InstaMed Blog

What Are Operating Rules?

Under the Patient Protection and Affordable Care Act (PPACA), the Operating Rules (developed by CAQH CORE) define the guidelines and standards for making electronic healthcare transactions more predictable and consistent, so the industry can be more efficient.

Upcoming mandated Operating Rules include:

Eligibility and Claim Status: Phases I and II

Deadline for payer compliance: January 1, 2013

Why providers should care:

With mandated standards for electronic eligibility transactions, it will be easier for providers to connect to payers to verify patient eligibility automatically before or during patient visits.  This enables providers to submit cleaner claims to get paid faster and save the administrative time it takes to check eligibility manually.

The standards for claim status transactions enable providers to monitor the status of submitted claims to correct denials and post remittances more quickly.  Additionally, it enables providers to quickly identify deductibles owed to bill patients sooner.

Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA): Phase III

Deadline for payer compliance: January 1, 2014

Why providers should care:

The electronic funds transfer (EFT) regulations mandate that payers include the trace number with the EFT payment, which enables providers to reconcile payments and remittances automatically, reducing hours of administrative work for reconciliation.  And with more payers supporting electronic payments, providers will receive payments faster than paper checks.  Finally, by receiving fully reconciled remittances electronically, providers can access summary reports on all remittances to save administrative time and costs.

The Big Picture: By transmitting and accepting CORE-certified transactions, providers can save 40+ hours of administrative work per week, receive payer payments two to three times faster and reduce days in accounts receivable by 40 to 70 percent.

Check back for our upcoming post with tips on adopting Operating Rules.

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