Standards for Healthcare Electronic Funds Transfer and Electronic Remittance Advice
This National Automated Clearing House Association (NACHA) rule supports the health plans' and healthcare providers' use of the ACH network for healthcare claims payments and payment-related information. The rule includes processing enhancements that address specific transaction identification and formatting requirements for healthcare claim payments in support of the Patient Protection and Affordable Care Act (PPACA).
In July 2012, the US Department of Health and Human Resources (HHS) finalized the Adoption of Standards for Healthcare Electronic Funds Transfer (EFTs) and Electronic 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 trace reassociation number (TRN).
For more detail, go to the NACHA website (opens in a new tab).
There are five major components of the rule which are outlined below.
- Originators of healthcare EFT transactions must populate the Company Entry Description of the CCD Entry with the value “HCCLAIMPMT”.
- Originators of healthcare EFT transactions must include an addenda record with each CCD entry used and are required to include the TRN data segment.
- 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.
- The tilde-data segment will need to be recognized by all payment participants as a valid data segment terminator.
- 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?
All health plans are required to be in compliance of the formatting standards for EFT and ERA and must be prepared to pay via ACH if requested by provider.
- NACHA CCD+Addenda is to be used as the standard to transmit EFT payments.
- Health plans are required to include the TRN for payments and associated data to link the payment to the electronic advice or ERA.
- All health plan EFT payments must contain a unique identifier indicating they are healthcare.
- Company Entry Description must have “HCCLAIMPMT”.
- Addenda indicator must be populated with a “1”.
- When populated with a “1” there must be one addenda record.
- For CCD entries that are healthcare EFT transactions, this field must contain the ANSI ASC X12 TRN data segment, which conveys the TRN used by the healthcare provider to match the payment to remittance data.
- If payment to providers is made by check, no changes are required.
- If payment is made by EFT, but advice is sent by paper EOB, no changes are required.
What does this mean for your company if you are a healthcare provider or receiver of payments?
- You may ask your financial institutions to provide any healthcare payment related information, including TRN, to you upon request in a secure manner. BB&T is prepared to handle these requests from you.
- You may request a health plan pay you electronically instead of via paper. This is your decision as you evaluate ways to post your claims more efficiently. The health plan should make every effort to not only provide the payment electronically but also make every effort to ensure ease of reassociation to the remittance advice.
- No changes are required if you continue to receive paper payment and/or paper remittance advice.
- If you do not receive electronic payments today through BB&T, but would like to explore that as a payment option, contact your Treasury Sales consultant for assistance.
How BB&T can help you
BB&T passes 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.
BB&T has a number of channels for you to receive information with TRN details:
- CashManager OnLine® Current Day and Previous Day Reporting
- Small Business Online Account History page
- BAI Data Transmission
For more information, contact us at 800-774-8179.
Glossary of 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 or 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 data segment within the Payment Related Information field.
- 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 EOB statement to the patient and or the provider. Some examples 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
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