Administrative Simplification


The Administrative Simplification provisions of the Affordable Care Act (ACA) adopt new standards and “operating rules” for how electronic transactions are conducted between HIPAA “covered entities” (health plans, clearinghouses and health care providers who conduct electronic health care transactions).  The provisions aim to create consistency, increase efficiency, and lower administrative costs across the health care system.

The new operating rules supplement existing HIPAA transactions and guidelines (ANSI X12 version 5010). They will require health plans to certify their compliance with the new rules.

The U.S. Department of Health and Human Services (HHS) appointed the National Committee on Vital Health Statistics (NCVHS) to recommend the entities responsible for authoring operating rules. Regulatory amendments associated with the final operating rules have multiple effective dates and will be phased in beginning 2012 through 2016.

The new operating rules affect the following HIPAA standard electronic transactions:

  • Eligibility for a health plan (270/271)
  • Health claim status (276/277)
  • Electronic Funds Transfer & Remittance Advice (835)
  • Health Plan Identifier (HPID)
  • Health claims attachments
  • Health claims or equivalent encounter information (837)
  • Enrollment/disenrollment in a health plan (834)
  • Health plan premium payments (820)
  • Referral certification/authorization (278)

The first transactions that require implementation are the eligibility and claim status transactions. HHS selected CAQH CORE* as the authoring entity for this first set of operating rules.

Aetna’s Take and Action

Aetna is well-positioned to comply with the Administrative Simplification Operating Rule requirements. As a covered entity, we comply with each of the HIPAA standard transactions today, and we are already CAQH CORE certified for the eligibility and claim status operating rules.

Although HIPAA does not require providers to conduct health transactions electronically, Aetna strongly encourages providers to do so. With the implementation of the new operating rules, electronic processing will make it even easier for providers to get the accurate information they need to effectively manage their practices.

Looking ahead, we will work with our contracted service providers to ensure all aspects of the Administrative Simplification regulations are met.

In addition, we will be gearing up to comply with another aspect of the ACA, which requires each health plan to have its own unique Health Plan Identifier (HPID). The HPID joins other unique identifiers (employer ID (EIN) and provider ID (NPI)) already mandated for use in HIPAA standard transactions.

As proposed, health plans may apply for an HPID beginning October 1, 2012 and must use the HPID to route electronic transactions no later than October 1, 2014.

Questions and answers

  • Are providers required to use these transactions? 
  • What is an operating rule? 
  • How will this provision be enforced? 

View all Administrative Simplification Q&As 

* The Council for Affordable Quality Healthcare Committee on Operating Rules for Information Exchange