Ongoing Maintenance of the CORE Code Combinations for CAQH CORE 360 Rule

Current Version of the CORE Code Combinations: October 2016 v3.3.1

Status of the CORE Code Combinations Maintenance Process:

Completed: July 2016 Compliance-based Review; adjustments published in current version of the CORE Code Combinations.  

In Progress: November 2016 Compliance-based Review & Collection of Potential Market-based Adjustments for 2016 Market-based Review via online Market-based Adjustments Survey.

Keeping Up with the CORE Code Combinations

If you have been tasked with implementing CAQH CORE 360: Uniform Use of CARCs and RARCs (835) Rule, part of the Affordable Care Act (ACA)-mandated EFT & ERA Operating Rules, you will find all the necessary tools and information here to comply with this operating rule.

These resources are provided free of charge by CAQH CORE, author of the operating rules, and are intended to help organizations comply with the law.

Background

The CAQH CORE EFT & ERA Operating Rules, among other things, simplify the language used to communicate about claim payment and remittance information. One of the five EFT & ERA Operating Rules, CAQH CORE 360 Rule, brings uniformity to use of Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), and Claim Adjustment Group Codes (CAGCs) by identifying a limited set of CARC/RARC/CAGC combinations to be used in defined universal business scenarios. These codes are used in combination to convey details about a claim adjustment or denial in the X12 v5010 835.

Together, the business scenarios and code combinations make up the CORE-required Code Combinations for CORE-defined Business Scenarios (CORE Code Combinations), a companion document to the CAQH CORE 360: Uniform Use of CARCs and RARCs (835) Rule.

The published CARC and RARC lists and, in turn, the CORE Code Combinations are updated three times per year. For a comprehensive overview of CAQH CORE 360 Rule and the CORE Code Combinations Maintenance Process, attend this free, pre-recorded CAQH CORE education session.

Current and Past Versions of the CORE Code Combinations

 
The current version of CORE Code Combinations for use with CAQH CORE 360 Rule is the October 2016 CORE Code Combinations v3.3.1.
 

As the table illustrates, this version aligns with CARC and RARC list updates published July 1, 2016. The July 2016 Compliance-based Review (CBR) also addressed one RARC that was approved for removal during the 2015 Market-based Review (MBR); the removal action was deferred until the July 2016 CBR due to expected code committee activity to modify the RARC description. NOTE: The table below contains 5 columns. Depending on your browser, you may need to scroll right using the scroll bar at the end of the section to view all 5 columns.

Date of Published CARC and RARC List Updates
(Updates Trigger Compliance-based Reviews of the CORE Code Combinations)
Resulting Version of the CORE Code Combinations
Does Version Include Market-based Adjustments from Industry?
Compliance Date
(Applies as of January 1, 2014 to all HIPAA-covered Entities)
Adjustments Between Versions of the CORE Code Combinations
July 1, 2016 October 2016 v3.3.1
(current)
Yes January 4, 2017 Adjustments from June 2016 v3.3.0 to October 2016 v3.3.1
March 1, 2016 June 2016 v3.3.0
(now deprecated)
Yes September 10, 2016 Adjustments from February 2016 v3.2.2 to June 2016 v3.3.0
November 1, 2015 February 2016 v3.2.2
(now depcreated)
No May 1, 2016 Adjustments from October 2015 v3.2.1 to February 2016 v3.2.2
July 1, 2015 October 2015 v3.2.1
(now deprecated)
No January 1, 2016 Adjustments from June 2015 v3.2.0 to October 2015 v3.2.1
March 1, 2015 June 2015 v3.2.0
(now deprecated)
Yes September 5, 2015 Adjustments from February 2015 v3.1.3 to June 2015 v3.2.0
November 1, 2014
February 2015 v3.1.3
(now deprecated)
No
May 2, 2015
July 1, 2014
October 2014 v3.1.2
(now deprecated)
No
 January 1, 2015
N/A Minor adjustments to address oversight from Market-based Review
July 2014 v3.1.1
(now deprecated)
Yes
October 2, 2014
March 1, 2014 and March 14, 2014
June 2014 v3.1.0
(now deprecated)
Yes
 September 4, 2014
November 1, 2013
February 2014 v3.0.4
(now deprecated)
No
May 1, 2014
July 1, 2013 & July 15, 2013
October 2013 v3.0.3
(now deprecated)
No
January 1, 2014
March 1, 2013
(now deprecated)
No
N/A
November 1, 2012
(now deprecated)
No
N/A
N/A
March 8, 2011
(now deprecated)
No
N/A
N/A
 
 
High-level Summary of Adjustments in the Version 3.3.1 of the CORE Code Combinations
 
Version 3.3.1 of the CORE Code Combinations includes updates based on:
  • Compliance-based Adjustments as part of the CAQH CORE Code Combinations Maintenance Process based on published CARC and RARC lists as of July 2016
  • One Market-based Adjustment deferred from the 2015 Market-based Review

The table below summarizes the Compliance-based Adjustments and deferred Market-based Adjustment approved by the CAQH CORE Code Combinations Task Group for inclusion in the current version of the CORE Code Combinations by CORE-defined Business Scenario.

 

Type of Adjustment

CORE-defined Business Scenario #1

CORE-defined Business Scenario #2

CORE-defined Business Scenario #3

CORE-defined Business Scenario #4

July 2016 Compliance-based Review

  • N/A
  • N/A
  • 16 RARCs added
  • 1 CARC added
  • 1 CARC description modified
  • N/A
Deferred 2015 Market-based Adjustment
  • 1 RARC removed
  • N/A
  • N/A
  • N/A
 
 

Summary of Compliance-based Adjustments in the October 2016 Version of the CORE Code Combinations

 

July 2016 Adjustments to Published Code Lists

October 2016 CORE Code Combinations v3.3.1 Compliance-based Adjustments

Deactivations

(1 CARC and 1 RARC deactivated by Code Committees)

  • N/A

Modifications

(1 CARC description and 7 RARC descriptions modified by Code Committees)

The 1 modified CARC was in the existing CORE Code Combinations, resulting in the following update:

  • Modification of CARC 61 in CORE-defined Business Scenario #3

The 7 modified RARCs could be considered for addition to the CORE Code Combinations, resulting in the following updates:

  • Addition of modified RARCs N414 and N416 to CARC 96 in CORE-defined Business Scenario #3
  • Addition of modified RARCs N411, N412, N413, N414, N415, N416, and N417 to CARC 119 in CORE-defined Business Scenario #3
  • Addition of modified RARC N415 to CARC 188 in CORE-defined Business Scenario #3
  • Addition of modified RARCs N411 and N412 to both CARCs 222 and 273 in CORE-defined Business Scenario #3

Additions

(1 new CARC and 4 new RARCs added by Code Committees)

The 1 new CARC met the CORE Code Combinations Evaluation Criteria and was considered for addition to the CORE Code Combinations, resulting in the following update:

  • Addition of CARC 278 and 1 associated RARC to CORE-defined Business Scenario #3 (a total addition of 2 code combinations)
1 of the 4 new RARCs met the CORE Code Combinations Evaluation Criteria and was considered for addition to the CORE Code Combinations, resulting in the following update:
  • Addition of RARC N773 to CARC 272 in CORE-defined Business Scenario #3

      

Summary of Market-based Adjustment in the October 2016 Version of the CORE Code Combinations

Market-based Adjustment Type

October 2016 CORE Code Combinations v3.3.1 Market-based Adjustment

Deferred Removal

  • Removal of RARC M1 from CARC 252 in CORE-defined Business Scenario #1

 

 

 

Timeline for Updates and Compliance with Updated CORE Code Combinations

The CORE Code Combinations are updated at scheduled intervals to align with updates to the published CARC and RARC lists, which are maintained by CARC/RARC Code Committees external to CAQH CORE. The following table illustrates the timeline.

Timeline for Updates to the CORE Code Combinations

Projected Dates of CARC & RARC List Updates

Scheduled Publication Date of CORE Code Combinations
(approximately 3 months after list updates)

Mandated Compliance Date for CORE Code Combinations

(90 days after date of publication)

~November 1

February 1

May 1

~March 1

June 4

September 4

~July 1

October 1

January 1

 

Beginning January 1, 2014, HIPAA-covered entities have 90 days to comply with published updates to the CORE Code Combinations.

Exception: In some instances, the effective date for code modifications and deactivations approved by the code maintenance committees is more than six months after publication of the updated code list. To accommodate code modifications or deactivations that go into effect after the compliance date for the new version of the CORE-required Code Combinations for CORE-defined Business Scenarios (e.g. adjustments with effective dates greater than six months from the code list publication date), CAQH CORE has incorporated the following exceptions to the 90 day compliance timeframe:

  1. Any deactivated CORE-required CARCs and RARCs may continue to be used until the effective deactivation/stop date as published by the respective code maintenance committee
  2. Any modified CORE-required CARCs and RARCs may continue to be used with their previous description until the effective date of the code description modification as published by the respective code maintenance committee

After the effective date, the unmodified or deactivated code can only continue to be used in “derivative business transactions”. Derivative business transactions are business messages where the CARC or RARC is being reported from an original business message that was initiated prior to the code adjustment effective date.

NOTE: The 04/19/13 CMS Notice to the Industry states that because the Maintenance Process was adopted in the IFC, covered entities should understand that revised and updated versions of the CORE Code Combinations are part of the regulation (applies to both Compliance and Market-based Adjustments to current CORE-defined Business Scenarios); covered entities are responsible for complying with the latest version.

Impact by Stakeholder Type

The CAQH CORE 360: Uniform Use of CARCs and RARCs Rule requirements and the impact of updated versions of the CORE Code Combinations vary depending on an entity’s stakeholder type.

NOTE: ACA Section 1104 mandates that all HIPAA covered entities comply with the EFT & ERA Operating Rules; however non-HIPAA covered entities play a crucial role in enabling their provider and health plan clients to realize the benefits of industry adoption and often act as Business Associates on behalf of a HIPAA covered entity.

 

 

Creators of the X12 v5010 835

Receivers of the X12 v5010 835

Applicable Stakeholder Types

Any organization with systems that creates the X12 v5010 835, which may include:

·   Health plans and/or PMB agents

·   Health plan-facing clearinghouses

·   Health plan-facing vendors

·   Health plan business associates

Any organization with systems that receive the X12 v5010 835 and extracts data for manual processing, which may include:

·      Providers

·      Provider-facing clearinghouses

·      Provider-facing vendors

·      Provider business associates

What requirements apply to my organization?

 

(Please refer to CAQH CORE 360 Rule for a full list of applicable rule requirements)

Systems creating the X12 v5010 835  must have the ability to:

·   Align its internal codes and corresponding business scenarios to the CORE-defined Business Scenarios CARC, RARC, CAGC and NCPDP Reject Code combinations specified in the CORE Code Combinations

·   Support the maximum CORE-required Code Combinations  in the v5010 X12 835 as specified in CORE Code Combinations

o   No other code combinations are allowed for use in the CORE-defined Business Scenarios.

o   When specific CORE-required Code Combinations are not applicable to meet the health plan’s or its PBM agent’s business requirements within the CORE-defined Business Scenarios, the health plan and its PBM agent is not required to use them

o   The only exception to this maximum set of CORE-required Code Combinations is when the respective code committees responsible for maintaining the codes create a new code or adjust an existing code. Then the new or adjusted code can be used with the Business Scenarios and a Compliance-based Review will consider the ongoing use of these codes within the maximum set of codes for the Business Scenarios

o   A deactivated code must not be used

·   In the case where a health plan or its PBM agent wants to use an existing code combination that is not included in the maximum code combination set for a given CORE-defined Business Scenario, a new code combination must be requested in accordance with the CORE Code Combinations Maintenance Process

·      When receiving a v5010 X12 835, a product extracting the data from the X12 v5010 835 for manual processing must make available to the end user:

o   Text describing the CARC/RARC/CAGC and CARC/NCPDP Reject Codes included in the remittance advice, ensuring that the actual wording of the text displayed accurately represents the corresponding code description specified in the code lists without changing the meaning and intent of the description

And

o   Text describing the corresponding CORE-defined Business Scenario

·      The requirement to make available text describing the corresponding CORE-defined Business Scenario to the end user does not apply to retail pharmacy

·      This requirement does not apply to an entity that is simply forwarding the X12 v5010 835 to another system for further processing

 

What does my organization need to do when an updated version of the CORE Code Combinations is published?

Organizations with systems that create the X12 v5010 835 should:

·   Adjust systems to support the maximum set of CORE-required Code Combinations and minimum set of CORE-defined Business Scenarios as specified in the updated version of the CORE Code Combinations for each version update

·   Implement an ongoing maintenance process given the CORE Code Combinations will be updated three times per year

Organizations with products that receive the X12 v5010 835 and extract data for manual processing should:

·     Adjust systems to ensure appropriate text is displayed as specified in the updated version of the CORE Code Combinations for each version update

·     Implement an ongoing maintenance process given the CORE Code Combinations will be updated three times per year

 

Providers should:

·     Ensure vendor /clearinghouse/other business associate (e.g. receiver of the v5010 X12 835) has updated its systems to align with the updated version of the CORE Code Combinations

·     Monitor code combinations sent via the v5010 X12 835 to ensure alignment with the updated version of the CORE Code Combinations

o   Report non-compliance to CMS as appropriate

 

The CORE Code Combinations Maintenance Process

The CARC and RARC lists are authored and maintained by CARC/RARC Code Committees designated by the Secretary of Health and Human Services.  Addition, modification, or removal of codes must be addressed by the appropriate committee, either the Claim Adjustment Status Code Maintenance Committee or Remittance Advice Remark Code Committee; this is out of scope for CAQH CORE. The CARC/RARC Code Committees meet and publish updates on the Washington Publishing Company’s website three times per year. The CAGCs are part of the X12 835 standard and are thus maintained by ASC X12.

 

CARCs

(Claim Adjustment Status Code Maintenance Committee)

RARCs

(Remittance Advice Remark Code Committee)

CAGCs

(ASC X12)

  • Total # of CARCs: 268
    • not all in CORE Code Combinations
  • There are approximately 35 CARC Committee members representing a variety of stakeholder including health plans, associations, vendors, and government entities
  • Entities can complete the CARC Change Request Form
  • Total # of RARCs: 932
    • not all in CORE Code Combinations
  • The RARC Committee members represent various components of CMS
  • Entities can complete the RARC Change Request Form
  • Total # of CAGCs: 4
    • All are in CORE Code Combinations
  • Part of the ASC X12 standard, therefore, can only be revised when a new HIPAA mandated version of X12 standards is issued; current version is ASC X12 v5010
  • Entities can submit a request to ASC X12

The CORE Code Combinations are maintained by the CAQH CORE Code Combinations Task Group.

The CAQH CORE Code Combinations Task Group conducts two types of reviews and adjustments of the CORE Code Combinations as part of its ongoing CAQH CORE Code Combinations Maintenance Process required by CAQH CORE 360 Rule:

Compliance-based Reviews: Occur three times per year and consider only additions, deactivations, or modifications to the current published CARC and RARC lists by the code committees since the last update to the CORE Code Combinations

Market-based Reviews: Occur once a year and address ongoing and evolving industry business needs. A Market-based Review considers industry submissions addressing:

·         Adjustments to the existing CORE Code Combinations for existing CORE-defined Business Scenarios (additions, removals, etc.) based on real-world usage data and/or a strong business case

·         Addition of new CORE-defined Business Scenarios and associated CORE-required Code Combinations based on real-world usage data and a strong business case

CAQH CORE has also established a Code Combinations Emergency Update Process.

The timeline below lays out the general timeframes for the CARC/RARC Code Committees and the CAQH CORE Code Combinations Maintenance Process. 

calendar_min2.PNG

*Goal is to publish the Market Adjustments  with Compliance-based Adjustments to ensure only 3 annual updates to the CORE Code Combinations. 
 

To learn more about the CORE Code Combinations Maintenance Process, see the FAQs for CAQH CORE 360 Rule. Questions include:

#8: How does the CAQH CORE 360 Rule address the need for the CORE-required Code Combinations for CORE-defined Business Scenarios to align with changes to the published CARC and RARC lists made by the respective Code Maintenance Committees as well as ongoing and evolving industry business needs?

#9: How are the CORE-required Code Combinations for CORE-defined Business Scenarios maintained via the CAQH CORE Code Combinations Maintenance Process?

#10: What is a CAQH CORE Code Combinations Compliance-based Review? When do these reviews occur?

#11: What is a CAQH CORE Code Combinations Market-based Review? When do these reviews occur?

#12: How can my organization submit codes for consideration during the CAQH CORE Code Combinations Market-based Review?

#15: How can my organization submit new Business Scenarios for consideration during the CAQH CORE Code Combinations Market-based Review?

#28: How will organizations be notified about and access new versions of the CORE-required Code Combinations for CORE-defined Business Scenarios?

#29: What is the schedule for adjustments to be made to the CORE-required Code Combinations for CORE-defined Business Scenarios?

 

How to Submit Market-based Adjustments

Why: CAQH CORE’s annual Market-based Reviews enable the industry to make adjustments to the CORE Code Combinations to address ongoing and evolving industry business needs such as new products and regulations.

Who: All entities that create, use or transmit HIPAA-covered transactions, plus all CAQH CORE Participants, may submit potential adjustments via the online 2016 Market-based Adjustments Survey.

How: The 2016 Market-based Review (MBR) will consider adjustments to the code combinations in the existing four CORE-defined Business Scenarios. Potential code combination adjustments that can be submitted via the online CAQH CORE 2016 Market-based Adjustments Survey include additions, removals, or relocations. As part of the CORE Code Combinations Maintenance Process, potential adjustments are considered within the context of the criteria used to evaluate the code combinations, how often they are used and the business case for the adjustments.

When: The 2016 Industry-wide Potential Market-based Adjustments Submission Period opened on Wednesday, November 30, 2016 and will close on Tuesday, January 31, 2017 (a 60-day submission period).

Next Steps: The CORE Code Combinations Task Group (i.e., Task Group) will review the submissions received via the 2016 Market-based Adjustments Survey from late February through May 2017. After the Task Group completes its review, an updated version of the CORE Code Combinations will be published and will include any Task Group-approved code combination adjustments.

Additional Resources:

  • Detailed instructions on how to complete the online survey can be found HERE. It is strongly recommended that organizations read the Instructions before beginning their submission
  • A sample completed CAQH CORE 2016 Market-based Adjustments Survey is available HERE for consultation as you plan your submission. 
  • CAQH CORE holds a training session to provide the industry with guidance on completing the market-based adjustments submission process. Materials from this training, including a video recording of the training, are available via the online CAQH CORE Education and Implementation Resource Center.  

 

Get Involved in the CAQH CORE Code Combinations Maintenance Process

Entities are encouraged to join CAQH CORE as a Participating Organization to:

  • Contribute to the evolution of CAQH CORE 360 Rule and the CORE Code Combinations via the CAQH CORE Code Combinations Task Group
  • Have a voice in the development of operating rules
  • Be part of a solution that is taking cost and complexity out of the healthcare system

CAQH CORE welcomes Participating Organizations representing a range of stakeholder groups.

Entities can also contribute a number of other ways, for example:

  • Submission of Market-based Adjustments to the CORE Code Combinations
  • Work directly with CMS OESS, the standard setting bodies like ASC X12, and the various industry code committees to advance industry knowledge
  • Attend CAQH CORE Town Hall Calls
    •  CAQH CORE holds bimonthly Town Hall calls to provide attendees an update on recent activities including status of CORE Code Combinations; enter your contact information below to be added to the distribution list
  • Respond to public surveys or submit requests to CORE@caqh.org

Trading Partner Collaboration: Conformance Testing and Voluntary CORE Certification

  • Conformance testing with your trading partners is a critical aspect to making your  operating rules implementation a success
    • HIPAA covered entities can quickly communicate their organization’s readiness to testing their conformance with trading partners by adding their company information to the CORE Partner Testing page of the CAQH website
    • Entities should consider voluntary CORE Certification to publicly communicate their systems meet the CAQH CORE EFT & ERA Operating Rule requirements

Contact CAQH CORE

CORE Code Combos

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