Operating Rules Overview
Guidance for the operating rules required by the Patient Protection and Affordable Care Act.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: August 10, 2020
What Are Operating Rules?
Operating rules, which are required by the Patient Protection and Affordable Care Act, are defined as “the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications.”
Operating rules set certain requirements for transactions that are covered by HIPAA. They specify the information that must be included when conducting standard transactions, making it easier for providers to use electronic means to handle administrative transactions.
CAQH CORE is the authoring entity of the operating rules currently adopted by HHS.
Introduction to Administrative Simplification (Video)
This 3-minute operating rules video offers a quick overview for providers.
Compliance Schedule
- January 1, 2013: Compliance date for Eligibility of a Health Plan and Health Claim Status
- View the Interim Final Rule and Operating Rules
- January 1, 2014: Compliance date for Health Care Electronic Funds Transfers (EFT) and Remittance Advice (ERA)
- View the Final Rule and Operating Rules for EFT and ERA
Pages in Operating Rules:
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For More Information
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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.