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Operating Rules

How can payers achieve and maintain compliance with Operating Rule mandates with limited time, resources and infrastructure complexities?

Edifecs Operating Rules solutions help health plans achieve and maintain ongoing service levels with CAQH CORE Operating Rules. We feel so strongly that Operating Rules are fundamental to frictionless exchange of information, that Edifecs created and continues to support the CORE Operating Rules testing platform free of charge 24/7/365. Our support team of EDI and Operating Rules subject matter experts and our consultants are available to help guide your way from implementation through certification and ongoing service level monitoring and compliance.

Product Spotlight

  • Value of Operating Rules Compliance

    Operating Rules were mandated several years ago by CMS. The enforcement date is January 1, 2016, giving payers a few extra months to ensure the required service levels are above compliance thresholds. Complying with Operating Rules simplifies healthcare transactions and creates a frictionless exchange of transactions which reduces operating expense. According to an IBM survey, plans may increase the volume of insurance verifications by 33% without adding staff, once compliance with Operating Rules is in place. In its newly released 10 year roadmap, HIMSS also echoes the importance of protocols for exchanging health information.

  • Simplifying the CORE certification testing process

    Edifecs has closely partnered with CORE on 162 certifications (and counting) and we’ve become the most trusted Operating Rules consultants in the business. We can help get you started by performing a gap analysis and creating a project plan. Our more advanced offerings provide full support to your Operating Rules initiative. We can even help deploy our newest monitoring dashboard solution so you have constant visibility into service level agreements across your enterprise.


Edifecs Operating Rules meets stringent response time requirements by deploying out-of-box transaction processing components for eligibility, claim status and EFT/ERA transactions.

What does the Edifecs Operating Rules solution do?

The Edifecs Operating Rules solution accelerates Operating Rules compliance and helps health plans monitor and maintain compliance for reporting to the Department of Health and Human Services.

  • Provides accurate framework for documenting compliance for certification. Our dashboards provide visibility to service level agreements and support ongoing monitoring of compliance
  • Our Operating Rules professional services team is the industry’s most experienced group. Period. If you have limited time to test or other resource constraints, we can help
  • There will be enormous implementation complexity compounded over future updates to Operating Rules. Edifecs can help you make sense of it all

Avoid enforcement penalties beginning January 1, 2016

Edifecs believes so strongly in administrative simplification through standardization that we built and maintain the CAQH CORE certification portal to help health plans achieve and maintain their CORE Operating Rules credential for free – 24/7/365.

  • Edifecs offers the first and only CORE certification platform in the industry that helps health plans achieve and maintain ongoing service levels associated with CAQH CORE Operating Rules
  • Edifecs Operating Rules includes out-of-the-box connectivity, transaction workflow and enrichment components to help you accelerate deployment of your transaction processing infrastructure covering your eligibility, claim status and ERA transactions.
  • Robust dashboards provide visibility into ongoing compliance with service level agreements required by Operating Rules

Can you afford these penalties?

If reducing administrative costs, building long term trust and goodwill with trading partners as well as more efficiently carrying on e-commerce weren’t enough, consider adding penalty avoidance in your ROI.

  • ACA penalties for health plans begin on April 1, 2015: $1 per member per day with maximum penalties of up to $20 - $40 per member per year
  • All HIPAA-covered entities are required to comply with the EFT and ERA Operating Rules, and HIPAA penalties for non-compliance are up to 1.5 million dollars
  • Penalties for HIPAA-covered entities are cumulative to ACA penalties – making the total burden of these penalties crushing to most health plans

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