CAQH CORE Phase I 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 I 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 I Policies and Rules

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

CORE Phase I Policies (100-105)

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

100: Guiding Principles

101: Pledge

102: Certification Policy

103: Exemption Policy

104: Testing Policy

105: Enforcement Policy

CORE Phase I Operating Rules (150-157)

150: Batch Acknowledgements Rule

151: Real Time Acknowledgements Rule

152: Companion Guide Rule

153: Connectivity Rule

154: Eligibility (270-271) Data Content Rule

155: Eligibility_Benefits Batch Response Time Rule

156: Eligibility_Benefits Real-Time Response Time Rule

157: System Availability Rule

Phase I: Certification Test Suite

Archive: The Phase I and Phase II CAQH CORE 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 I Rules, CORE Phase I certification or applying for a CORE seal, please contact CAQH at (202) 861-1492 or email CORE.

To view the CORE Phase II rules click here.

CAQH Program: