What do the Healthcare EFT Standard and EFT & ERA Operating Rules Mean for Providers?

The Patient Protection and Affordable Card Act (ACA) mandated the identification of a HIPAA standard for electronic funds transfer (EFT) and the development of operating rules to support the HIPAA standards for EFT and Electronic Remittance Advice (ERA).  The goal of the HIPAA standards and operating rules is to standardize transactions, automate the process through the use of computer-to-computer transactions, reduce manual processing to improve back office processing, and improve customer service. 

The healthcare EFT standard for payments processed through the ACH Network was identified as the NACHA CCD+Addenda.  The Addenda Record of the CCD must contain the TRN Reassociation Trace Number as defined by ASC X12 in the 835 TR3 version 5010 implementation guide.  The TRN Reassociation Trace Number is used to match the ACH payment to the ERA remittance information.  Use of the identical TRN Reassociation Trace Number in the ACH and ERA allows the providers to automate the reconciliation of the payment and remittance information and potentially enable straight-through processing, depending on the providers accounting capabilities.      

In addition to automatic reassociation, providers can experience a number of other benefits by using the healthcare EFT standard: 

  • Faster receipt of payments and improved cash flow
  • Improved efficiencies
  • Reduced costs
  • Reduced potential for fraud

What does all this mean to healthcare providers?  Providers have the right under HIPAA to request and receive any HIPAA standard transactions, including the healthcare EFT standard, from all health plans.  Federal regulations 45 CFR §162.925 requires that health plans deliver a HIPAA standard transaction, if it is requested by the provider.  As provider, you can request to receive your claims reimbursement payments via the ACH Network effective January 1, 2014 and the health plans must deliver it to you promptly. Comments from Matthew Albright, Director of the Administrative Simplification Group of the Office of E-Health Standards and Services (OESS) at CMS, stated during a CAQH CORE CMS OESS Open Mic Session on December 17 “that health plans may not incentivize a provider to use an alternate transaction method other than the adopted standard or disincentivize a provider from using a standard transaction.” If a health plan can not or will not deliver claims reimbursement payments to you using the healthcare EFT standard, a HIPAA violation can be filed with CMS. 

The healthcare EFT & ERA Operating Rules were developed in collaboration with NACHA and CAQH CORE to address some barriers to provider adoption of EFT & ERA.  Before the Operating Rules were developed, NACHA and CAQH CORE conducted research to identify barriers to EFT & ERA adoption by providers.  The EFT & ERA operating rules addressed the some of the challenges regarding EFT & ERA enrollment, reassociation of EFT & ERA, standardized use of the CARCs and RARC codes for specific business scenarios, and standardized connectivity.  

Mandated EFT & ERA Operating Rules:
January 1, 2014 Compliance Date




Rule

High-Level Requirements

Data Content

Uniform Use of CARCs and RARCs (835) Rule
Claim Adjustment Reason Code (CARC)
Remittance Advice Remark Code (RARC)

Rule 360

•Identifies a minimum set of four CAQH CORE-defined Business Scenarios with a maximum set of CAQH CORE-required code combinations that can be applied to convey details of the claim denial or payment to the provider

Infrastructure

EFT Enrollment Data Rule

Rule 380

•Identifies a maximum set of standard data elements for EFT enrollment
•Outlines a flow and format for paper and electronic collection of the data elements
•Requires health plan to offer electronic EFT enrollment

ERA Enrollment Data Rule

Rule 382

•Similar to EFT Enrollment Data Rule

EFT & ERA Reassociation (CCD+/835) Rule

Rule 370

•Addresses provider receipt of the CAQH CORE-required Minimum ACH CCD+ Data Elements required for re-association
•Addresses elapsed time between the sending of the v5010 835 and the CCD+ transactions
•Requirements for resolving late/missing EFT and ERA transactions
•Recognition of the role of NACHA Operating Rules for financial institutions

Health Care Claim Payment/Advice (835) Infrastructure Rule

Rule 350

•Specifies use of the CAQH CORE Master Companion Guide Template for the flow and format of such guides
•Requires entities to support the Phase II CAQH CORE Connectivity Rule.
•Includes batch Acknowledgement requirements*
•Defines a dual-delivery (paper/electronic) to facilitate provider transition to electronic remits

For healthcare providers, the new EFT & ERA Operating Rules will help improve the EFT & ERA enrollment process by standardizing the specific data elements and format used on the enrollment forms and requires the health plans to offer an electronic enrollment option.  The EFT & ERA Reassociation Rule mandates that the EFT & ERA be originated within three business days to eliminate the delay in receiving both parts of the payment transactions and requires health plans to develop a reporting process if part of the transaction is not received by the provider. 

To learn more, visit healthcare.nacha.org or CAQH CORE for additional information and resources.