CAQH CORE Phase II Rules

In December 2011, CMS issued a notice adopting CMS-0032-IFC: Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transactions as a Final Rule. All HIPAA-covered entities are required by Federal law to adopt the Phase I CAQH CORE Eligibility Operating Rules and the Phase II CAQH CORE Eligibility & Claim Status Operating Rules*, by January 1, 2013. For more information on the mandate click HERE. Phase II CORE Certification is voluntary.

*NOTE: In the Final Rule for Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transaction, CAQH CORE requirements pertaining to use of Acknowledgements are NOT included for adoption. Although HHS is not requiring compliance with any operating rule requirements related to Acknowledgements, the Final Rule does note “we are addressing the important role acknowledgements play in EDI by strongly encouraging the industry to implement the acknowledgement requirements in the CAQH CORE rules we are adopting herein.”

Complete Set of CORE Phase II Policies and Rules

View a single document with the complete set of CORE Phase II Policies and Rules.

CORE Phase II Policies (200-205)

CORE Phase II Glossary for terms related to CORE Phase II rules.

200: Guiding Principles

201: Pledge

202: Certification Policy

203: Exemption Policy

204: Testing Policy

205: Enforcement Policy

CORE Phase II Operating Rules (250, 258-260, 270)

250: Claim Status Rule

258: Normalizing Patient Last Name Rule

259: AAA Error Code Reporting Rule

260: Eligibility Data Content Rule

270: Connectivity Rule

Phase II: Certification Test Suite

Archive: The CORE Phase I and Phase II policies and rules were updated in 2011 to reflect HIPAA 5010 requirements and associated errata. The CORE Phase I and Phase II Rules 5010 Adjustment Summary and the complete set with tracked changes for substantive HIPAA v5010 to the HIPAA 4010 version of the CORE Phase I Operating Rules are available for review.

Trading Partner Testing and Voluntary CORE Certification

For more information about the CORE Phase II Rules, CORE Phase II certification or applying for a CORE seal, please contact CAQH at (202) 861-1492 or email CORE.

CAQH Program: