Frequently Asked Questions - I. General CAQH CORE Eligibility & Benefits Operating Rules Questions

What do the CAQH CORE Eligibility & Benefits (270/271) Operating Rules address?

Submitted by dasteriadis@caqh.org on Wed, 07/28/2021 - 12:59
What do the CAQH CORE Eligibility & Benefits (270/271) Operating Rules address?

The CAQH CORE Eligibility & Benefits (270/271) Operating Rules address the following: 

Eligibility Rule

Addresses

High-Level CAQH CORE Key Requirements

Data Content

Need to drive further industry value in transaction processing

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Respond to generic and explicit inquiries for a defined set of 175+ service type codes and 4 categories of services for procedure codes with:

  • Health plan name
  • 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
  • Delivery of Telemedicine Benefits
  • Maximum and Remaining Coverage Benefits
  • Authorization or Certification Determination
  • Communication of Tiered Benefits
  • Enhanced Patient Identification
  • Error Reporting Requirements

Infrastructure

Industry needs for common guidelines/accessible documentation

  • Companion Guide – common flow/format
  • System availability service levels – minimum 90% 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 Public Internet e.g., supports plug and play method (SOAP and digital certificates and clinical/administrative alignment)
  • Acknowledgements (transactional)*

Single Patient Attribution**

Provider need for attribution information at point of service for value-based arrangements.

  • Requires a health plan (or its agent) to return the patient attribution status (yes/no/partial) and effective dates of attribution.
  • Data content rule standardizes the minimum data elements a health plan must return to identify patients within the VBP population, including a VBP contract name and effective dates of attribution
  • Infrastructure rule standardizes expectations for exchange and requires health plans to send providers an updated attributed patient roster (including updated dates of effective attribution) at least once per month

*The HHS Final Rule excludes rule requirements pertaining to use of Acknowledgments.

**This rule was approved by CAQH CORE Participants in 2020 and is not federally mandated.

The CAQH CORE Eligibility & Benefits (270/271) Operating Rules also address standard testing, certification, and enforcement processes to ensure CAQH CORE conformance for entities seeking CORE Certification.

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What entities should implement the CAQH CORE Eligibility & Benefits (270/271) Operating Rules?

Submitted by kcooper@caqh.org on Tue, 04/19/2022 - 16:28
What entities should implement the CAQH CORE Eligibility & Benefits (270/271) Operating Rules?

The CAQH CORE Eligibility & Benefits Operating Rules apply to all HIPAA covered entities or their agents that conduct the following transactions:

  • X12 v5010X279A1 Health Care Eligibility Benefit Inquiry and Response (270/271) Technical Report Type 3 (TR3) and associated errata

NOTE: Entities acting in the role of a Business Associate of a HIPAA covered entity may also need to implement various aspects of the CAQH CORE Eligibility & Benefits Operating Rules. The HHS website provides charts to help organizations determine whether an organization or individual is a HIPAA covered entity. Currently, the CAQH CORE Eligibility & Benefits (270/271) Operating Rules are federally mandated under ACA Section 1104 for all HIPAA covered entities. Please note requirements around acknowledgements and CAQH CORE Eligibility & Benefits Single Patient Attribution rule have not been adopted by HHS for mandatory adoption. HHS will determine if the CAQH CORE Eligibility & Benefits Single Patient Attribution Rule and CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule Requirements around acknowledgments will be included in any regulatory mandates. Stakeholder entities are immediately eligible to implement the operating rules and to pursue CORE Certification.

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What CAQH CORE Eligibility & Benefits (270/271) Operating Rules are mandated under the ACA?

Submitted by kcooper@caqh.org on Tue, 04/19/2022 - 16:30
What CAQH CORE Eligibility & Benefits (270/271) Operating Rules are mandated under the ACA?

As the ACA Administrative Simplification provisions build on and update the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), ACA §1104 requires all HIPAA- covered entities to comply with the ACA-mandated standards and applicable operating rules by their compliance dates.

The first set of Federal operating rules addresses the eligibility & benefits transaction; the compliance date for these operating rules was January 1, 2013. In December 2011, HHS adopted the CAQH CORE Eligibility & Benefits (270/271) Infrastructure and Data Content Operating Rules to fulfill the ACA §1104 Federal mandate, with the exception of rule requirements pertaining to use of Acknowledgements. Additionally, the CAQH CORE CAQH CORE Eligibility & Benefits (270/271) Single Patient Attribution Data Rule, added to the rule set in 2020, is not included in the ACA mandate.

NOTE: HHS is the designated authority on any decisions regarding interpretation, implementation, and enforcement of the regulations adopting the HIPAA and ACA Administrative Simplification standards and provisions. Within CMS, the National Standards Group (NSG) enforces the regulations addressing the HIPAA and ACA-mandated transactions, national identifiers, operating rules, health plan certification, and additional standards.

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What resources are available to assist my organization with implementation of the CAQH CORE Eligibility & Benefits (270/271) Operating Rules?

Submitted by kcooper@caqh.org on Tue, 04/19/2022 - 16:32
What resources are available to assist my organization with implementation of the CAQH CORE Eligibility & Benefits (270/271) Operating Rules?

CAQH CORE has several resources and tools available at no cost to assist entities with implementation of the CAQH CORE Eligibility & Benefits (270/271) Operating Rules, including:

  • CAQH CORE has developed an Eligibility & Benefits Analysis & Planning Guide to assist entities with determining which CAQH CORE Rule requirements their organization will need to comply, which CAQH CORE Rule requirements are outsourced, and with identifying the remediation necessary to ensure conformance of outsourced functions. The Analysis & Planning Guide includes three tools:
      • CAQH CORE Stakeholder & Business Type Evaluation to determine your organization’s stakeholder type(s) and understand the role of your intermediaries that conduct the eligibility transactions
      • CAQH CORE Systems Inventory & Impact Assessment Worksheet to assess your organization’s external and internal systems that conduct eligibility transactions and are impacted by the CAQH CORE Operating Rules
      • CAQH CORE Gap Analysis Worksheet to determine the level of system(s) remediation necessary for your organization to adopt the business requirements of the CAQH CORE Operating Rules
  • CAQH CORE holds frequent education sessions with various industry partners on implementation of the CAQH CORE Operating Rules. Information on upcoming sessions and materials (both slides & audio) from past sessions is available on the CAQH website.
  • CORE Certification also offers a useful resource for entities to ensure successful implementation of applicable CAQH CORE Eligibility & Benefits (270/271) Rule requirements. CORE Certification has been embraced by many entities given its value in assisting with CAQH CORE Operating Rule adoption and ensuring the greatest ROI is achieved with trading partners. CORE Certification testing with a CAQH CORE-authorized testing vendor is available online at no cost to entities.
  • For every CAQH CORE Operating Rule for a particular transaction, a CORE Certification Master Test Suite is developed that outlines all the requirements for entities seeking CORE Certification. These test suites include information about key concepts such as the role of trading partners that also apply to the general adoption of the CAQH CORE Eligibility & Benefits (270/271) Operating Rules, beyond CORE Certification. See Eligibility & Benefits Master Test Suite to learn more.
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Do the CAQH CORE Eligibility & Benefits (270/271) Operating Rules apply to Direct Data Entry (DDE)?
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