Most Financial Institutions Impacted by Administrative Simplification Interim Final Rule with Comment

On August 10, the U.S. Department of Health and Human Services (HHS) Office of the Secretary released the Administrative Simplification: Adoption of Operating Rules for Health Care Electronic Funds Transfers (EFT) and Remittance Advice Transactions interim final rule with comment (IFC), adopting the Complete Set of Phase III CAQH CORE EFT & ERA Operating Rules, including the CORE v5010 Master Companion Guide Template.

Specifically, the IFC adopts the following rules:

The IFC did not adopt the Health Care Claim Payment/Advice Batch Acknowledgement Requirements in Section 4.2 of the CAQH CORE Rule 350.

The Impact on Financial Institutions

Financial institutions should understand how healthcare legislation and the new healthcare operating rules impact not only their customers but also their organization.

Of the five CORE Operating Rules adopted, the Phase III CORE EFT and ERA Reassociation Rule will have direct impact to financial institutions.

  • It requires health plans to proactively inform healthcare providers during EFT enrollment that the healthcare provider will need to contact its financial institution to arrange for the delivery of the CORE-required Minimum CCD+ Data Elements. It also states that the “Healthcare Provider must proactively contact its financial institution to arrange for the delivery of the CORE-required Minimum CCD+ Data Elements.”
  • It identifies three fields in the ACH CCD record that are used for reassociation of the ACH Entry and the Electronic Remittance Advice (ERA): 1) the Effective Entry Date field (CCD Record 5, Field 9); 2) the Amount field (CCD Record 6, Field 6); and 3) the Payment Related Information field (CCD Record 7, Field 3).
  • The new regulation was effective August 10, 2012 with a mandatory compliance date of January 1, 2014. Health Plans and Healthcare Providers can begin following the Phase III CORE Health Care Operating Rules immediately, but must comply no later than January 1, 2014.

In addition, the NACHA Operating Rules, Subsection 3.1.5.3, require financial institutions to provide payment-related information in the CCD addenda record to the Receiver if requested. All financial institutions must be able to deliver the CORE-required Minimum CCD+ Data Elements to the Healthcare Provider if requested.

Due to the CORE EFT & ERA Reassociation Rule, financial institutions that have healthcare providers as customers can expect an increase in requests to receive this information for reassociation.  The August IFC estimates that there are 708,842 Healthcare Providers in the U.S.  It further estimates that the current usage of EFT by the healthcare industry of 33 percent for all health care claim payments will rise to 84 percent by 2023. The combination of the percentage increase across a large number of entities would result in a significantly larger number of healthcare EFT payments received by RDFIs, for which reassociation information will be contained within the ACH record.

Healthcare Requests Enhancements to the NACHA Operating Rules

CAQH CORE and the healthcare industry have requested enhancements to the NACHA Operating Rules because of provider difficulties in receiving the information contained in the Payment Related Information field of the CCD addenda record.

Many healthcare providers bank with more than one financial institution, and providing consistent information via a secure, electronic channel would help reduce the time and costs associated with reconciliation of claim payment processing consistent with the goals of the Patient Protection and Affordable Care Act (ACA).

Included in Section 4.4 of the CAQH CORE EFT & ERA Reassociation (CCD+/835) Rule are the following requested enhancements to the CCD+ standard and the NACHA Operating Rules[1]

  • “Establish a standard format for the electronic delivery of the CORE-required Minimum CCD+ Reassociation Data Elements between the Healthcare Provider and its financial institution; include relation to CCD+”
  • “Require all financial institutions to deliver the CORE-required Minimum CCD+ Reassociation Data Elements to Healthcare Providers”
  • “Establish a standard connectivity “safe harbor”[2] for the delivery of the CORE-required Minimum CCD+ Reassociation Data Elements to Providers that aligns with current healthcare industry efforts”

The proposed rule, if approved by the voting membership, would add significant improvements to the efficiency with which healthcare payments are processed at a national level.

For more information on these and related topics, visit NACHA's website at nacha.org and NACHA’s healthcare microsite at healthcare.nacha.org.



[2] For this purpose, a “safe harbor” can be understood to be an approved method to comply with the rule.