Adding Detail to AAA Error Codes
AN EXAMPLE OF the efficiencies the operating rules offer a
provider and its trading partners can be seen in changes to
the AAA Error Code.
Providers sending an “eligibility for a health plan” request
to a payer may receive an AAA Error Code stating “member
not found.” This is a general error that can be caused by a
variety of issues. It may be that the patient is not covered by
the health plan. Or it could be that the patient’s name was
misspelled or incorrectly keyed in. Yet providers would only
know the cause of the error by picking up the phone.
The eligibility for a health plan operating rule states that
payers must provide as much information as possible in an
AAA Error Code, and they must do so in a standard way. If
the payer can determine the patient name is incorrect, the
operating rule states it must send back an “invalid name”
error code rather than the generic “member not found”
message.
The provider can then recheck the submission or get
the correct spelling from the patient, instead of calling the
health plan and determining the problem. The more specific
error messages reduce the time it takes to get eligibility information, which results in fewer administrative expenses.
“We think that operating rule is huge,” Farmer says. “Just
the fact of harnessing again the many flexibilities within the
AC X12 standards and putting that to work in the business
world where you require payers to give back the data in a
very specific manner.
“That is the way that you reduce costs in this business.”
Gwen Lohse is deputy director of the Council for Affordable
Quality Healthcare (CAQH) and managing director of the Committee on Operating Rules for Information Exchange (CORE),
based in Washington, DC. CORE developed the operating rules
that take effect next year.
“The health plans do it differently, the vendors do it differently, the providers do it differently,” she says. “We have written
the operating rules to apply to all the entities that touch these
transactions; we set expectations for all of them.”
An ACA Mandate
Section 1104 of the Affordable Care Act (ACA), enacted in 2010,
established a national healthcare operating rule mandate to
help simplify and streamline administrative operations for all
healthcare stakeholders.
ACA grants the Department of Health and Human Services
the authority to create and adopt a single set of operating rules
for all HIPAA transaction standards. The goal is to create uniformity in the implementation of electronic transaction standards,
which simplifies the transaction and in turn reduces administrative costs.
In December 2011 HHS published its final rule on the first
two operating rules—rules governing the 270–271 standards for
“eligibility for a health plan” transactions and the 276–277 standards for “health claim status inquiry” transactions.
Trading partners have until January 2013 to implement the
rules into practice. Those who do not comply face possible financial penalties issued by the Centers for Medicare and Medicaid Services (CMS), the administrator of the mandate.
HHS’s advisory committee on HIPAA transactions recommended that CORE develop the first operating rules. CAQH
formed CORE in 2005 to develop voluntary operating rules that
providers, vendors, and payers could use to simplify transaction
standards. Because CORE’s operating rules for eligibility and
claims status transactions were already in use in the industry,
the committee was a natural choice.
CORE’s voluntary rules became the basis for HHS’s mandated rules, so organizations that have voluntarily adopted them
should have a smooth transition to the mandated rules and a
headstart on the January 2013 deadline.
CORE brought together a wide selection of industry stakeholders in 2005 when it began developing the two operating
rules. This consensus—from providers, clearinghouses, vendors, payers, and others—ensured that the industry would embrace the operating rules in the pursuit of lowering cost and rising productivity, Lohse says. To date there has not been a major
organized effort against their implementation.
“We had a solid set of rules that meet the regulatory framework
that also have industry consensus and speak to the cost savings
expected from this section of the [ACA] statute,” Lohse says. “By
all those groups coming together you are really assuring what
comes out with the final regulation meets the goals anticipated.”
What Is an Operating Rule?
An operating rule is a set of policies that dictate how a transaction standard is implemented and used. It supports the standard, providing detail on how it should be used to simplify administrative work and increase data use for a positive return on
investment.
The operating rules do not change the transaction standards,
just enhance and fine-tune them by providing detail. In some
cases, the rules address the infrastructure of the transaction, in
others the content of transactions. In all instances, the operating rules are intended to simplify the variances that exist in how
trading partners currently employ the standards.
Key transaction components covered by the operating rules
include:
x Rights and responsibilities of parties in a transaction
x Security
x Exception processing
x Transmission standards and formats
x Response time standards
x Liabilities
x Error resolution
Setting Universal Expectations
The operating rules have specific requirements for eligibility
requests and health claim status checks. In eligibility requests,
for example, the rules state payers must confirm patient benefit
coverage and co-pay, in/out of network variances, coinsurance
and base deductive information, as well as provide financials for
