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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 complying with operating

    The 2014 CAQH Index was released on March 17, 2015.  It reported a potential annual savings of $8 billion dollars for U.S. healthcare that can be directly attributed to the adoption of the electronic business transactions specified in CORE Operating Rules.  As the first and only CORE conformance testing vendor, nobody has more experience with conformance testing.  Edifecs has the services and solutions to help you quickly achieve compliance and maintain it for the long haul.

  • Simplifying the CORE certification testing process

    Edifecs has closely partnered with CORE for 174 certifications and counting.  Over the last 10 years, our EDI team have become the de facto experts in CORE conformance testing.  We have developed service offerings and products to expedite achieving CORE compliance and maintain it for the long run.


Edifecs is the de facto expert in CORE conformance testing and Operating Rules. Our products and services help accelerate the achievement of Operating Rule compliance – and our ongoing monitoring tool helps you maintain and document service levels.

What does the Edifecs Operating Rules solution do?

Edifecs CORE conformance testing experts can help you every step along your journey to Operating Rules compliance.

  • Edifecs consultants can help you perform a gap analysis of current state compared to the Operating Rules, creating a road map to compliance
  • After you have implemented new technologies or remediated old ones, Edifecs Extended Monitoring solution provides configurable and scalable HIPAA and CORE validation that prepares you for CORE certification
  • Using the CORE conformance testing built and maintained by Edifecs, you will iteratively pass use cases apt for your role in exchanging transactions to earn the coveted CORE seal
  • If a random or complaint-driven audit occurs, know that you’re compliant with Edifecs ongoing testing and monitoring tool for your production environment

Officers can attest with confidence on January 1, 2016

Identifying and addressing gaps between conformance testing and production environments before going live is essential to introducing maintaining smooth CORE compliant operations.

  • Edifecs Extended Monitoring solution provides configurable and scalable HIPAA and CORE validation that prepares you for CORE certification
  • Edifecs service level monitoring orchestrates a production-like trading partner interaction to help identify gaps that cannot be revealed during internal testing or during the CORE conformance testing processes.
  • Health plan executives, can view the service levels in Edifecs’ ongoing surveillance portal and gain immediate confidence in their ability to attest compliance on behalf of the health plan.

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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