Phase I & II CAQH CORE Eligibility & Claim Status Operating Rules

II. Interdependent CAQH CORE Eligibility & Claim Status Requirements

1. What are the CAQH CORE Eligibility and Claim Status Rule requirements for entities to support Real Time and/or Batch Processing?

The ACA-mandated CAQH CORE Eligibility & Claim Status Operating Rules require that all entities support real time processing of both the X12 270/271 and X12 276/277 transactions. Real time requirements are addressed in the following ACA-mandated CAQH CORE Eligibility & Claim Status Operating Rules:

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 & Claim Status Operating Rules. Batch requirements are addressed in the following ACA-mandated CAQH CORE Eligibility & Claim Status Operating Rules:

NOTE: The HHS Final Rule adopting the Phase I and Phase II CAQH CORE Eligibility and Claim Status Operating Rules to fulfill the ACA Section 1104 Federal mandate excludes rule requirements pertaining to the use of Acknowledgements. However, entities seeking Phase I &/or Phase II CORE Certification must implement all of the CAQH CORE Eligibility and Claim Status Operating Rules applicable to their stakeholder type, including those rule requirements pertaining to use of Acknowledgments

2. Are there any CAQH CORE Eligibility and Claim Status Operating Rules that provide requirements regarding how often claim status inquiries or eligibility transactions should be submitted? (e.g., do CAQH CORE Operating Rules either support or exclude a provider or vendor from sending daily batches of claim status inquiries for every outstanding claim, regardless of the status response received the previous day?)

No. Neither the Phase I nor Phase II CAQH CORE Eligibility and Claim Status Operating Rules address the frequency of submission for either eligibility inquiries or claim status inquiries.

However, both the Phase I and Phase II Rules require all entities to support real time. The frequency of submission should not be an issue since it is anticipated that eligibility or claim status inquiries can be submitted as frequently as needed by the provider. Per the CAQH CORE Eligibility and Claim Status Operating Rules, a health plan is required to have its systems supporting eligibility and claim status inquiries available 86% of the time over a calendar week.

Batch processing is optional and not required by the CAQH CORE Eligibility and Claim Status Operating Rules. If, however, batch processing mode is offered, conformance to applicable CAQH CORE Eligibility and Claim Status Operating Rules requirements is required.

3. Do the CAQH CORE Eligibility Operating Rules apply when an entity is providing eligibility transaction services as an Application Service Provider (ASP) for providers and the entity translates the non-standard eligibility transactions in a proprietary format into the standard transaction or vice versa as provided for in §162.930 Additional Rules for Healthcare Clearinghouses of the HIPAA Transactions Final Rule?

Yes. Since the Phase I and Phase II CAQH CORE Eligibility and Claim Status Operating Rules build on the X12 270/271 transactions, an ASP acting as a provider’s health care clearinghouse would have to comply with all of the applicable CAQH CORE Eligibility and Claim Status Operating Rules in order to be conformant with the Phase I and II CAQH CORE Rules.

4. Does my organization have to return eligibility information if the requester of the information does not meet my organization's requirements for patient identification?

The Phase I and Phase II CAQH CORE Eligibility and Claim Status Operating Rules address rules that will improve patient matching rates (CAQH CORE 258: Normalizing Patient Last Name Rule and CAQH CORE 259: AAA Error Code Reporting Rule), but do not address/include any rules for your organization’s policies on patient identification requirements.

5. Do the CAQH CORE Eligibility and Claim Status Operating Rules apply to Direct Data Entry (DDE)?

No. Per CMS, the ACA-mandated CAQH CORE Eligibility & Claim Status Operating Rules would not apply to DDE transactions; see CMS FAQ 6117 for more information.