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

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.

No. The CAQH CORE Eligibility & Benefits (270/2711) Data Content Rules (CAQH CORE 154 & 260 Rules) do not address the use of diagnosis/procedure codes in either an X12 270 eligibility inquiry or an X12 271 response. Therefore, the health plan or information source can determine data content for an X12 271 response to such an X12 270 inquiry.

Yes. If a request is submitted for a service type that is not required by this rule, and the receiving health plan does not support the service type(s), that health plan is required to respond as required by the X12 270/271 TR3 in Section 1.4.7.1.

Yes, CAQH CORE 260: Eligibility & Benefits (270/271) Data Content Rule Version 2.1.0 requires that entities, at a minimum, return the coverage status for each specific benefit (service type) included in a X12 270 eligibility request that is required in response to an explicit inquiry (see Table 4.1.1.2 in the Rule). That is, even if you are exercising your company’s discretion not to return patient financial liability information for one of the listed “discretionary” service types, you must return the health plan coverage status for that code in the EB01 segment in the 2110C or 2110D loop, as appropriate.

Yes. The CAQH CORE 260 Rule requires that a health plan must return patient financial responsibility information for co-insurance, co-payment, and both base and remaining deductible (including in and out-of-network variance, if applicable) for each Service Type Code returned in the X12 271 Response.

No. If your organization chooses to respond with active/inactive only, then your organization should not return any of the patient liability types. As detailed in the rule’s subsections, 2.3.1, 2.3.2 and 2.3.3, the health plan may choose not to provide the patient liability information for certain service types and instead return active/inactive information only. However, if the health plan chooses to return patient liability information, it must do so for all three required patient liability types (co-payment, co-insurance and deductible) as applicable to the product.

CAQH CORE 260: Eligibility & Benefits (270/271) Data Content Rule Version 2.1.0 does not restrict the range of dates applicable to deductibles to be a full year. The CAQH CORE Rule requires that a begin date applicable to deductibles must be returned for the health plan coverage and that alternatively a range of dates may be returned. The range of dates is determined by the health plan and may be less than or greater than a full year. See §4.1.4.

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.

The CAQH CORE 154 Rule, which is extended and modified by CAQH CORE 260, requires health plans to provide patient benefit coverage information in response to an X12 270 eligibility inquiry either up to 12 months in the past or up to the end of the current month.

Health plans are not required to return remaining deductible for past time periods as it would not be feasible for a health plan to attempt to reconstruct what the remaining deductible may have been for any date in the past. Similarly, it would be not be possible for health plans to project what the remaining deductible could be at a future date.

No. The CAQH CORE Eligibility & Benefits (270/271) Data Content Rules (154 & 260) 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.

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.

A CAQH CORE Operating Rule cannot change or modify the meaning or definition of any X12 standard or code. To assist the industry with a common understanding of some of the CORE-required STCs, CAQH CORE developed supplemental descriptions. These supplemental descriptions are for guidance only to aid in a common industry understanding of the STCs, as noted in Footnote #2 in Table 4.1.1.1 of the rule. Clarification or interpretation of the definition of a Service Type Code can be obtained from ASC X12 via its online ASC X12 Interpretation Portal.

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.

Health plans that have carved out certain benefits to another entity may not have the patient financial data available to respond to an X12 270 inquiry. The CAQH CORE Eligibility & Benefits (270/271) Data Content Rules (CAQH CORE 154 & 260 Rules) identify certain benefits as discretionary for reporting patient financial responsibility for carved out benefits. In the situation that a health plan has carved out benefit to another entity, the health plan has the discretion of reporting the patient financial data. This does not preempt the requirement for a health plan to return the other required data in the X12 271 response (i.e. health plan name, status, etc.).

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 the 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 the 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.