CAQH CORE has updated its operating rule structure. The CAQH CORE FAQs are in the process of being updated to align with the new structure. CAQH CORE appreciates your patience as these updates are made.
Implementation of the CAQH CORE Operating Rules for Eligibility & Benefits, Claim Status and Payment & Remittance is mandated for all HIPAA-covered entities by the ACA (with the exception of requirements pertaining to acknowledgments). Implementation of the CAQH CORE Operating Rules for Prior Authorization & Referrals, Health Care Claims, Benefit Enrollment and Premium Payment is currently voluntary. HHS will determine whether the voluntary CAQH CORE Operating Rules will be included in any future regulatory mandates. CAQH CORE offers CORE Certification for all the CAQH CORE Operating Rules
CAQH CORE has developed Frequently Asked Questions (FAQs) addressing all 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.
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
part b: ACA Section 1104 Mandate for Federal Operating Rules
I. Overview: ACA Section 1104 Provisions for Federal Operating Rules
III. Requirements for Federal Operating Rules Addressing the Payment & Remittance Transactions
part c: CAQH CORE Eligibility & Benefits Operating Rules
I. Overview of CAQH CORE Eligibility & Benefits Operating Rules
II. Interdependent CAQH CORE Eligibility & Benefit Requirements
III. CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule
IV. CAQH CORE Eligibility & Benefits Data Content (270/271) Rule
V. CAQH CORE Eligibility & Benefits (270/271) Single Patient Attribution Data Rule
part d: CAQH CORE Claim Status Operating Rules
part e: CAQH CORE Payment & Remittance Operating Rules
I. Overview of CAQH CORE Payment & Remittance Operating Rules
II. Interdependent CAQH CORE Payment & Remittance Requirements
III. CAQH CORE Payment & Remittance (835) Infrastructure Rule
IV. CAQH CORE Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule
V. CAQH CORE Payment & Remittance Reassociation (CCD+/835) Rule
VI. CAQH CORE Payment & Remittance EFT Enrollment Data Rule
VII. CAQH CORE Payment & Remittance ERA Enrollment Data Rule
VIII. Resources for Implementing the CAQH CORE Payment & Remittance Operating Rules
part f: 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
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 Rule
part g: Phase V CAQH CORE Operating Rules
I. Overview of Phase V CAQH CORE Operating Rules
II. Phase V CAQH CORE Prior Authorization 278 Request / Response Data Content Rule
Part h: CAQH CORE Operating Rules in Development
Part i: Certification: ACA Section 1104 Certification, CORE Certification, 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
- i. CORE Certification Testing Overview
- ii. Eligibility & Benefits CORE Certification Testing
- iii. Claim Status CORE Certification Testing
- iv. Payment & Remittance CORE Certification Testing
- v. Prior Authorization & Referrals CORE Certification Testing
- vi. Health Care Claims CORE Certification Testing
- vii. Benefit Enrollment CORE Certification Testing
- viii. Premium Payment CORE Certification Testing
III. Introduction to Proposed CORE HIPAA Credential
