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Operating Rules

The Administrative Simplification provisions under the Affordable Care Act (ACA) of 2010 require the Secretary to adopt operating rules for each HIPAA transaction. ACA defines operating rules as "…the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications…"

The compliance dates for use of the operating rules are:

Currently required:

  • eligibility for a health plan 
  • health claim status
  • electronic funds transfers (EFT)
  • health care payment and remittance advice (ERA)

January 1, 2016 for:

  • health care claims or equivalent encounter information
  • coordination of benefits
  • health plan enrollment/disenrollment
  • health plan premium payment
  • referral certification and authorization transactions

The purpose of operating rules is to add additional administrative simplification to the electronic standard transactions by requiring specific business actions so that the standards can be performed in a more uniform way.

Eligibility and Claim Status
On June 30, 2011, HHS adopted through an Interim Final Rule with Comments (IFC) operating rules for eligibility for a health plan and health care claim status transactions. The IFC was finalized by HHS on December 7, 2011.

Covered entities, as defined by HIPAA, must comply with the named operating rules as of January 1, 2013.

The IFC for EFT and ERA operating rules was published on August 10, 2012 and finalized by HHS on April 19, 2013.  Payers are required to comply with these operating rules as of January 1, 2014.