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Operating Rules

How can you rapidly achieve compliance with CORE Operating Rules (and sustain it) while simultaneously better serving trading partners and ensuring that your organization receives the value promised by standardized transactions?

Edifecs strongly believes in the frictionless exchange of healthcare transactions. Based on the challenges we have seen more than 190 health plans overcome, Edifecs has developed products and consulting services solutions to help you rapidly achieve compliance with CORE Operating Rules – no matter your size, your approach or where you are on your journey.

Solution Spotlight

Edifecs Ongoing Monitoring

Available by phase, transaction, via the cloud or on premise for comprehensive compliance, Edifecs Ongoing Monitoring solution provides continual surveillance and documentation. The solution connects trading partners using both batch and real-time connectivity methods and it notifies you when service levels are at risk – prompting investigation and action that ensures ongoing compliance is maintained.


No matter where you are in your journey to Operating Rules compliance, what phases are relevant, or what approach you take, Edifecs has services and solutions to enable you to quickly achieve compliance and remain compliant for the long run.

Edifecs professional services

  • Edifecs Operating Rules experts objectively evaluate your current state and compared with the final rule to build a gap analysis scorecard
  • Strategic conclusions are defined. Then, comparisons are drawn to best practices across people, process and technology
  • Gaps are prioritized. Options to close them are explored. Buy versus build decisions are evaluated
  • A prioritized implementation roadmap is developed and encompasses short and long term goals

Attest with confidence

Edifecs Extended Testing Solution orchestrates a production-like trading partner interaction

  • The solution identifies gaps that could not otherwise be revealed during internal testing or CORE conformance testing
  • Edifecs Extended Solution provides configurable HIPAA and CORE validation that scales to your needs
  • Information gathered from testing over an extended period of time (one month or longer) is translated to executive dashboards for transparency into your organization’s ability to comply with Operating Rules

Operating Rules Foundation Module

Operating Rules span a wide spectrum of technical and business centric requirements for successful implementation and compliance.

  • Edifecs bundles these capabilities into one comprehensive operating rules solution
  • Product configuration is built in to meet your specific requirements
  • The diagram illustrates the “out of the box” capabilities for Operating Rules phases I, II, and III

Ongoing surveillance

Transaction volume and exchange of information for business needs will continue to grow rapidly. Will your infrastructure support these requirements and remain compliant with service levels?

  • Edifecs Ongoing Monitoring solution tracks monthly operating rules measures by delivering near real time visibility to the performance of your production environment transactions
  • Production reports support full integration with in-transaction workflows
  • Take preventative action when thresholds are near – avoiding penalties
  • Position your organization to scale with new partnerships and new information exchange requirements

Can you afford these penalties?

Reduce administrative costs, build long term goodwill with trading partners while avoiding steep penalties.

  • ACA penalties for health plans are $1 per member per day with a maximum penalty of up to $20 - $40 per member per year
  • All HIPAA-covered entities are required to comply with the EFT and ERA Operating Rules. Penalties for non-compliance are up to $1.5 million
  • Penalties for HIPAA-covered entities are cumulative to ACA penalties

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