CMS Pub. 100-04, ch. 24, § 40.2.7

The Secretary of Health and Human Services (HHS) adopted HIPAA transaction

Operating Rules under section 1104(b) (2) of the Administrative Simplification provision

of the ACA, requiring covered entities to comply with new administrative transaction

standards. The purpose of the Administrative Simplification provision is to establish

national standards for the electronic transfer of healthcare information. The Operating

Rules are targeted at simplifying administrative processes, and reducing administrative

burden and costs for both providers and payers.

The Operating Rules were designed to be added to existing electronic transmission

standards for the processing of health information and administrative transactions. The

Council for Affordable Quality Healthcare’s (CAQH) Committee on Operating Rules for

Information Exchange (CORE) was chosen as the operating rules authoring entity for

eligibility and healthcare claim status standard transactions. CORE released three phases

of operating rules.

A/B MACs, DME MACs, CEDI or other contractors if designated by CMS are

responsible for supporting the implementation and adherence to the CAQH CORE

Operating Rules for electronic transactions, including but not limited to all future

operating rules. This support includes implementing necessary changes via Technical

Direction Letters as well as Change requests (CRs) and participating in development

meetings with CMS to ensure compliance for the Operating Rules.