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
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.
II. Introduction to CAQH CORE Participation
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.
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 and Claim Status Operating Rules
These FAQs address technical rule requirements and stakeholder specific implementation for the Eligibility & Benefits and Claim Status sets of ACA-mandated operating rules. (Formerly 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: CAQH CORE Payment & Remittance Operating Rules
These FAQs address technical rule requirements and stakeholder specific implementation for the EFT & ERA set of ACA-mandated 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 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.
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
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 f: Phase V CAQH CORE Operating Rules
Implementation of the Phase V CAQH CORE Operating Rules is currently voluntary. HHS will determine if the Phase V CAQH CORE Operating Rules will be included in any regulatory mandates. The Phase V FAQs are for use by entities completing voluntary implementation of the operating rules and/or pursuing Phase V CORE Certification.
These FAQs address technical rule requirements and stakeholder specific implementation for the 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 G: 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.
Part H: Certification: ACA Section 1104 Certification, CORE Certification, Proposed CORE HIPAA Credential, and CORE Endorsement
These FAQs address certification-related topics including CORE Certification policies, CORE Certification testing 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
