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

IV. CAQH CORE 151: Real Time Acknowledgements Rule

1. Does the CAQH CORE 151: Real Time Acknowledgement Rule mean that my organization’s system must always return both of these types of Acknowledgements: ASC X12 Implementation Acknowledgement (999) and the X12 271 response?

No. For real time inquiries, your organization’s system must return the X12 271 response or an ASC X12 Implementation Acknowledgement (999) when the functional group is rejected, to be conformant with this rule. Thus, your organization’s system must return only one of these transactions, depending on the processing results, not both.

2. Can a clearinghouse or vendor act on behalf of a health plan or provider for real time Acknowledgments?

Yes. Each health plan seeking CORE Certification will have to work with its clearinghouse and/or vendor to jointly complete CORE Certification testing in order for the health plan to be awarded the CORE Certification Seal. A clearinghouse or vendor would not be able to certify “generically” as a health plan and then transfer such certification to any health plan.

3. The TA1 Interchange Acknowledgment is described in the HIPAA Implementation Guide Appendix B: EDI Control Directory. Do the CAQH CORE Operating Rules require its use?

No. The CAQH CORE Acknowledgement Rules do not address the use of the ASC X12 Interchange Acknowledgement TA1. 

4. Is an acknowledgement necessary if the user sends eligibility data in a proprietary (not an X12 270) format in a real time mode?

Good business practices for electronic message exchange encourage all senders and receivers to appropriately acknowledge receipt and both acceptance/rejection and errors found in any message. Accordingly, the Phase I CAQH CORE Rules are focused on the conduct of the HIPAA-named X12 270/271 transaction sets. CAQH CORE Rules are focused on the ASC X12 standards as well. Thus, the CAQH CORE 151 Rule only addresses the use of the ASC X12 Implementation Acknowledgement (999) and when to use it when conducting the X12 270/271 transaction sets. Additionally, in order to become CORE-certified, an entity is required to attest to its compliance with HIPAA, which requires the use of the appropriate X12 implementation guides.

5. Are all CAQH CORE Operating Rules with regard to acknowledgement only applicable to scenarios where my organization receives data in an X12 270 format?

Yes. Good business practices for electronic message exchange encourage all senders and receivers to appropriately acknowledge receipt and both acceptance/rejection and errors found in any message. Accordingly, the Phase I CAQH CORE Rules are focused on the conduct of the HIPAA-mandated X12 270/271 transaction sets. CAQH CORE Operating Rules are focused on the X12 standards as well. Thus, the CAQH CORE 151 Rule only addresses the use of the ASC X12 Implementation Acknowledgement (999) and when to use it when conducting the X12 270/271 transaction sets. Additionally, in order to become CORE-certified, an entity is required to attest to its compliance with HIPAA, which requires the use of the appropriate X12 implementation guides.