Operating Rules

Achieve and Maintain Operating Rules Compliance

The Patient Protection and Affordable Care Act (ACA) mandated that health plans comply with a series of Operating Rules requirements for administrative simplification. Non-compliance can result in substantial financial penalties. Edifecs Operating Rules solution is a comprehensive offering that provides health plans with a technology framework to meet, monitor, and report compliance for certification with the Department of Health and Human Services. It also enables you to manage transaction workflows for all phases and is the only authorized solution for CAQH CORE certification.

Operating Rules Solution Infographic


Analysis and Assessment

  • Conduct business process and gap assessments for implementation
  • Identify current performance levels and gaps requiring remediation

Edifecs offers a suite of capabilities to identify gaps when implementing different phases of Operating Rules and to recommend remediation steps.

Production Level Testing to Identify Implementation Gaps

  • Perform production level testing
  • 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 and errors

Our suite of services orchestrates a production-like trading partner interaction and helps identify implementation gaps that can’t be uncovered during internal testing or CORE certification testing.

Ongoing Surveillance to Track Operating Rule Compliance

  • View executive-level dashboards for visibility into overall compliance levels in accordance with reporting and documentation requirements
  • Gain access to interactive detailed dashboards for compliance levels, including response time SLAs, transactions and acknowledgments balancing, AAA Error reporting, 271 data content validation, and more
  • Receive business alerts and notifications to facilitate timely compliance review and action

Monitor, document and report on Operating Rule Compliance with executive-level and detailed views, drill-downs of non-compliant systems, and notifications to facilitate timely compliance review.