CORE Phase III Rules

CORE Phase III Scope

The CORE Phase III rule development process is underway. CORE-participant organizations working with CAQH developed the scope of work for the CORE Phase III Operating Rules. As with all CORE Phases, the Phase III scope was developed based on input from multiple sources and using a priority selection process to assess a large list of Phase III scope options against key filters.

Determining the scope of Phase III rules involved broad representation, both in number and stakeholder type, from CORE participant organizations. More than 150 individuals, representing over 60 CORE-participant organizations, participated in at least one of three Phase III group-discussion exercises. Several other discussions with CORE participants and industry partner organizations also contributed to the Phase III scope considerations.

The following areas are in the CORE Phase III rules scope:

1. 276/277 Claims Status Transaction: Build out data content requirements
2. 270/271 Eligibility/Benefits Transaction: Further enhance this transaction’s data content requirements, e.g., develop rules related to provider network identification and improved patient identification
3. New Transactions (835 Payment/Remittance Advice and 278 Authorizations, Precertifications & Referrals:
   • Apply Phase I and II infrastructure rules to electronic remittance advices (real-time response time, system availability, connectivity and acknowledgements), and build out these transactions’ data content requirements
4. Connectivity: Build upon connectivity given it allows for connections to all other health IT applications and is a key aspect for interoperability
5. Insurance ID Cards: Address rules on standard ID cards (WEDI ID Card Implementation Guide will be key)

CORE Phase III DRAFT Rules

Draft CORE Phase III rules are being written and reviewed. The final rules will be posted upon completion.

CORE Phase III Eligibility and Claim Status Due to ACA Mandated Operating Rules Efforts
(Approved by Tiger Team Work Group Efforts):
• Draft Phase III CORE Uniform Use of Claim Status Category and Claim Status Codes (276/277) Rule
• Draft Phase III CORE Acknowledgements for v5010 837 Claims Rule

Part of EFT/ERA Operating Rules Efforts Due to ACA Mandate:
• Draft Phase III CAQH CORE EFT and ERA Operating Rule Set,
  Version for CORE Steering Committee Review
• CORE v5010 Master Companion Guide Template
        View substantive v5010 edits as tracked changes

Draft Operating Rules to be Considered in Later Phases of CORE:
• Draft Phase III CORE Real Time 276/277 Claim History Availability Rule
• Draft Phase III CORE Health Care Services Request for Review/Response (278) Rule
• Draft Phase III CORE Health Insurance Identification Card Rule
• Draft Phase III CORE Eligibility & Benefits Data Content (270/271) Rule

Please contact CAQH staff with your questions and suggestions.