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

V. CAQH CORE 152: Companion Guide Rule

1. Why was the CAQH CORE 152: Companion Guide Rule Version 1.1.0 created?

Health plans have independently created companion guides that often vary in format and structure. Such variance can be confusing to trading partners and providers. CAQH CORE adapted its CAQH CORE Master Companion Guide Template based on the CAQH/WEDI Best Practices Companion Guide Template developed jointly in 2003, with input from multiple health plans, system vendors, provider representatives and healthcare/HIPAA industry experts. The template organizes information into several simple sections and provides for a common information flow and format, while at the same time giving health plans the flexibility to tailor the document to meet their particular needs. The template covers a broad range of HIPAA-mandated transaction sets and is not specific to any one of them.

2. Does the CAQH CORE 152 Rule require a change to my entire current Companion Guide documents for the X12 837 claims?

No. Similar to the other Phase I CAQH CORE Operating Rules, the scope of the CAQH CORE 152: Companion Guide Rule Version 1.1.0 is limited to the X12 270/271 eligibility and benefits inquiry/response transactions.

3. Can I combine multiple transaction sets (e.g., X12 270/271 and 276/277) in a single Companion Guide?

Yes. Entities, may, if they wish, combine their Companion Guides for separate transactions into a single document. The flow and format of the CAQH CORE v5010 Master Companion Guide Template would still need to be followed, but sections could be repeated, tables added for the second transaction, etc., without altering said flow and format.

4. If pursuing CORE Certification, will all of the detailed content of my organization’s X12 270/271 Companion Guide be analyzed and evaluated for certification testing?

No. If completing CORE Certification testing, your organization is only required to submit to the CAQH CORE-authorized testing vendor:

  1. The Companion Guide’s table of contents
  2. A page showing your organization’s requirements for the presentation of segments, data elements and codes.

Your selected CAQH CORE-authorized testing vendor will assess these documents to determine that your Companion Guide conforms to the CAQH CORE required flow and format.

5. For entities seeking CORE Certification, how does CAQH CORE determine conformance with the CAQH CORE V5010 Master Companion Guide template?

The CAQH CORE 152 and 250 Rules require health plan Companion Guides covering the X12 270/271 and X12 276/277 transactions to follow the format/flow as defined in the CAQH CORE v5010 Master Companion Guide Template.

As part of CORE Certification testing, CAQH CORE-authorized testing vendors evaluate the following to determine if an entity’s Companion Guide(s) conforms to the CAQH CORE 152 & 250 Rules Companion Guide Requirements:

  • If the order of the Companion Guide table of contents matches the table in the CAQH CORE v5010 Master Companion Guide Template

  • If the Companion Guide format for specifying the X12 270/271 &/or X12 276/277 data content requirements is consistent with the format in the CAQH CORE v5010 Master Companion Guide Template

If a specific section(s) of the CAQH CORE v5010 Master Companion Guide Template is not appropriate for a particular entity’s Companion Guide, the CAQH CORE 152 and 250 Rules do allow the entity to exclude this section(s) from their guide.

6. Does the CAQH CORE 152 Rule require HIPAA covered entities to publish a Companion Guide if they do not currently do so?

No. The CAQH CORE Operating Rules do not require any entity to publish a Companion Guide if they do not already do so. CAQH CORE 152: Companion Guide Rule specifies that should an entity publish a company guide, it must conform to the format/flow as defined in the CAQH CORE v5010 Master Companion Guide Template.

7. Does the CAQH CORE 152 Rule require health plans to request approval from ASC X12 prior to publication of their CORE-compliant Companion Guide(s)?

No. The Federally mandated CAQH CORE Eligibility & Claim Status Operating Rules, as adopted by HHS, do not require any entity to submit its Companion Guide to ASC X12 for review and approval prior to publication.

Entities seeking CORE Certification are required to submit to the CAQH CORE-authorized testing vendor: 1) The Companion Guide’s table of contents and 2) A page showing the organization’s requirements for the presentation of segments, data elements and codes. The CAQH CORE-authorized testing vendor will evaluate these documents to determine if they are consistent with the format in the CAQH CORE v5010 Master Companion Guide Template.