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

VII. CAQH CORE 154: Eligibility & Benefits 270/271 Data Content Rule

Please refer to the Phase II CAQH CORE 260: Eligibility & Benefits (270/271) Data Content Rule FAQs. As the Phase II CAQH CORE 260 Rule builds upon and enhances the Phase I rule, both rules must be combined when determining the overall CAQH CORE rule requirements for the X12 270/271 eligibility data content.

  1. Does the CAQH CORE Rule require a DTP segment in the X12 270 inquiry at either the subscriber or dependent levels or both?
  2. Does the CORE Rule require a DTP segment in the EQ loop in a 270 Inquiry? Does the CAQH CORE Rule require a DTP segment in the EQ loop in a X12 270 inquiry?
  3. Does the CAQH CORE 154 Rule allow an inquiry about eligibility dates in the past or future?
  4. Is the ‘begin date’ the date on which coverage starts or when a patient was enrolled?
  5. Does an X12 271 response that conforms to the CAQH CORE 154: Eligibility & Benefits (270/271) Data Content Rule Version 1.1.0 guarantee that the health plan will pay a claim submitted covering the same individual?
  6. When a plan has global deductibles, can a health plan satisfy the CAQH CORE 154: Eligibility & Benefits (270/271) Data Content Rule Version 1.1.0 to report deductibles by returning a deductible amount applicable globally to the health plan only on the EB segment with service type code 30?
  7. How is pre-determination handled?
  8. For emergency services, why was Code 86 selected rather than 52?
  9. Some of our older health plans do not have a separate chiropractic benefit but include coverage for this benefit under the physician office visit benefit. In this situation it would be inaccurate to respond to an explicit X12 270 inquiry about chiropractic benefit with a "not- covered" code in EB01 per the CAQH CORE 154: Data Content Rule. How can we respond to an explicit X12 270 inquiry for chiropractic benefit in this situation and not violate the CAQH CORE 154: Data Content Rule?
  10. Is the test script for the Data Content Rule: “Extract from a valid X12 271 response transaction as defined in the CAQH CORE Rule the data indicating the name of the health plan covering the individual specified in the X12 270 eligibility inquiry," explicitly stated in the CAQH CORE 154: Eligibility & Benefits 270/271 Data Content Rule as a provider requirement?
  11. The CAQH CORE 154 Rule, Subsection 2.6 – Are all entities required to support explicit request for each of the CORE Service Types? What does ‘support’ mean? What if most do not apply to my organization?
  12. In the CAQH CORE 154 Rule, can multiple service codes be displayed?
  13. Have any other insurance companies expressed concern over the "patient responsibility" representation for coinsurance? My organization is concerned that the 90/70 type of coinsurance percentages used today (representing the percent paid by the insurer) will be confusing when displayed as a 10/30 (switching to "patient responsibility representation"). I believe it is an industry standard for the coinsurance to be displayed as the percent paid by the insurer. if my organization must send coinsurance as member responsibility, can we also display/send an additional coinsurance for the payer responsibility percentage?
  14. In the CAQH CORE 154: Eligibility & Benefits (270/271) Data Content Rule, it says that for several service types (including dental, vision, pharmacy), patient liability amounts (co-pay, coinsurance, deductible) are not required. In the CAQH CORE test bed data several scenarios have actual liability amounts listed. If the X12 271 response that we return does not include this data, will this be acceptable?
  15. Does the history on plan name changes need to be kept? If it's still the same plan from last year but has a different name this year, can the current name be used when replying to a request for last year?
  16. Is a health plan required to respond back with the health plan name (assuming it is available within the system[s]) in EB05 element of all EB segments sent back in the response?
  17. Can an X12 271 response to an explicit X12 270 Inquiry containing one of the CORE-required Service Type Codes (STCs) identified in Rule Subsection 1.4 provide information about STCs beyond the requested CORE-required STC?
  18. What patient financials are health plans required to provide in an X12 271 response to an X12 270 inquiry?
  19. As the CAQH CORE Eligibility Data Content Rules (CAQH CORE 154 & 260 Rules) do not require that the X12 271 response to an X12 270 inquiry include a specified grouping of Service Type Codes (STCs), are health plans/information sources prohibited from returning such an STC grouping in the X12 271 response?
  20. Do the CAQH CORE Eligibility Data Content Rules (CAQH CORE 154 & 260 Rules) require health plans to support date ranges in an ASC X12 270 inquiry?
  21. Why are some Service Type Codes (STCs) identified as “discretionary” in the CAQH CORE Eligibility Data Content Rules (CAQH CORE 154 & 260 Rules)? What information must a health plan return in response to the “discretionary” STCs?
  22. Do the CAQH CORE Eligibility& Benefits (270/271) Data Content Rules (CAQH CORE 154 & 260 Rules) require health plans to address the situation where a patient’s benefit coverage changes from the time of the X12 270 Inquiry to the date of service?
  23. When do the CAQH CORE Eligibility & Benefits (270/271) Data Content Rules (CAQH CORE 154 & 260 Rules) require health plans/information sources to return health plan base and remaining deductible?
1. Does the CAQH CORE Rule require a DTP segment in the X12 270 inquiry at either the subscriber or dependent levels or both?

No. The CAQH CORE 154: Eligibility & Benefits (270/271) Data Content Rule Version 1.1.0 does not require that a DTP segment be used. The DTP segment in the X12 270 may be used to request a benefit coverage date 12 months in the past or up to the end of the current month.

2. Does the CORE Rule require a DTP segment in the EQ loop in a 270 Inquiry? Does the CAQH CORE Rule require a DTP segment in the EQ loop in a X12 270 inquiry?

No. The CAQH CORE 154 Rule does not require that a DTP segment be used. However, the X12 270 may use the DTP segment to request a benefit coverage date up to 12 months in the past or up to the end of the current month.

3. Does the CAQH CORE 154 Rule allow an inquiry about eligibility dates in the past or future?

Yes. A provider may submit an inquiry asking about eligibility for a health plan for either past or future dates. However, a health plan is not required by the CAQH CORE Rule to report eligibility dates older than 12 months in the past or beyond the end of the current month. When the health plan does not support such an inquiry, it is required to return the X12 271 with the appropriate AAA segment indicating the dates of service requested are outside of its reporting period.

4. Is the ‘begin date’ the date on which coverage starts or when a patient was enrolled?

The use of code "346" for Plan Begin Date in the X12 271 response required by CAQH CORE means the effective date of health plan coverage actually in operation and in force for the individual. See also CAQH CORE 154 Rule, Section 3.7.

5. Does an X12 271 response that conforms to the CAQH CORE 154: Eligibility & Benefits (270/271) Data Content Rule Version 1.1.0 guarantee that the health plan will pay a claim submitted covering the same individual?

No. An X12 271 response from a health plan does not guarantee that the health plan will reimburse the provider for health services if a claim is submitted.

6. When a plan has global deductibles, can a health plan satisfy the CAQH CORE 154: Eligibility & Benefits (270/271) Data Content Rule Version 1.1.0 to report deductibles by returning a deductible amount applicable globally to the health plan only on the EB segment with service type code 30?

Yes. Many health plans have a single deductible that applies to all benefits provided under that health plan. When this is the situation, a health plan should return a deductible amount only on the EB segment with Service Type Code 30. The CAQH CORE 154: Eligibility & Benefits (270/271) Data Content Rule Version 1.1.0 requires the use of code "C" Deductible in EB01-1390 Eligibility or Benefit Information data element and use of EB07-782 Monetary Amount to indicate the dollar amount of the deductible for the type of service specified in EB03-1365 service type code. Since Service Type Code 30 is defined to mean health plan benefit coverage, this is the service type code that must be used when returning a global or universal deductible amount that applies to the health plan.

7. How is pre-determination handled?

The Phase I CAQH CORE Operating Rules do not address pre-determination.

8. For emergency services, why was Code 86 selected rather than 52?

Code 52 is specific to hospital emergency services; Code 86 is general. CAQH CORE selected Code 86 so that emergency services provided in outpatient/urgent care/walk-in facilities would be included. Code 86 is what is required to be returned. When a health plan has different deductible amounts for hospital emergency medical services they may return an additional EB segment using Service Type Code 52 Hospital-Emergency Medical in addition to the EB segment using Code 86.

9. Some of our older health plans do not have a separate chiropractic benefit but include coverage for this benefit under the physician office visit benefit. In this situation it would be inaccurate to respond to an explicit X12 270 inquiry about chiropractic benefit with a "not- covered" code in EB01 per the CAQH CORE 154: Data Content Rule. How can we respond to an explicit X12 270 inquiry for chiropractic benefit in this situation and not violate the CAQH CORE 154: Data Content Rule?

In this situation the health plan or information source could use multiple EB segments in the 271 response to an explicit X12 270 code 33 inquiry. The first EB segment would be EB01 = V Cannot Process and EB03 = 33 Chiropractic. The second EB segment would be EB01 = 1 Active Coverage and EB03 = 98 Professional (Physician) Office Visit to indicate that chiropractic services in are included in the office visit benefit. Subsequent EB segments would then also be returned with the appropriate patient financial responsibility information for deductible, co-pay, co-insurance and in/out-of-network amounts if applicable.

10. Is the test script for the Data Content Rule: “Extract from a valid X12 271 response transaction as defined in the CAQH CORE Rule the data indicating the name of the health plan covering the individual specified in the X12 270 eligibility inquiry," explicitly stated in the CAQH CORE 154: Eligibility & Benefits 270/271 Data Content Rule as a provider requirement?

No. The requirement for receivers of the X12 271 to have the systems capability to display the content of the X12 271 is stated in the CORE Certification Testing Script #2. The CAQH CORE 154: Eligibility & Benefits (270/271) Data Content Rule does not explicitly require providers and provider vendors to have this capability.

However, the need for providers and provider vendors to demonstrate this display capability as a requirement of certification was discussed and agreed to by the CORE Participants. The CORE Participants felt that without requiring provider systems to display the required content, requiring the content to be provided by the health plans would not address the business need to make the information usefully available to the providers. This is the rationale for why this requirement is included in the Phase I CAQH CORE Certification Test Suite.

11. The CAQH CORE 154 Rule, Subsection 2.6 – Are all entities required to support explicit request for each of the CORE Service Types? What does ‘support’ mean? What if most do not apply to my organization?

The CAQH CORE 154: Eligibility & Benefits (270/271) Data Content Rule requires all CORE-certified entities to be able to support an explicit inquiry about each of the 12 CAQH CORE-required service types. Support means that an entity must be able to receive and respond to an explicit X12 270 inquiry- an inquiry for only one of the CAQH CORE-required service types, such as 33-Chiropractic. If the health plan does not include coverage for that specific service type (benefit), the health plan must respond with a X12 271 indicating that the specific service type is not covered and return all of the other information required by the CAQH CORE Rule.

12. In the CAQH CORE 154 Rule, can multiple service codes be displayed?

CAQH CORE Rules are specific to “what” data is to be exchanged and what that data represents. Neither the CAQH CORE Rules nor the X12 270/271 Technical Report Type 3 (TR3) Implementation Guide address the displaying of information. Therefore, how the HIS/PMS vendor chooses to “display” this information, is solely under the purview and control of these IT system vendors.

13. Have any other insurance companies expressed concern over the "patient responsibility" representation for coinsurance? My organization is concerned that the 90/70 type of coinsurance percentages used today (representing the percent paid by the insurer) will be confusing when displayed as a 10/30 (switching to "patient responsibility representation"). I believe it is an industry standard for the coinsurance to be displayed as the percent paid by the insurer. if my organization must send coinsurance as member responsibility, can we also display/send an additional coinsurance for the payer responsibility percentage?

The CAQH CORE 154: Eligibility & Benefits (270/271) Data Content Rule does not address how patient financial responsibility information is displayed by the provider's system once the X12 271 is received and the data extracted. Therefore, how the HIS/PMS vendor chooses to “display” this information, is solely under the purview and control of these IT system vendors. The rule only specifies that the co-insurance is returned as the percent that is the patient's responsibility, which is consistent with the proper use of the EB segment.

14. In the CAQH CORE 154: Eligibility & Benefits (270/271) Data Content Rule, it says that for several service types (including dental, vision, pharmacy), patient liability amounts (co-pay, coinsurance, deductible) are not required. In the CAQH CORE test bed data several scenarios have actual liability amounts listed. If the X12 271 response that we return does not include this data, will this be acceptable?

Yes, this will be acceptable.

15. Does the history on plan name changes need to be kept? If it's still the same plan from last year but has a different name this year, can the current name be used when replying to a request for last year?

The CAQH CORE 154 Rule does not address this aspect of a plan name. It only requires the health plan to return the plan name if it is available.

16. Is a health plan required to respond back with the health plan name (assuming it is available within the system[s]) in EB05 element of all EB segments sent back in the response?

Since the CAQH CORE 154 Rule does not explicitly identify which EB segments are to carry the health plan name, it could appear on all or some of the EB segments returned. Therefore, the health plan should include the name of the health plan (when available) in EB05 ONLY when EB03=30 Health Benefit Plan Coverage and not return it redundantly on every other EB segment, unless the name of the health plan is different for a given service type.

17. Can an X12 271 response to an explicit X12 270 Inquiry containing one of the CORE-required Service Type Codes (STCs) identified in Rule Subsection 1.4 provide information about STCs beyond the requested CORE-required STC?

Yes. The CAQH CORE Operating Rules represent a floor and not a ceiling. The CAQH CORE Eligibility & Benefits Data Content Rules (CAQH CORE 154 & 260 Rules) do not limit a health plan’s X12 271 response to only the explicit inquiry STC. If the explicit inquiry STC is on the list of CORE-required STCs, the CAQH CORE 154 and 260 Rules require that health plans include in their X12 271 response the required information for that STC. Additionally, the X12 271 response can include information about other STCs. For a STC that is not required by the CAQH CORE Rules, the ASC X12N v5010 270/271 TR3 requires that health plans respond with the generic inquiry response.

18. What patient financials are health plans required to provide in an X12 271 response to an X12 270 inquiry?

For health plans and information sources, the CAQH CORE Eligibility & Benefits (270/271) Data Content Rules (CAQH CORE 154 & 260 Rules) require that an X12 271 response to an X12 270 inquiry include:

  • Patient financials for co–insurance, co–payment, and base and remaining deductibles
  • Patient financial responsibility for both in–network and out–of–network if the financial amounts are different
19. As the CAQH CORE Eligibility Data Content Rules (CAQH CORE 154 & 260 Rules) do not require that the X12 271 response to an X12 270 inquiry include a specified grouping of Service Type Codes (STCs), are health plans/information sources prohibited from returning such an STC grouping in the X12 271 response?

No. CAQH CORE Operating Rules represent a floor and not a ceiling. The CAQH CORE Eligibility & Benefits (270/271) Data Content Rules (CAQH CORE 154 & 260 Rules) do not preclude a health plan from returning additional STCs in the X12 271 Response. A health plan can return additional STCs to ensure that the provider has the level of detail required to meet its specific business needs.

20. Do the CAQH CORE Eligibility Data Content Rules (CAQH CORE 154 & 260 Rules) require health plans to support date ranges in an ASC X12 270 inquiry?

No. The CAQH CORE Eligibility & Benefits (270/271) Data Content Rules (CAQH CORE 154 & 260 Rules) do not require support for a date range inquiry. Entities can make individual determinations on whether or not to support this type of inquiry. The CAQH CORE 154 and 260 Rules do require that health plans, vendors, and clearinghouse support X12 270 requests for benefit information at least 12 months into the past and up to the end of the current month. This requirement would include returning benefit information for the current plan period if such a request was received.

21. Why are some Service Type Codes (STCs) identified as “discretionary” in the CAQH CORE Eligibility Data Content Rules (CAQH CORE 154 & 260 Rules)? What information must a health plan return in response to the “discretionary” STCs?

For certain STCs, the patient financial data is not required to be returned for some benefits as they are considered carve outs, too general, or are related to sensitive benefits (e.g., behavioral health). The health plan name (if available within its own system), the coverage status of the specific benefit, and the eligibility dates must be returned regardless of whether the health plan or information source is exercising its discretion to not return patient financial responsibility. The discretionary STCs are:

1 – Medical Care

35 – Dental

88 – Pharmacy

A6 – Psychotherapy

A7 – Psychiatric – Inpatient

A8 – Psychiatric – Outpatient

AI – Substance Abuse

AL – Vision (Optometry)

MH – Mental Health

While the CAQH CORE 154 Rule includes STC 30 in the list of discretionary STCs, the CAQH CORE 260 Rule removes STC 30 from the list of discretionary codes.

22. Do the CAQH CORE Eligibility& Benefits (270/271) Data Content Rules (CAQH CORE 154 & 260 Rules) require health plans to address the situation where a patient’s benefit coverage changes from the time of the X12 270 Inquiry to the date of service?

No. The CAQH CORE Eligibility & Benefits Data Content Rules do not require that the X12 271 response contain final coverage information which is not subject to change. The X12 271 response data is current as of the date of the X12 271 response. There is no guarantee that the information reported in any given X12 271 response will not change. Changes to coverage can occur due to factors outside the control of the health plan. Any X12 271 response received from a health plan should not be construed to be a guarantee that the health plan will reimburse the provider for health services if a claim is submitted.

23. When do the CAQH CORE Eligibility & Benefits (270/271) Data Content Rules (CAQH CORE 154 & 260 Rules) require health plans/information sources to return health plan base and remaining deductible?

The CAQH CORE Eligibility & Benefits (270/271) Data Content Rules require that X12 271 responses to both generic and explicit X12 270 inquiries include patient financial responsibility for co-pay, co-insurance, and health plan base and remaining deductible for each Service Type Code (STC) returned with exceptions for discretionary reporting. The CAQH CORE Eligibility & Benefits Data Content Rules require health plans to return the dollar amount for both the base and remaining deductible for all CORE-required STCs listed in Table 4.1.1.1 in CAQH CORE 260 Rule. The health plan may, at its discretion, elect not to return patient financial responsibility information (deductible, co-payment or co-insurance) for nine discretionary STCs. Appendix 1 in CAQH CORE 260 Rule, Section 6.1 specifies all of the CAQH CORE STCs and identifies for which codes return of patient financial responsibility information is mandatory or discretionary.