ACA Section 1104 Mandate for Federal Operating Rules

II. Requirements for Federal Operating Rules Addressing the Eligibility & Claim Status Transactions

1. What do the ACA-mandated CAQH CORE Eligibility & Benefits and Claim Status Operating Rules address?

The CAQH CORE Eligibility & Benefits and Claim Status Operating Rules streamline the way eligibility/benefits and claim status healthcare administrative information is exchanged electronically. Easier, more reliable access to this information at the point of care can reduce the amount of time providers spend on administration by improving the accuracy of claims submitted, providing enhanced information on patient financial responsibility, and checking the status of a patient claim electronically.

The ACA-mandated CAQH CORE Eligibility & Benefits and Claim Status Operating Rules address the following:

Type of Rule Address high-level caqh core key requirements
data content: eligibility & benefits Need to drive further industry value in transaction processing

Respond to generic and explicit inquiries for a defined set of 50+ high volums services with:

  • Health plan name and coverage dates
  • Static financials (co-pay, co-insurance, base deductibles)
  • Benefit-specific and base deductible for individual and family
  • In/Out of network variances
  • Remaining deductible amounts
  • Enhanced Patient Identification and Error Reporting requirements
infrastructure: eligibility & benefits and claim status Industry needs for common/ accessible documentation
  • Companion Guide - commom flow/format
  • System Availability service levels - minimum 86% availability per calendar week
  • Real-time and batch turnaround times (e.g., 20 seconds or less for real time and next day for batch
  • Connectivity via internet and aligned with NHIN direction, e.g. supports plug and play method (SOAP and digital certificates and clinical/ administrative alignment
  • Acknowledgements (transactional)*

*NOTE: The HHS Final Rule excludes rule requirements pertaining to use of acknowledgements

2. What CAQH CORE Eligibility & Benefits and Claim Status Operating Rules have been adopted to fulfill the ACA Section 1104 mandate?

The December 2011 HHS Final Rule adopts the use of all the CAQH CORE Operating Rules related to the Eligibility & Benefits and Claim Status transactions to fulfill the ACA mandate, with the exception of rule requirements pertaining to use of Acknowledgements. Specifically, the Final Rule adopts the following CAQH CORE Operating Rules:

  • Rules addressing the – ASC X12N/005010X279 Health Care Eligibility Benefit Inquiry and Response (270/271) (hereafter referenced as ASC X12N v5010 270/271) Transactions:
  • Rules addressing the ASC X12N/005010X212 Health Care Claim Status Request and Response (276/277) and associated errata (hereafter referenced as ASC X12N v5010 276/277) Transactions:

NOTE: Rule requirements pertaining to use of Acknowledgements are not included for adoption in the HHS Final Rule.

3. Does the HHS Final Rule adopting the CAQH CORE Eligibility & Benefits and Claim Status Operating Rules to fulfill the ACA Section 1104 mandate require adoption of the CAQH CORE Rule requirements pertaining to use of Acknowledgements?

No. The HHS Final Rule does not require adoption of the CAQH CORE Operating Rule requirements pertaining to use of Acknowledgements. The Final Rule does note that, “without Acknowledgements, it is difficult for the sender to know whether the intended recipient received the transmission, which often results in the sender repeatedly querying the intended receiver as to the status of the transmission...until such time as the {Health and Human Services} Secretary adopts a standard for Acknowledgments, we support the industry’s ongoing voluntary use of Acknowledgements and encourage even more widespread use.”

4. What entities are required to comply with the ACA-mandated CAQH CORE Eligibility & Benefits and Claim Status Operating Rules?

By January 1, 2013, HIPAA-covered entities must meet all technical rule requirements outlined in the CAQH CORE Eligibility & Benefits and Claim Status Operating Rules  that apply to their organizations, except implementation of the rule requirements for Acknowledgements. The CMS website provides charts to help organizations determine whether an organization or individual is a HIPAA-covered entity. See the CMS website for more information on the operating rules compliance and enforcement requirements.

5. What entities are required to certify with HHS that their data and information system are in compliance with the ACA-mandated CAQH CORE Eligibility & Benefits and Claim Status Operating Rules?

Beyond general HIPAA compliance, ACA Section 1104 requires health plans to file a statement with HHS certifying that their data and information systems are in compliance with any applicable standards and associated operating rules for eligibility for a health plan and health claim status.

6. Does the HHS Final Rule adopting the CAQH CORE Eligibility & Benefits and Claim Status Operating Rules to fulfill the ACA Section 1104 mandate require HIPAA-covered entities to adopt the CAQH CORE requirements for real time processing?

Yes. The ACA-mandated CAQH CORE Eligibility & Benefits and Claim Status Operating Rules require that all entities support real time processing of both the ASC X12N v5010 270/271 and ASC X12N v5010 276/277 transactions. Real time requirements are addressed in the following ACA-mandated CAQH CORE Eligibility & Benefits and Claim Status Operating Rules:

NOTE: The CAQH CORE Operating Rules do not require entities to support batch processing if they do not currently do so. However, if entities do currently support batch processing, they must also implement and conform to all applicable batch processing requirements outlined in the ACA-mandated CAQH CORE Eligibility & Benefits and Claim Status Operating Rules. Batch requirements are addressed in the following ACA-mandated CAQH CORE Eligibility & Benefits and Claim Status Operating Rules:

7. Are entities using e-prescribing required to comply with the ACA-mandated CAQH CORE Eligibility & Benefits and Claim Status Operating Rules?

No. Per ACA Section 1104, HIPAA-covered entities must comply with all applicable requirements of the ACA-mandated CAQH CORE Eligibility & Benefits and Claim Status Operating Rules. However, CMS did not adopt operating rules for e-prescribing.

8. Do the ACA-mandated CAQH CORE Eligibility & Benefits and Claim Status Operating Rules apply to Direct Data Entry (DDE)?

No. the ACA-mandated CAQH CORE Eligibility & Benefits and Claim Status Operating Rules do not apply to DDE transactions.