Compliance is complex and
non-compliance is costly ($20/Member/Year)

Trust your compliance to a rock-solid industry leader

Operating Rules

Do you have the capability to support eligibility & claim status transactions in both real-time & batch as required by ACA? Are deadlines tight because of limited resources & subject matter expertise during implementation of Operating Rules? Are you aware that your remittance advice (ERA) must use only standardized reason codes?

Operating Rules simplify administration but implementing Operating Rules is not simple. Compliance is critical due to stiff penalties. Edifecs products can help your organization rapidly build capabilities to support Operating Rules transactions that will improve service while reducing costly manual operations. Edifecs has helped more than 20 organization successfully implement Operating Rules and has helped hundreds more achieve CORE certification. Edifecs offers a full range of software solutions and services to achieve and maintain CORE compliance. Learn More

Solution Spotlight

  • Extended Testing Solution

    Reduce the risk of  production non-compliance
    Built directly on the CORE certification testing scenarios, our solution identifies implementation gaps by modeling the variation in production system load. It analyzes test results and provides dashboards to identify implementation gaps that require remediation and highlight areas to research.

  • Operating Rules Solution

    Reduce cost and time to implement Operating Rules transactions and achieve compliance
    For successful testing and implementation, Operating Rules must span a wide spectrum of technical and business centric requirements. Edifecs offers a scalable solution that includes HIPAA and CORE validation, and an orchestration engine to manage out-of-the-box transaction workflows for Operating Rules phases I, II and III transactions. Edifecs is a CORE compliant connectivity solution.

  • Edifecs Ongoing Monitoring

    Track and Manage Operating Rules compliance
    The Edifecs solution includes out-of-the-box dashboards and reports to comprehensively track compliance measures, and when needed, research the root cause of non-compliance issues. The product supports full integration with existing transaction workflows. Using this tool, health plans can confidently access and validate compliance measures across the mandate requirements and business lines.


No matter where you are in your compliance journey or what approach you take, Edifecs enables you to quickly achieve and maintain compliance.


Edifecs offers a suite of capabilities to identify gaps in implementing different phases of Operating Rules and recommend remediation steps. Our team offers services to assist you prepare:

  • Conducts business process assessments
  • Transaction support gaps
  • Transaction content and infrastructure gaps
  • Identifies current performance levels and gaps associated requiring remediation
  • Recommends project tasks and participate in critical path activities from analysis, to certification, to extended testing, to ongoing implementation and monitoring of the Operating Rules.


Operating Rules requires wide range of technical and business centric capabilities for successful implementation and compliance. These capabilities include:

  • Performing HIPAA and CORE validations of transactions
  • Performing partner-specific validations of transactions
  • Following CORE compliant connectivity protocols and authentication processes

Production Level Testing

Edifecs Extended Testing Solution orchestrates a production-like trading partner interaction to enable you to:

  • Perform production level testing with Edifecs as your trading partner
  • Access comprehensive test cases covering most of data content and infrastructure
  • Ensure adequate coverage and completeness of test plans
  • Access intuitive dashboards to identify gaps per Operating Rule

Ongoing surveillance

Transaction volume and information exchange is continuing to grow rapidly and is predicted to do so through 2020. Will your infrastructure support increasing volume, multiple transaction types and protocols while remaining compliant with mandated service levels? Edifecs offers production monitoring capabilities to maintain compliance and ensure on-going compliance as new programs come on-line. The solution:

  • Track responses/acknowledgements and their timeliness
  • Track eligibility data content errors and AAA errors
  • Track ERA and EFT re-association, and CARC/RARC errors
  • Report the errors and statistics in dashboards

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