The Phase I CAQH CORE 154: Eligibility & Benefits Data Content (270/271) Rule provides an important first step toward improving eligibility and benefits verification. It outlines a set of requirements for health plans to return base patient financial responsibility amounts related to deductible, co-pay and co-insurance for a set of 12 services in the X12 271 eligibility response transaction. It also includes requirements for vendors, clearinghouses and providers to transmit and use this financial data.
The Phase II CAQH CORE 260: Eligibility & Benefits Data Content (270/271) Rule extends and enhances the Phase I X12 271 response transaction by requiring the return of remaining deductible amounts for both the Phase I CORE-required 12 service type codes and an additional 39 other service type codes. The Phase II CAQH CORE Rule also requires, in addition to base patient financial responsibility, that year- to-date remaining or accumulated amounts be returned for explicit benefits eligibility requests.