Frequently Asked Questions

  ADA/508 friendly site



FAQ

By Topic: HIPAA Administrative Simplification Subtopic: Affordable Care Act


What is meant by “certification of compliance” with HIPAA operating rules and standards?
Certification of compliance” refers to the requirements in section 1173(h) of the Social Security Act (which was added b... (more)

What is the trace number segment (TRN Segment) that is required in an electronic funds transfer for health ...
The TRN Segment is a series of three data elements, plus one situational data element, that matches the TRN Segment in t... (more)

Are HIPAA covered entities required to use the ACH Network to transmit and receive health care claim paymen...
No.  As of January 1, 2014, health plans and providers are not prohibited from using other networks such as Fedwire... (more)

Does a health plan that uses a bank or clearinghouse to format its health care electronic funds transfer (E...
Yes. As of January 1, 2014, if a health plan uses a clearinghouse or financial institution to format non-standard dat... (more)

Since the January 1, 2014 compliance date for the operating rules for the health care electronic funds tran...
Providers have a number of choices for receiving health care payments from health plans, including Electronic Funds T... (more)

What do health plans have to do to comply with the health care electronic funds transfers (EFT) standards a...
As of January 1, 2014, health plans must use the CCD+Addenda as the format that they send to their bank to initiate an E... (more)

If an individual (i.e., a subscriber or a patient) uses his or her credit or debit card to pay for premiums...
The HIPAA standards must be used by “covered entities,” which are health plans, health care clearinghouses and health ca... (more)

If a health plan does not conduct a particular HIPAA transaction – for example, the health care claim statu...
If a covered entity is required to comply with the standards for a particular transaction, then the covered entity is... (more)

What is the ACH Network?
The ACH Network is the Automated Clearing House (ACH) Network, one of the networks through which electronic funds transf... (more)

Do the CAQH CORE Phase I and Phase II Operating Rules for the Eligibility for a Health Plan and Health Care...
No, the CAQH CORE Phase I and Phase II operating rules for the Eligibility for a Health Plan and a Health Care Cl... (more)

What do providers have to do to comply with the health care electronic funds transfers (EFT) standards adop...
There are no requirements in the January 10, 2012 interim final rule that apply directly to providers.  The heal... (more)

Are the health care electronic funds transfers (EFT) standards, adopted in the interim final rule Administr...
 Yes.  As of January 1, 2014, whenever a health plan transmits an electronic  health care claim paymen... (more)

Can providers require both paper and electonic remittance advice (ERA) from a health plan?
Yes, according to the CAQH CORE EFT & ERA Operating Rule Set, providers can request both paper and electronic remitt... (more)

What is the applicability of CORE “safe harbor"?
The Phase I CORE 153 Connectivity Rule, Version 1.0.0 provides business rules and guidelines for what CORE refers to ... (more)

When is the ASC X12 835 ( payment and remittance advice) standard required when conducting electronic funds...
The ASC (Accredited Standards Committee) X12 835 TR3 standard is required when a health plan transmits payment informati... (more)

Do the HIPAA transaction requirements, including the operating rules, apply to transactions between a healt...
No, the HIPAA transaction requirements, including the operating rules, generally apply to electronic transactions betwee... (more)

Are there standard requirements for health plans when they use the ACH Network to pay health care claims vi...
Yes.  As of January 1, 2014, health plans must use the CCD+Addenda as the format that they send to their bank to... (more)

Do the operating rules for eligibility for a health plan transaction adopted in July 2011 under the Afforda...
No. CMS did not adopt operating rules for e-prescribing transactions. E-prescribing is not an adopted HIPAA transaction.... (more)

Is CORE certification required for covered entities to be compliant with the CORE operating rules for eligi...
No. We do not require compliance with any aspect of CORE certification. CORE currently administers a voluntary certifica... (more)

What is the compliance date for the provisions in the Administrative Simplification:  Adoption of Stan...
January 1, 2014. ... (more)

Who is required to comply with the adopted operating rules for claims status and eligibility under the Affo...
All covered entities as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) are required ... (more)

If a health plan cannot be certain whether an individual will be covered for a particular claim or what the...
Health plans must comply with the adopted operating rules and standards for the eligibility for a health plan transac... (more)

If a health plan's product is not designed to require co-pays, deductibles, and/or co-insurance, is the hea...
Health plans must comply with the adopted operating rules and standards for the eligibility for a health plan transac... (more)

Is a health plan or provider compliant with the HIPAA transactions and code sets regulations if a clearingh...
If a covered entity chooses to use a business associate to conduct transactions on its behalf, the covered entity mus... (more)

In which version of the NACHA Operating Rules & Guidelines do I find the implementation specifications ...
The CCD+Addenda implementation specifications are detailed in the 2011 NACHA Operating Rules & Guidelines.  ... (more)

Do federal requirements pre-empt state requirements for compliance with the adopted operating rules for eli...
When a state requirement related to the eligibility for a health plan or health care claim status transactions is contra... (more)

What is the relationship between an operating rule and a standard?
Operating rules support the adopted standards for health care transactions by fostering and enhancing uniform use of ... (more)

Where can I get answers to technical questions and help with implementing the ASC X12 5010 TR3 Reports, NCP...
For technical questions about the ASC X12 transactions and standards, the Accredited Standards Committee (ASC) X12 pr... (more)

Has a standard format for health plan companion guides been adopted for any of the adopted transaction stan...
Yes.  The interim final rule, “Administrative Simplification: Adoption of Operating Rules for Eligibility for a ... (more)

Does compliance with operating rules apply to HIPAA transactions conducted within the same corporate entity...
Yes. Covered entities must conduct standard transactions, which includes using the adopted operating rules, when transmi... (more)

What is an operating rule for a transaction and how is it different from a transaction standard?
In the interim final rule, “Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health P... (more)

If a state Medicaid agency does not have deductibles, but has “spend downs,” does it have to return the spe...
There are no HIPAA operating rules that address spend down amounts.... (more)

Do the HIPAA requirements for the eligibility for a health plan transaction and health care claims transact...
No, under the definition of "health plan" at 45 CFR 160.103, issuers of long-term care nursing home fixed indemnity poli... (more)

Who is the authoring entity for the operating rules for eligibility and claims status transactions?
The Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) is the... (more)

Is the use of the e-prescribing transaction affected by the operating rules for eligibility transactions ad...
See revised FAQ# 7357.... (more)

Have operating rules been adopted for all of the HIPAA transactions for which the Secretary has adopted a s...
No. Operating rules have been adopted so far for the eligibility for a health plan transaction and the health care claim... (more)

Do the CORE operating rules for eligibility apply only to real time transactions?
No. The CORE operating rules apply to both real time and batch transactions as specified in each of the respective opera... (more)

Are there adopted operating rules for the retail pharmacy eligibility transaction?
No. The National Council for Prescription Drug Programs (NCPDP), Version D.0 Telecommunication standard provides enough ... (more)

Are there adopted operating rules for acknowledgements transactions?
No. While there are standards for acknowledgments, and these may be used on a voluntary basis between willing trading pa... (more)