CAQH CORE Eligibility & Claim Status Operating Rules

I. Overview of CAQH CORE Eligibility & Claim Status Operating Rules

  1. What do the Phase I and Phase II CAQH CORE Eligibility & Claim Status Operating Rules address?
  2. Why are the Phase I CAQH CORE Operating Rules only for the eligibility/benefits transactions?
  3. What entities should implement the Phase I and Phase II CAQH CORE Eligibility and Claim Status Operating Rules?
1. What do the Phase I and Phase II CAQH CORE Eligibility & Claim Status Operating Rules address?

The Phase I and Phase II CAQH CORE Eligibility 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 and Claim Status Operating Rules address the following: 

The Phase I and Phase II CAQH CORE Rules also address standard testing, certification, and enforcement processes to ensure CAQH CORE conformance for entities seeking CORE Certification.

2. Why are the Phase I CAQH CORE Operating Rules only for the eligibility/benefits transactions?

The CORE Participants determined that the CAQH CORE Operating Rules could have the most immediate impact if Phase I focused on improving eligibility and benefits verification. CORE Participants decided to address only the X12 270/271 electronic data interchange (EDI) eligibility transactions in Phase I along with the necessary infrastructure needs including the use of the ASC X12 Implementation Acknowledgement (999) with later phases of CAQH CORE to include other types of transactions. Phase II CAQH CORE, for example, includes operating rules for both the X12 270/271 eligibility transaction and the X12 276/277 claims status transaction, as well as extending the use of the ASC X12 Implementation Acknowledgement (999) to the X12 276/277.

3. What entities should implement the Phase I and Phase II CAQH CORE Eligibility and Claim Status Operating Rules?

As the ACA Administrative Simplification provisions build on and update the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), ACA Section 1104 requires all HIPAA covered entities to comply with the ACA-mandated standards and applicable operating rules by their compliance dates. The CMS website provides charts to help organizations determine whether an organization or individual is a HIPAA covered entity.

The first set of Federal operating rules addresses the eligibility and claims status transactions; the compliance date for these operating rules was January 1, 2013. In December 2011, HHS adopted the Phase I and Phase II CAQH CORE Eligibility and Claim Status Operating Rules to fulfill the ACA Section 1104 Federal mandate, with the exception of rule requirements pertaining to use of Acknowledgements. By January 1, 2013, HIPAA covered entities must meet all technical rule requirements outlined in the CAQH CORE Eligibility and Claim Status Operating Rules (both Phase I and Phase II) that apply to their organizations, except implementation of the rule requirements for Acknowledgements.

See CAQH CORE FAQs Part B: ACA Section 1104 Mandate for Federal Operating Rules for more information on the ACA Section 1104 Administrative Simplification provisions.

Please Note: CMS is the HHS 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 Office of E-Health Standards and Services (OESS) enforces the regulations addressing the HIPAA and ACA-mandated transactions, national identifiers, operating rules, health plan certification, and additional standards. More detailed information on the provisions, as well as compliance and enforcement requirements, is available on the CMS website and via the CMS FAQs.