The CAQH CORE Eligibility & Benefits Operating Rules enhance the exchange of eligibility information between health plans and provider through consistent infrastructure and data content requirements including the exchange of patient financial information.
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 CAQH CORE Eligibility & Benefits Operating Rules and the CAQH CORE Claim Status Operating Rules* by January 1, 2013. For more information on the mandate click HERE.
*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 CAQH CORE Eligibility & Benefits Operating Rules
- In 2020, the CAQH CORE Participants approved the CAQH CORE Eligibility & Benefits Single Patient Attribution Data Rule to enable provider notification of an attributed patient under a value-based care contract within the eligibility work flow. While implementation of this rule is not required under federal mandate, beginning in January 2022 it will be required for Eligibility & Benefits CORE Certification and in January 2023 for Recertification.
CORE Certification & Endorsement
CORE Certification for Eligibility & Benefits is available to all entities that create, transmit or use eligibility transactions. Entities that do not use, create or transmit eligibility transactions can demonstrate their support for CAQH CORE’s mission and its operating rules through CORE Endorsement.
Visit the Resource Library webpage to access FAQs, Analysis & Planning Guides, Webinars and more to support implementation of the CAQH CORE Operating Rules.
For more information about the operating rules process or CORE Certification, contact CAQH CORE at CORE@caqh.org.