Changes to the NACHA Operating Rules and Guidelines

On October 31, 2012, the NACHA's voting membership approved amendments to the NACHA Operating Rules that support Health Plans’ and Providers’ use of the ACH Network for healthcare claims payments and payment-related information. The new Rules go into effect September 20, 2013.

Financial institutions should consider the new Rules in combination with the healthcare industry operating rules for Electronic Funds Transfers (EFT) and Electronic Remittance Advice (ERA) developed by the Council on Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE), in collaboration with NACHA, and the designation by the Department of Health and Human Services (HHS) of the CCD entry as the Healthcare EFT Standard transaction.   

Taken together, the complementary sets of rules provide for the efficient and standardized electronic payment of healthcare claims, and the reassociation of the payments with healthcare remittance information (“reassociation”), resulting in administrative simplification by Health Plans and Healthcare Providers.

Next Steps for Financial Institutions

The September 20 effective date gives financial institutions time to assess their readiness to send and receive healthcare CCD entries for and from Health Plans and Healthcare Providers. Health Plans will be working toward implementation of HHS’ January IFC and August IFC by their January 1, 2014 compliance deadline.

Originators and ODFIs can begin using the transaction identification and formatting standards outlined in the Rules earlier than the effective date. Use of the standards will not cause processing problems for RDFIs and Receivers. Similarly, RDFIs could begin offering an electronic option for the delivery or provision of payment-related information when they are ready.

Five Major Components of the Rule

Unique Identification of Healthcare EFTs

The new Rule requires Originators to clearly identify CCD Entries that are Healthcare EFT Transactions using a specific identifier. The presence or absence of this healthcare-specific indicator offers RDFIs certainty in distinguishing Healthcare EFTs from non-healthcare CCD Entries, allowing RDFIs to comply with the Rules, as well as specific processing requests from healthcare customers. Specifically, the Rules require Originators of Healthcare EFT Transactions to populate the Company Entry Description field of the CCD Entry with the value “HCCLAIMPMT.”

Additional Formatting Requirements for Healthcare EFT Transactions

For each CCD Entry that contains the healthcare indicator, the Originator is required to ensure that the CCD Entry complies with the following formatting requirements, which are necessary to provide Receivers (Healthcare Providers) with clear identification of the source and purpose of the payment.

Company Name: Requires an Originator of a Healthcare EFT Transaction to populate the Company Name field of the CCD Entry with the name of the health plan. In situations where an organization is self-insured, this field could contain the name of the organization’s third-party administrator that is recognized by the Healthcare Provider and to which the Healthcare Provider submits its claims.

Addenda Record and Payment-Related Information Requirements for Healthcare EFT Transactions:  Requires Originators to include an addenda record with each CCD Entry used for a Healthcare EFT Transaction. The Rule also requires Originators to populate the Payment Related Information field of such an addenda record with the ANSCI ASC X12 Version 5010 835 Reassociation Trace Number (TRN) data segment. Healthcare Providers need the TRN data segment, along with additional information contained within the Entry, to associate the Healthcare EFT with the ERA that is transmitted separately.

Delivery of Payment-Related Information (Reassociation Number)

An RDFI is required to provide or make available, either automatically (if such a service is established by the RDFI) or upon request by a Receiver that is a Healthcare Provider, all information contained within the Payment Related Information field of an Addenda Record transmitted with a CCD Entry that is a Healthcare EFT Transaction.

The RDFI will be required to provide or make available the Payment Related Information no later than the opening of business on the RDFI’s second Banking Day following the Settlement Date of the Entry.

Further, this Rule will require the RDFI to offer or make available to the Healthcare Provider an option to receive or access the Payment Related Information via a secure, electronic means that provides a level of security that, at a minimum, is equivalent to 128-bit RC4 encryption technology. The Rule clarifies that the new reassociation information delivery requirements apply to Heathcare EFTs that are sent to Non-Consumer Accounts of Receivers.

Addition of New EDI Data Segment Terminator

This Rule provides for the use of a second data segment terminator, the tilde (“~”), to any data segments carried in the Addenda Record of the CCD Entry. As the tilde is a valid character for ACH Entries, it should already be recognized as such by the ACH processing software. However, EDI translation software might need modification to recognize the tilde as a valid data segment terminator for the CCD Addenda Record and NACHA-approved banking conventions.

Healthcare Terminology within the NACHA Operating Rules

This Rule expands the defined terms within the NACHA Operating Rules to 1) incorporate three healthcare-specific concepts within their scope, and 2) define a Non-Consumer Account to ensure appropriate application of healthcare-specific rules by ACH participants.

For more information about healthcare payments, visit the ACH Rules vertical on NACHA’s website at www.nacha.org.