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April 2013 Centers for Medicare & Medicaid Services (CMS) Finalizes the Adoption of Operating Rules for EFT and ERA Transactions

On April 19, 2013, CMS announced that the Administrative Simplification: Adoption of Operating Rules for Health Care Electronic Funds Transfers (EFT) and Remittance Advice Transactions Interim Final Rule with Comment Period (IFC) is a Final Rule that is in effect now. CMS made the decision not to change any of the policies in the IFC after careful review of all comments received.

CMS did note that the health care industry identified concerns regarding Claim Adjustment Reason Code (CARC) /Remittance Advice Remark Code (RARC) combination lists that create challenges for implementers. In order to address these concerns, CMS will publish a separate notice entitled, “CORE Code Combination Maintenance Process in the EFT & ERA Operating Rule Set.”

As it was noted in the August 2012 What’s New, “the new EFT/ERA standards and Operating Rules impact the electronic payment transmission mechanisms for TRICARE purchased care as a health plan and bill payer.”

To learn more about the EFT and ERA Transaction, click here. To download the EFT & ERA Operating Rule Set, visit http://www.caqh.org/.

January 2013 CMS Announces 90-Day Discretionary Enforcement Period for Compliance with Eligibility and Claims Status Operating Rules

On January 2, 2013, the Centers for Medicare and Medicaid Services’ (CMS) Office of E-Health Standards and Services (OESS) announced a 90-day discretionary enforcement period for compliance with the Eligibility for a Health Plan and Health Care Claims Status Operating Rules. The discretionary enforcement period means that OESS will not initiate enforcement action until March 31, 2013 for Health Insurance Portability and Accountability Act (HIPAA) covered entities that are not in compliance with the operating rules.

Although the compliance date of January 1, 2013 does not change, CMS initiated the 90-day discretionary enforcement period due to industry feedback that suggested a majority of HIPAA covered entities would not be ready to comply. While OESS will not take enforcement action during this period, it will still accept complaints regarding compliance with the operating rules. If requested by OESS, covered entities that are the subject of complaints must produce evidence of either compliance or a good faith effort to become compliant with the operating rules during the 90-day period.

To view the official CMS announcement of the 90-day discretionary enforcement period click here.

“On October 1, 2013, the Department of Defense established the Defense Health Agency (DHA) to manage the activities of the Military Health System. These activities include those previously managed by TRICARE Management Activity (TMA), which was disestablished on the same date. During the next several months, all TMA websites will change to reflect the new DHA. We appreciate your patience during this transition."
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