The Department of Health and Human Services (HHS) has released an interim administrative simplification final rule for electronic funds transfers (EFT) and remittance advice (ERA) transactions. The rule is open for public comment until October 9. The implementation and use of these newest operating rules is expected to encourage electronic payments and to reduce administrative inefficiencies associated with paper and manual processes.
The rule calls for the adoption of Phase III Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for InformationExchange (CORE) EFT & ERA Operating Rule Set, including the CORE v5010 Master Companion Guide Template, for health care EFT and ERA transactions, but does not adopt the acknowledgment requirements. This is a tremendous victory for physicians, since it enables them to determine the patient’s financial responsibility when care is provided, and allows them to settle payment before the patient leaves the office.
The highlights of the EFT and ERA operating rules include the following requirements:
Health plans must provide standardized and streamlined paper-based and online EFT and ERA enrollment forms.
Physicians must work with their banks to ensure all the EFT information sent by the health plans is transmitted to the practice so that the EFT can be re-associated with the ERA.
Health plans must transmit the EFT within three days of the transmission of the ERA.
Health plans that issue proprietary paper claim remittance advice must continue to offer paper remittance advice for a minimum of 31 days from the implementation of ERA to ensure a smooth transition.
Health plans must use standard claims adjustment reason and remark codes for four common business scenarios. The four business scenarios include:
1. Additional Information Required—Missing/Invalid/Incomplete Documentation
2. Additional Information Required—Missing/Invalid/Incomplete Data from Submitted Claim
3. Billed Service Not Covered by Health Plan
4. Benefit for Billed Service Not Separately Payable
Health plans must use a standardized and streamlined companion guide to describe any health plan–specific rules associated with the EFT and ERA transactions.