From HFMA: Engaging in operating rule development and adoption amidst the era of healthcare automation
Over two decades ago, HIPAA aimed to streamline healthcare administration by mandating electronic standards for common revenue cycle transactions, including eligibility, claims, payment and remittance advice. Despite implementation, industrywide variation persisted, hindering automation goals. CORE emerged to develop operating rules, or business rules, to address these challenges.
In 2009, the Affordable Care Act recognized the concept of operating rules, defining them as “the necessary business rules and guidelines for electronic exchange of information that are not defined by a standard or its implementation specifications.” Shortly thereafter, the secretary of HHS designated CORE as the national operating rule authoring entity under HIPAA.
Today, CORE has eight sets of operating rules that enhance electronic transactions and simplify administrative tasks developed by participating healthcare organizations. HHS has mandated three rule sets through regulation, and in 2023, the National Committee on Vital and Health Statistics (NCVHS) recommended additional rules for mandate, focusing on:
- Benefit coverage
- Telehealth
- Prior authorization
- Value-based payment
Operating rules play a pivotal role in automating administrative transactions, contributing to annual industry savings of $193 billion.