claim payments. The operating rules build upon industry-wide health care electronic fund transfer (EFT) standards that HHS adopted in January of this year.

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 rule announced today 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 rule 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.

This rule, Administrative Simplification:  Adoption of Operating Rules for Health Care Electronic Funds Transfers (EFT) and Remittance Advice Transactions were developed through extensive discussions with industry stakeholders. The rule adopts the Council for Affordable Quality Healthcare’s Committee on Operating Rules for Information Exchange (CAQH CORE) Phase III EFT & ERA Operating Rule Set, including the CORE v5010 Master Companion Guide Template, with the exception of Requirement 4.2 of the Phase III CORE 350 Health Care Claim Payment/Advice (835) Infrastructure Rule. Collectively, these rules are referred to as the EFT & ERA Operating Rule Set.

The effective date of this regulation is August 10, 2012.  All HIPAA-covered entities must be in compliance with the EFT & ERA Operating Rule Set by January 1, 2014.

Section 1104 of the Affordable Care Act (the Affordable Care Act) requires HHS to issue a series of regulations over the next five years for the purpose of streamlining health care administrative transactions, encouraging greater use of standards by providers, and making existing standards work more efficiently. This regulation is the third in that series. It adopts EFT and ERA operating rules that, when implemented by health plans, are estimated to save the industry, primarily physician practices, between $300 million and $3.3 billion over the next ten years.

Some of the future administrative simplification rules will address the adoption of:

• A standard unique identifier for health plans;
• A standard for claims attachments; and
• Requirements that health plans certify compliance with all HIPAA standards and operating rules.

A fact sheet with technical information on the rule is found here.