Standards for Healthcare Electronic Funds Transfers and Electronic Remittance Advice

This rule supports the health plans' and health care providers' use of the ACH network for health care claims payments and payment-related information. The rule includes processing enhancements that address specific transaction identification and formatting requirements for health care claim payments in support of The Patient Protection and Affordable Care Act (PPACA).

Overview

In July 2012, the U.S. Department of Health and Human Resources (HHS) finalized the Adoption of Standards for Healthcare Electronic Funds Transfer (EFTs) and Remittance Advice (ERAs) These standards are designed to assist providers of healthcare services with reconciling an electronic payment with the electronic remittance by connecting these through a TRN or Trace Reassociation Number.

There are five major components of the rule which are outlined below. For more expanded detail, go to https://healthcare.nacha.org/nacharuleshealthcare.

  1. Originators of healthcare EFT transactions must populate the Company Entry Description of the CCD Entry with the value “HCCLAIMPMT.”
  2. Originators of healthcare EFT transactions must include an addenda record with each CCD entry used and are required to include the TRN (Reassociation Trace Number) data segment.
  3. A receiving financial institution must make available, upon request by the healthcare provider, all information contained within the payment related information field of an addenda record transmitted with a CCD Entry that is a healthcare EFT transaction.
  4. The tilde-data segment will need to be recognized by all payment participants as a valid data segment terminator.
  5. Expanded healthcare terminology will be contained as part of the NACHA Operating Rules.
What does this mean for your company if you originate payments or represent a health plan?
What does this mean for your company if you are a healthcare provider or receiver of payments?

How can BB&T help you through this transition?

Effective Sept. 20, 2013, BB&T will begin to pass the reassociation or TRN information to your bank statement free of charge. This information will be available on a next-day basis and will contain the first 57 characters of the addenda record.

Need expanded detail? BB&T has a number of channels for you to receive that information with expanded TRN detail:

  • CashManager OnLine Current Day and Previous Day Reporting
  • Small Business OnLine Account History page
  • BAI Data Transmission

For more information you may contact us at 800-810-5625.

Glossary

Healthcare Terminology within the NACHA Operating Rules

ASC – Accredited Standards Committee

CAQH – Council on Affordable Quality Healthcare

CCD – Corporate Credit or Debit

CORE- Required Minimum CCD+ Re-association Data Elements: 

  • Information transmitted by a Health Plan to a Healthcare Provider for the purpose of re-associating a Healthcare EFT Transaction with an electronic remittance advice.
  • CORE - Required Minimum CCD+ Re-association Data Elements includes:
    • Effective Entry Date field
    • Amount field
    • Payment Related Information field of the CCD Entry

CTX – Corporate Trade Exchange

EFT – Electronic Funds Transfer

Electronic Remittance Advice (ERA): – an electronic file that is sent from the Health Plan payer to the Healthcare Provider that can be used to post and close accounts receivable. This is called an ERA or sometimes referred to as an Explanation of Benefits (EOB).

Government programs: – The government may also act as the insurer under sponsored programs such as:

  • Medicare - 65 and older or certain disabilities
  • Medicaid – low income individuals and families
  • Tricare -Uniformed service members, retirees and their families

HHS – US Department of Health and Human Services

Healthcare EFT Transaction: – a CCD+ Entry originated by a Health Plan to a Healthcare Provider with respect to a healthcare claim payment. Under this definition, a Healthcare EFT Transaction must include one addenda record that contains 835 TRN (Re-association Trace Number) data segment within the Payment Related Information field.

Health Plan: 

  • An individual or group plan that provides, or pays the cost of, medical care.
  • The insurance company receives the claim from the service provider and determines eligibility, compensation rate for the provider, deductibles and co-pays. The insurance company makes payment to the provider, and sends an Explanation of Benefits (EOB) statement to the patient and or the provider. Some example are Blue Cross and Blue Shield, Aetna, United Healthcare and Kaiser Permanente.

Healthcare Provider: – a provider of medical or health services, and any other person or organization who furnishes, bills, or is paid for healthcare in the normal course of business.

HIPAA: – the federal law that protects personal medical information and recognizes the rights to relevant medical information of family caregivers and others directly involved in providing or paying for care.

Medical Clearinghouses: – aggregators (senders and receivers) of mountains of medical claim information almost all of which is managed by software.

Tilde (“~”) data segment terminator: – indicates the end of any data segment carried in the Addenda Record of the CCD Entry (alternative to backslash). The tilde is commonly used in the healthcare industry to indicate the end of a healthcare data segment.

ODFI – Originating Depository Financial Institution

RDFI – Receiving Depository Financial Institution

FAQ

Standards for Healthcare Electronic Funds Transfers (EFTs) and Electronic Remittance Advice (ERAs)

  • Created by the Patient Protection and Affordable Care Act (PPACA) in 2010
  • Requires electronic payments by Medicare beginning Jan. 1, 2014
  • Subject to the operating rules developed by the not-for-profit entity named by the Secretary of HHS
    • CAQH CORE is the entity responsible for operating rules
    • NACHA is the standards organization for mandated electronic payments

General Questions

Insurance/Health Plan Entities

Medical / Health Care Providers

Technical Aspects of the new Health Care EFT Standard and rules

Locations

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