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Operating Rules Overview

Guidance for the operating rules required by the Patient Protection and Affordable Care Act.

Final

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: August 10, 2020

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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.

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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
  • January 1, 2014: Compliance date for Health Care Electronic Funds Transfers (EFT) and Remittance Advice (ERA)

Pages in Operating Rules: 

The referenced media source is missing and needs to be re-embedded.
The referenced media source is missing and needs to be re-embedded.
The referenced media source is missing and needs to be re-embedded.

Keep Up to Date!

Sign up for Administrative Simplification Email Updates and follow us on Twitter, and check out our Resources and FAQs.

For More Information 

HHS is committed to making its websites and documents accessible to the widest possible audience, including individuals with disabilities. We are in the process of retroactively making some documents accessible. If you need assistance accessing an accessible version of this document, please reach out to the guidance@hhs.gov.

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.