Prepares health plans to realize the full benefits of improved operational visibility, efficiency and near real-time availability of a patient’s eligibility, claims status and financial responsibility


Operating rules mandated over the past few years now carry significant financial penalties when they’re not observed by health plans. Both ACA and HITECH established operating rules to achieve administrative simplification. In January 2013 these regulations became requirements for health plans, who must also certify their compliance. Advantages of the operating rules include near real-time documentation of patient eligibility and financial responsibility either before or at the point of care. Additional benefits such as cost savings, increases in call center productivity and greater member satisfaction have been documented by a number of studies. IBM research concluded that industrywide implementation of the Phase I CORE Operating Rules will potentially save $3 billion over three years. Evidence shows early-adopter payers received a return on their investment within the first year of implementation.

About the Edifecs Operating Rules Solution

The Edifecs Operating Rules solution reflects lessons learned from early adopters and industry best practices. The comprehensive solution enables health plans to maintain compliance with operating rules and improve their operational visibility. It hastens the shift from costly phone transactions to more efficient automated ones.

Health plans also gain the ability to monitor compliance and report for certification to the Department of Health and Human Services. The Edifecs Operating Rules solution also leverages other widely used Edifecs products to:

  1. Securely connect and exchange healthcare documents with trading partners in a compliant manner by automating infrastructure previously addressed through call center operations
  2. Validate healthcare transactions in a compliant manner with Operating Rules SLA requirements as well as payer-specific SLAs
  3. Query back-end adjudication systems so as to provide context-rich responses for eligibility and claim status information (patient financials, deductibles, etc.)
  4. Provide operational visibility to the new compliance transactions for executives, as well as detailed views for certification purposes
  5. Identify and rapidly resolve compliance errors and exceptions through end-to-end transaction lifecycle visibility, business alerts and notifications


  • Replaces inefficient call center telephone inquiries with automated transactions.
  • Reduces penalty risk by accelerating compliance and reducing resource burden.
  • Increases member satisfaction and call center productivity by improving customer support.
  • Improves business processes and lowers maintenance costs, thus building foundation for strategic platform.

Explore more, go to Operating Rules Insights »

By offering this updated platform, Edifecs is demonstrating its strong commitment to providing multi-stakeholder solutions that streamline administrative exchanges.

Gwendolyn Lohse




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