Frequently Asked Questions

Implementation of the Phase I, II, and III CAQH CORE Operating Rules is mandated for all HIPAA-covered entities by the ACA (with the exception of requirements pertaining to acknowledgments). Implementation of the Phase IV CAQH CORE Operating Rules is currently voluntary. HHS will determine if the Phase IV CAQH CORE Operating Rules will be included in any regulatory mandates. CAQH CORE offers CORE Certification for Phases I, II, and III and CORE Certification for Phase IV will be available in Summer 2016.

CAQH CORE offers more than 700 Frequently Asked Questions (FAQs) addressing all four phases of the CAQH CORE Operating Rules, general CAQH CORE information, CORE Certification and future development of operating rules. You may find your FAQ by clicking on the links below or using the search bar above to identify key words.

Additional CAQH CORE Resources are available for implementing the CAQH CORE Operating Rules: See CAQH CORE Implementation Resources and CAQH CORE Events.

If you have any questions not addressed by the CAQH CORE Online Resources, please email CORE@caqh.org.

NOTE: The CAQH CORE FAQs are for informational purposes only; in the case of a discrepancy between this document and CAQH CORE Operating Rule text and/or Federal regulations, the latter take(s) precedence. No adjustments to CAQH CORE rule requirements will be made via the FAQ process.

part a: General CAQH CORE FAQs

General FAQs address CAQH CORE’s background and mission, the CAQH CORE Rules Development Process, and procedures and policies related to CORE Participation, CORE Certification, and CORE Endorsement.

I. Overview of CAQH CORE

II. Introduction to CORE Participation

III. CAQH CORE Measures of Success

IV. CAQH CORE Resources and Links

V. General CAQH CORE Operating Rules

part b: ACA Section 1104 Mandate for Federal Operating Rules

These FAQs address HHS adoption status of the ACA-mandated operating rules and related ACA Federal compliance requirements.

NOTE: The CMS National Standards Group (NSG) is the authority on the HIPAA and ACA Administrative Simplification provisions; more detailed information on the provisions, as well as compliance and enforcement requirements, is available on the CMS website and via the CMS FAQs.

I. Overview: ACA Section 1104 Provisions for Federal Operating Rules

II. Requirements for Federal Operating Rules Addressing the Eligibility & Claim Status Transactions

III. Requirements for Federal Operating Rules Addressing the EFT & ERA Transactions

part c: Phase I & II CAQH CORE Eligibility & Claim Status Operating Rules

These FAQs address technical rule requirements and stakeholder specific implementation for the first set of ACA-mandated operating rules. (CAQH CORE Phase I and II) 

I. Overview of CAQH CORE Eligibility & Claim Status Operating Rules

II. Interdependent CAQH CORE Eligibility & Claim Status Requirements

III. CAQH CORE 150: Batch Acknowledgements Rule

IV. CAQH CORE 151: Real Time Acknowledgements Rule

V. CAQH CORE 152: Companion Guide Rule

VI. CAQH CORE 153: Connectivity Rule

VII. CAQH CORE 154: Eligibility & Benefits 270/271 Data Content Rule

VIII. CAQH CORE 155: Batch Response Time Rule

IX. CAQH CORE 156: Real Time Response Time Rule

X. CAQH CORE 157: System Availability Rule

XI. CAQH CORE 250: Claim Status Infrastructure Rule

XII. CAQH CORE 258: Normalizing Patient Last Name Rule

XIII. CAQH CORE 259: AAA Error Code Reporting Rule

XIV. CAQH CORE 260: Eligibility & Benefits Data Content (270/271) Rule

XV. CAQH CORE 270: Connectivity Rule

XVI. Resources for Implementing the CAQH CORE Eligibility & Claim Status Operating Rules

part d: Phase III CAQH CORE EFT & ERA Operating Rules

part e: Phase IV CAQH CORE Operating Rules

Implementation of the Phase IV CAQH CORE Operating Rules is currently voluntary. HHS will determine if the Phase IV CAQH CORE Operating Rules will be included in any regulatory mandates. The Phase IV FAQs are for use by entities completing voluntary implementation of the operating rules and/or pursuing Phase IV CORE Certification which will be available in Summer 2016.

These FAQs address technical rule requirements and stakeholder specific implementation for the Phase IV CAQH CORE Operating Rules.

I. Overview of Phase IV CAQH CORE Operating Rules

II. CAQH CORE 450: Health Care Claim (837) Infrastructure Rule

III. CAQH CORE 452: Health Care Services Review - Request for Review and Response (278) Infrastructure Rule

IV. CAQH CORE 454: Benefit Enrollment and Maintenance (834) Infrastructure Rule

V. CAQH CORE 456: Premium Payment (820) Infrastructure Rule

VI. CAQH CORE 470: Connectivity Rule

VII. Resources for Implementing the Phase IV CAQH CORE Operating Rules

part f: CAQH CORE Operating Rules in Development

These FAQs address both current CAQH CORE rules development to address the remaining ACA Section 1104 operating rules and drafted voluntary CAQH CORE Operating Rules in development. 

I. Development of Remaining ACA-Mandated Operating Rules

II. Development of Voluntary Operating Rules

part g: ACA Section 1104 Certification, CORE Certification, Proposed CORE HIPAA Credential, and CORE Endorsement

These FAQs address certification-related topics including the requirements of ACA Section 1104 Certification, the proposed options to certify compliance including CORE Certification, the Proposed CORE HIPAA Credential and CORE Endorsement.

I. Background on ACA Section 1104 Certification

II. Introduction to CORE Certification

A. CORE Certification: Overview & Policies

B. CORE Certification: Stakeholder Specific Questions

C. CORE Certification: Testing

III. Introduction to Proposed CORE HIPAA Credential

IV. Introduction to CORE Endorsement

V. Related Resources and Links

Type: 
Audience: 
CAQH Program: