Frequently Asked Questions - II. CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule

The CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule vEB.1.0 is the most current version of the Eligibility & Benefits Infrastructure Rule.

 

 

  1. What was included in the CAQH CORE April 2022 Infrastructure update and how does it impact the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule?
  2. How does an entity determine which version of CAQH CORE Connectivity to use when implementing the HIPAA mandated CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rules?
  3. Currently my organization’s EDI system only returns an X12 Implementation Acknowledgement (999). If the functional group is rejected, must my system be changed to comply with the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule?
  4. What are the CAQH CORE Eligibility & Benefits (270/271) Rule requirements for entities to support Real Time and Batch Processing?
  5. Will there be a difference in system availability requirements for Batch versus Real Time Processing Modes?
  6. Does my organization have to send back an eligibility response if my system is down?
  7. Why did the CAQH CORE Participants increase the weekly system availability requirement from 86% to 90% system availability for the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule in 2022?
  8. Is the additional 24-hour downtime available per calendar quarter required to be taken in one 24-hour period?
  9. Is the additional 24-hour downtime per calendar quarter in addition to the weekly allocated downtime?
  10. Does the new quarterly system availability downtime requirement define calendar quarter?
  11. My organization includes system availability schedules in our Companion Guide. Does this satisfy the CAQH CORE Operating Rule requirements for system availability reporting?
  12. Does the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule require HIPAA-covered entities to publish a Companion Guide if they do not currently do so?
  13. Why was the CAQH CORE Master Companion Guide Template updated?
  14. Why were the Companion Guide Requirements created?
  15. Can I combine multiple transaction sets (e.g., X12 270/271 and 276/277) in a single Companion Guide?
  16. If pursuing CORE Certification, will all the detailed content of my organization’s X12 270/271 Companion Guide be analyzed and evaluated for certification testing?
  17. For entities seeking CORE Certification, how does CAQH CORE determine conformance with the CAQH CORE Master Companion Guide Template?
What was included in the CAQH CORE April 2022 Infrastructure update and how does it impact the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 15:34
What was included in the CAQH CORE April 2022 Infrastructure update and how does it impact the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule?

  • Substantive Adjustment to system availability requirements. The weekly system availability requirement was updated across all CAQH CORE Infrastructure Rules, including the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule from 86% per calendar week to requiring systems to be available 90% per calendar week.  Additionally, a new quarterly system availability requirement was added, allowing systems 24 additional downtime hours per calendar quarter, in excess of the allowable weekly system downtime or 17 hours (10% system downtime per calendar week).
  • Non-Substantive Update to CAQH CORE Connectivity. Per CAQH CORE Certification Policy, CORE-certified entities will be required to comply with the most recent published and CAQH CORE adopted version of CAQH CORE Connectivity within two years of publication. Therefore, by January 1, 2023, CAQH CORE Connectivity vC4.0.0 will be required for all CAQH CORE Infrastructure Operating Rules. To align the rule requirements with this policy, the connectivity requirement language in the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rules was updated to require “the most recent published and CAQH CORE adopted version” of CAQH CORE Connectivity.
  • Non-Substantive Update to CAQH CORE Master Companion Guide Template. As the Companion Guide templates were originally written, they were to be used in tandem with the v5010 X12 Implementation Guides. However, as new CAQH CORE Operating Rules have been written, not all operating rules use the v5010. To align with the need to address multiple X12 versions, references to a specific X12 version were adjusted to be modifiable in the CAQH CORE Master Companion Guide.

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How does an entity determine which version of CAQH CORE Connectivity to use when implementing the HIPAA mandated CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rules?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 15:36
How does an entity determine which version of CAQH CORE Connectivity to use when implementing the HIPAA mandated CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rules?

All HIPAA covered entities are required to support CAQH CORE Connectivity vC1.1.0 and vC2.2.0 for the HIPAA-mandated eligibility and benefits transaction (please see Mandated Operating Rules webpage for full list of federally mandated operating rules with original naming conventions).  

Additionally, all CAQH CORE Infrastructure Operating Rules require use of “most recent published and CAQH CORE adopted version of the CAQH CORE Connectivity Rule” (please see the CAQH CORE Connectivity webpage for more information).  

Per CORE Certification Policy, entities seeking CORE Certification are required at a minimum to implement the version of CORE Connectivity published two years prior from when pursuing certification testing. Optionally, entities can choose to implement any newer versions of CORE Connectivity published within the past two years and attain certification depending on testing availability.

NOTE: HHS will determine if updates to CAQH CORE Connectivity Rule requirements will be included in any regulatory mandates.

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Currently my organization’s EDI system only returns an X12 Implementation Acknowledgement (999). If the functional group is rejected, must my system be changed to comply with the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 15:44
Currently my organization’s EDI system only returns an X12 Implementation Acknowledgement (999). If the functional group is rejected, must my system be changed to comply with the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule?

Yes. The Eligibility & Benefits Infrastructure Rule require that the health plan or information receiver must always return an X12 Implementation Acknowledgement (999) for all functional groups, whether or not the group is rejected. This requirement allows the provider to know within a reasonable timeframe if the submitted batch of inquiries was accepted by the health plan and will be processed. Likewise, the rule also requires that the provider must always return an X12 Implementation Acknowledgement (999) Functional Acknowledgement for all functional groups whether the group is rejected or not, thereby allowing timely resolution of any issues.

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What are the CAQH CORE Eligibility & Benefits (270/271) Rule requirements for entities to support Real Time and Batch Processing?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 15:45
What are the CAQH CORE Eligibility & Benefits (270/271) Rule requirements for entities to support Real Time and Batch Processing?

The CAQH CORE Eligibility & Benefits (270/271) Operating Rules require that all entities support real time processing of the X12 270/271 transactions. 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 CAQH CORE Eligibility & Benefits (270/271) Operating Rules. Real time and batch requirements are addressed in the following CAQH CORE Eligibility & Benefits (270/271) Operating Rules:

§  CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule

§  CAQH CORE Eligibility & Benefits (270/271) Data Content Rule

§  CAQH CORE Eligibility & Benefits (270/271) Single Patient Attribution Data Rule

§  CAQH CORE Connectivity Rule vC1.1.0

§  CAQH CORE Connectivity Rule vC2.2.0

§  CAQH CORE Connectivity Rule vC4.0.0

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Will there be a difference in system availability requirements for Batch versus Real Time Processing Modes?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 15:46
Will there be a difference in system availability requirements for Batch versus Real Time Processing Modes?

No. The system availability requirements apply to Batch and Real Time Processing Modes, with no difference in system availability based   on the processing mode. CAQH CORE will conduct research and environmental scans to obtain data on the feasibility of separate system availability requirements in potential future infrastructure updates, as separate requirements may make better business sense as the industry moves to more API-driven interactions between providers and health plans.

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Does my organization have to send back an eligibility response if my system is down?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 15:46
Does my organization have to send back an eligibility response if my system is down?

No. If your eligibility system is in conformance with the system availability requirements in the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule, then it is not required to send back an eligibility response while your system is down.

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Why did the CAQH CORE Participants increase the weekly system availability requirement from 86% to 90% system availability for the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule in 2022?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 15:48
Why did the CAQH CORE Participants increase the weekly system availability requirement from 86% to 90% system availability for the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule in 2022?

Each set of CAQH CORE Operating Rules includes an infrastructure rule with requirements for system availability and reporting, including the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule. In response to feedback from CAQH CORE Participants and the CAQH CORE Board, in September 2021 CAQH CORE surveyed Participating Organizations to determine where there may be consensus to update the CAQH CORE Infrastructure Operating Rule requirements to align with evolving business needs and technology. The survey focused on system availability and response time requirements across all rule sets and clear consensus emerged to update the system availability requirements across the CAQH CORE Infrastructure Rules.

Significant discussions occurred related to system availability needs. Ultimately, CORE Participants compromised by approving a new quarterly system availability requirement to accommodate large system migrations if weekly system availability was increased from 86% per calendar week to 90% per calendar week. With this weekly availability increase, the new quarterly system availability allows health plans and their agents to use 24 additional hours of system downtime per calendar quarter for system migrations, mitigations, and other system needs that may require additional downtime.

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Is the additional 24-hour downtime available per calendar quarter required to be taken in one 24-hour period?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:06
Is the additional 24-hour downtime available per calendar quarter required to be taken in one 24-hour period?

No. The 24-hour downtime can be taken in any increment of time throughout the calendar quarter to allow for larger system upgrades, as needed.

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Is the additional 24-hour downtime per calendar quarter in addition to the weekly allocated downtime?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:07
Is the additional 24-hour downtime per calendar quarter in addition to the weekly allocated downtime?

Yes. The new requirement specifies an additional 24 hours available quarterly in excess of the 17 hours weekly allowable downtime, or 10% of a calendar week.

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Does the new quarterly system availability downtime requirement define calendar quarter?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:08
Does the new quarterly system availability downtime requirement define calendar quarter?

No. The new quarterly system availability requirement does not define calendar quarter. The definition of a calendar quarter is agreed upon between trading partners.

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My organization includes system availability schedules in our Companion Guide. Does this satisfy the CAQH CORE Operating Rule requirements for system availability reporting?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:08
My organization includes system availability schedules in our Companion Guide. Does this satisfy the CAQH CORE Operating Rule requirements for system availability reporting?

Partially. CORE-certified health plans (or their agents), clearinghouses/switches, or other intermediaries must publish their regularly scheduled system downtime in an appropriate manner (e.g., on websites or in Companion Guides). This allows the healthcare provider to better manage staffing levels. Additionally, the system availability requirements in the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule outline requirements for reporting/publishing non-routine downtimes, and unscheduled/emergency downtimes.

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Does the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule require HIPAA-covered entities to publish a Companion Guide if they do not currently do so?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:09
Does the CAQH CORE Eligibility & Benefits (270/271) Infrastructure 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 an entity to publish a Companion Guide if they do not already do so. The Companion Guide requirements specify that should an entity publish a company guide; it must conform to the flow and format as defined in the CAQH CORE Master Companion Guide Template.

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Why was the CAQH CORE Master Companion Guide Template updated?
Why were the Companion Guide Requirements created?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:10
Why were the Companion Guide Requirements 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 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 common information flow and format, while at the same time giving health plans the flexibility to tailor the document to meet their needs. The template covers a broad range of HIPAA-mandated transaction sets and is not specific to any one of them.

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

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:11
Can I combine multiple transaction sets (e.g., X12 270/271 and 276/277) in a single Companion Guide?

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

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

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:11
If pursuing CORE Certification, will all 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.

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

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For entities seeking CORE Certification, how does CAQH CORE determine conformance with the CAQH CORE Master Companion Guide Template?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:12
For entities seeking CORE Certification, how does CAQH CORE determine conformance with the CAQH CORE Master Companion Guide Template?

The CAQH CORE Eligibility & Benefits (270/271) Operating Rules require health plan Companion Guides covering the X12 270/271 transactions to follow the flow and format as defined in the CAQH CORE 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 Eligibility & Benefits (270/271) Companion Guide Requirements:

§   If the order of the Companion Guide table of contents match the table in the CAQH CORE Master Companion Guide Template

§   If the Companion Guide format for specifying the X12 270/271 data content requirements is consistent with the format in the CAQH CORE Master Companion Guide Template

If a specific section(s) of the CAQH CORE Master Companion Guide Template is not appropriate for a particular entity’s Companion Guide, the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule allows the entity to exclude this section(s) from their guide.

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