HIPAA operating rules

HIPAA Operating Rules Section of the Affordable Care Act (ACA) was enacted and amended in March 2010 and requires the adoption of a single set of operating rules for each of the transactions listed in the ACA.

There are several types of Operating Rules in CAQH CORE Phase I and Phase II and the rules surrounding the standard compliance of the data content are the type of rules that are implemented in the HIPAA Compliance Check module. Other categories of rules (such as rules governing response time and rules related to formatting of Implementation Guides) are not enforced by the Compliance Check module. These rules are expressed as if they were WEDI/SNIP Type 4 rules which allows them to be reported on the 999 Business Acknowledgement. By default these rues are disabled when the product is installed and must be manually enabled in order for these data extra checks to be performed.

The rule text reported on a failure of one of these rules will begin with an Operating Rule Indicator (“OR”) plus the phase of CAQH CORE which described the rule (“I” or “II”). For example:

“ORI - 2110C EB05 required when 2110C present”