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The ACA Operating Rules

Learn about the Affordable Care Act (ACA) operating rules.

ACA Operating Rules

The Patient Protection and Affordable Care Act of 2010 was signed into federal law on March 23, 2010. Now known as the Affordable Care Act (ACA), this law has since made health insurance accessible to millions of uninsured people.

Section 1104 of the Administrative Simplification provisions of the ACA builds upon the Health Insurance Portability and Accountability Act of 1996 (HIPAA) by establishing several new, expanded, or revised provisions that will enhance the usefulness of existing HIPAA transactions and reduce administrative costs. This includes, but is not limited to, the following mandates:

  • Operating rules for HIPAA transactions
  • Requirements that health plans certify compliance with the standards and operating rules
  • Penalties for health plans that fail to comply or to certify their compliance with applicable standards and operating rules.

Under the ACA, Congress required the adoption of new operating rules for the health care industry. In order to create as much uniformity as possible within the implementation of electronic standards, Congress directed the U.S. Secretary of Health and Human Services (HHS) to adopt a single set of operating rules (outlined below) to further streamline existing transactions:

  • Eligibility & Claims Status Rule – Implemented on January 1, 2013
  • Electronic Funds Transfer (EFT)/Remittance Advice (RA) Rule – Implemented on January 1, 2014
  • Claims Attachments (not yet issued)
  • Enrollment/Disenrollment in a Health Plan (not yet issued)
  • Health Claims or Equivalent Encounter Information (not yet issued)
  • Health Plan Premium Payments (not yet issued)
  • Referral Certification and Authorization (not yet issued)

MassHealth continues to monitor the Centers for Medicare & Medicaid Services (CMS) as well as the Council for Affordable Quality Healthcare (CAQH) websites for the most up-to-date information on ACA Operating Rules.

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