ACA Federal Mandate for Healthcare Operating Rules

The Patient Protection and Affordable Care Act (ACA), Section 1104 “…establishes new requirements for administrative transactions that will improve the utility of the existing HIPAA transactions and reduce administrative costs.” ACA Section 1104 requires the Secretary of the Department of Health and Human Services (HHS) to adopt and regularly update standards, implementation specifications, and operating rules for the electronic exchange and use of health information for the purposes of financial and administrative transactions. ACA Section 1104 applies to HIPAA covered entities and business associates engaging in HIPAA standard transactions on behalf of covered entities.

Operating rules are defined in the Affordable Care Act as the “necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications." Operating rules specify the information that must be included when conducting standard transactions covered under HIPAA, making it easier for providers to use electronic means to handle administrative transactions.

View the CMS website for more detail on the Administrative Simplification provisions of the ACA.

Learn how CMS enforces Administrative Simplification requirements by watching this video.

ACA Section 1104 Transactions Requiring Operating Rules

ACA Section 1104 required development of operating rules to address and support administrative transactions covered under HIPAA. CAQH CORE is designated by the Secretary of the Department of Health and Human Services (HHS) as the Operating Rule Authoring Entity for the HIPAA-mandated administrative transactions.

Phases to Business Transactions Naming Conventions: Currently Adopted Operating Rules

In May 2020 CAQH CORE updated its phase-based operating rule structure to align with the business processes supported by the rules. Therefore, rather than five phases of operating rules spanning seven transactions, under the new structure there are seven sets of operating rules organized by healthcare business processes. This change aligns with current stakeholder operations, enhances flexibility to update requirements, enables more rapid and targeted rule development efforts, and eliminates the potential for an infinite number of future operating rule phases. As a result of this transition, the CAQH CORE Operating Rule naming and versioning conventions were updated. No substantive changes were made to the operating rules requirements. CAQH CORE has provided links to the federally mandated versions of the operating rules for reference below along with a crosswalk to the new naming and versioning conventions. Click here for more information on the new operating rules structure.