Frequently Asked Questions - III. CAQH CORE Eligibility & Benefits (270/271) Data Content Rule

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

 

  1. How can the industry understand the differences between the HIPAA-mandated sections of the Eligibility & Benefits Data Content Rule EB.1.0 versus the updated sections made in EB.2.0?
  2. How does CAQH CORE select the categories of service and procedure codes to include?
  3. Are Procedure Codes on eligibility inquiries and responses HIPAA-mandated?
  4. The TA1 Interchange Acknowledgment is described in the HIPAA Implementation Guide Appendix B: EDI Control Directory. Do the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule require its use?
  5. How is pre-determination handled?
  6. Does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule allow an inquiry about eligibility dates in the past or future?
  7. Can CAQH CORE provide guidance regarding operating rule best practices pertaining to the return of tiered benefit information on an X12 271 Response relevant to what is being requested via an explicit X12 270 Inquiry?
  8. What should be included in an MSG segment when a tiered benefit cannot be determined?
  9. Can an X12 271 Response to an explicit X12 270 Inquiry containing one of the CORE-required Service Type Codes (STCs) provide information about STCs beyond the requested CORE-required STC?
  10. Are the CAQH CORE Eligibility & Benefits (270/271) Operating Rules requirements related to acknowledgements only applicable to scenarios where my organization receives data in an X12 270 format?
  11. Does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule 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?
  12. Does the CAQH CORE Eligibility & Benefits (270/271) Data Content rule require all entities to support explicit request for each of the CORE Service Type Code? What does ‘support’ mean? What if most do not apply to my organization?
  13. Is the test script for the Eligibility & Benefits (270/271) 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
  14. Is the ‘begin date’ the date on which coverage starts or when a patient was enrolled?
  15. As a health plan, if I receive an X12 270 Request for a Service Type Code not required by the CAQH CORE Eligibility & Benefits Data Content (270/271) Rule and the plan does not support that Service Type Code, are we required to respond and, if so, how
  16. Is a health plan required to respond back with the health plan name in EB05 element of all EB segments sent back in the response?
  17. What patient financials are health plans required to provide in an X12 271 Response to an X12 270 Inquiry?
  18. Does an X12 271 Response that conforms to the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule guarantee that the health plan will pay a claim submitted covering the same individual?
  19. When a plan has global deductibles, can a health plan satisfy the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule to report deductibles by returning a deductible amount applicable globally to the health plan only on the EB segment with Se
  20. Why does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule use Code 86 rather than 52 for emergency services?
  21. 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 chiropr
  22. How does the current CAQH CORE Eligibility & Benefits (270/271) Data Content Rule address network status?
  23. Have health plans 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) may be confusin
  24. In the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule, it says that for several service type codes (e.g., 35-Dental, 88-Pharmacy, Or AL- Vision)), patient liability amounts (co-pay, coinsurance, deductible) are not required as they are c
  25. As the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule does 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 return
  26. Does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule require health plans to support date ranges in an X12 270 Inquiry?
  27. Why are some Service Type Codes (STCs) identified as “discretionary” in the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule? What information must a health plan return in response to the “discretionary” STCs?
  28. If a health plan chooses not to respond with co-payment to one of the optional codes (e.g., 35-Dental, 88-Pharmacy, Or AL- Vision), does this mean it should still respond with coinsurance and deductible for these optional codes?
  29. Can CAQH CORE provide more detailed definitions for the CORE-required Service Type Codes (STCs) beyond what is provided in the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule?
  30. When does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule require health plans/information sources to return health plan base and remaining deductible?
  31. Does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule specify that the range of dates applicable to deductibles that may be returned in an X12 271 eligibility response must be for a full year, or can the range of dates be for less than
  32. Why does the Eligibility & Benefits (270/271) Data Content Rule require health plans to return patient remaining deductible information only for the current time period, when health plans are required to return the other patient benefit information fo
  33. What are the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule requirements for health plans to return eligibility and benefit data, including coverage status and patient financial information, for benefits that are not directly administere
  34. As a health plan, are we required to respond to explicit service type code benefit inquiries? We do not currently return patient financial responsibility information, i.e., co-pay and deductible, for several behavioral health-related benefits/services
  35. As a health plan, does the rule require that we return patient financial responsibility (i.e., co-pay and deductible) in the X12 271 Response if we currently do not do so?
  36. Does my organization have to return eligibility information if the requester of the information does not meet my organization's requirements for patient identification?
  37. How does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule Normalizing Patient Last Name requirements propose the handling of patient last name when the beneficiary has two last names (e.g., Maria Garcia DeSanchez)?
  38. What recommendations does CAQH CORE have for instances where the last name contains concatenated last name + suffix? For example, with the patient’s name comes in as JAMES C POMP II, the last name may be stored as “POMPII”. How can we tell if the last
  39. In reviewing the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule, I could not find any statement on how hyphenated or apostrophized last names should be handled, e.g., O'Donnell-Griswold? Should it be just Odonnell? Or is this addressed i
  40. Can a health plan/information source return a AAA error segment that contains only the first error condition detected or must it return as many AAA segments as there are errors in the X12 270?
  41. Is the receiver of the X12 271 Response expected to be able to detect all AAA segment error conditions reported by the vendor/health plan and display them to an end user?
  42. When a health plan’s search criteria detects errors during its subscriber/dependent verification editing process, does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule AAA Error Code Reporting requirement specify in what loop (subscrib
  43. Does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule AAA Error Code Reporting requirement require a health plan to validate date of birth?
  44. Does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule AAA Error Code Reporting requirement require that entities use specific AAA03 error codes for specific errors?
  45. Is a health plan or information source required to return an X12 271 Response with the specified AAA error codes for each test script for the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule AAA Error Code Reporting requirement specified i
  46. How does a health plan identify the correct error condition description to return when multiple error conditions are mapped to the same code?
  47. Does this rule require specific search or match criteria logic to be used when validating member demographic data?
  48. What must the receiver of the X12 271 Response display when receiving multiple AAA error codes?
How can the industry understand the differences between the HIPAA-mandated sections of the Eligibility & Benefits Data Content Rule EB.1.0 versus the updated sections made in EB.2.0?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:12
How can the industry understand the differences between the HIPAA-mandated sections of the Eligibility & Benefits Data Content Rule EB.1.0 versus the updated sections made in EB.2.0?

CAQH CORE launched a Task Group in 2021 to evaluate opportunity areas for Operating Rule enhancement for the Electronic Delivery of Patient Financial and Benefit Information Rule. For ease of Rule reference, all updated and new rule requirements are highlighted in grey.

Which CAQH CORE Eligibility & Benefit Operating Rules are federally mandated?

All HIPAA-covered entities are required by Federal law to adopt the CAQH CORE Eligibility & Benefits (270/271) Operating Rules by January 1, 2013 for the X12 270/271 eligibility transaction. This includes the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule and the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule. For more information on the mandate click HERE. The CAQH CORE Eligibility & Benefits (270/271) Single Patient Attribution Data Rule, which enables provider notification of an attributed patient under a value-based care contract within the eligibility workflow, is not federally mandated.

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How does CAQH CORE select the categories of service and procedure codes to include?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:13
How does CAQH CORE select the categories of service and procedure codes to include?

Categories of service are selected through consensus-based processes using environmental scans, straw polls, and discussions. Additional categories of service may be considered as part of CAQH CORE’s future rule updates.

The categories of service for procedure code based inquires and responses that are supported by the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule include: 

·       Physical Therapy

·       Occupational Therapy

·       Imaging

·       Surgery

Note: if the procedure code(s) received in the v5010 270 cannot be placed into any of the above types of service categories, the health plan and its agent should attempt to evaluate and respond appropriately to the request.

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Are Procedure Codes on eligibility inquiries and responses HIPAA-mandated?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:14
Are Procedure Codes on eligibility inquiries and responses HIPAA-mandated?

No. While these requirements are not currently mandated under HIPAA, CORE-certified entities will be required to support CORE-required categories of service for procedure codes based on eligibility inquiries and responses to obtain or maintain CORE Certification.

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The TA1 Interchange Acknowledgment is described in the HIPAA Implementation Guide Appendix B: EDI Control Directory. Do the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule require its use?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:15
The TA1 Interchange Acknowledgment is described in the HIPAA Implementation Guide Appendix B: EDI Control Directory. Do the CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule require its use?

No. The CAQH CORE Acknowledgement Rules do not address the use of the X12 Interchange Acknowledgement TA1. 

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How is pre-determination handled?
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Does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule allow an inquiry about eligibility dates in the past or future?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:16
Does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule allow an inquiry about eligibility dates in the past or future?

Yes. A provider may submit an inquiry to a health plan asking about eligibility 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 Response with the appropriate AAA segment indicating the dates of service requested are outside of its reporting period.

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Can CAQH CORE provide guidance regarding operating rule best practices pertaining to the return of tiered benefit information on an X12 271 Response relevant to what is being requested via an explicit X12 270 Inquiry?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:20
Can CAQH CORE provide guidance regarding operating rule best practices pertaining to the return of tiered benefit information on an X12 271 Response relevant to what is being requested via an explicit X12 270 Inquiry?

Yes. The X12 v5010 271 must include the following data in EB Loops 2110C/2110D for each applicable tiered benefit:

·       Coverage Status of Benefit

·       Benefit-Specific Base Deductible

·       Benefit-Specific Remaining Deductible

·       Co-Pay Amount

·       Co-Insurance Amount

·       Coverage Level

·       Benefit-specific Base Deductible Dates

·       Remaining Benefit Coverage

·       Authorization or Certification Indication

·       In/Out of Network Indication

NOTE: Each EB loop must also include an MSG segment identifying the benefit tier and the MSG segment content must begin with “MSG*BenefitTier…”.

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What should be included in an MSG segment when a tiered benefit cannot be determined?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:21
What should be included in an MSG segment when a tiered benefit cannot be determined?

In cases when a tiered benefit cannot be determined, include “MSG*Benefit Tier cannot be determined.”

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Can an X12 271 Response to an explicit X12 270 Inquiry containing one of the CORE-required Service Type Codes (STCs) provide information about STCs beyond the requested CORE-required STC?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:22
Can an X12 271 Response to an explicit X12 270 Inquiry containing one of the CORE-required Service Type Codes (STCs) 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 (270/271) Data Content Rule do not limit a health plan’s X12 271 Response to only the explicit inquiry STCs . If the explicit inquiry STC is on the list of CORE-required STCs, the CAQH CORE 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 Eligibility & Benefits (270/271) Data Content Rule, the X12 v5010 270/271 TR3 requires that health plans respond with the generic inquiry response.

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Are the CAQH CORE Eligibility & Benefits (270/271) Operating Rules requirements related to acknowledgements only applicable to scenarios where my organization receives data in an X12 270 format?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:22
Are the CAQH CORE Eligibility & Benefits (270/271) Operating Rules requirements related to acknowledgements only applicable to scenarios where my organization receives data in an X12 270 format?

Yes. Good business practices for electronic message exchange encourage all senders and receivers to appropriately acknowledge receipt and both acceptance/rejection and errors found in any message. Accordingly, the CAQH CORE Eligibility & Benefits (270/271) Operating Rules are focused on the conduct of the HIPAA-mandated X12 270/271 transaction sets. Thus, the CAQH CORE Eligibility & Benefits Infrastructure Rule only addresses the use of the X12 Implementation Acknowledgement (999) and when to use it when conducting the X12 270/271 transaction sets. Additionally, to become CORE-certified, an entity is required to attest to its compliance with HIPAA, which requires the use of the appropriate X12 implementation guides.

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Does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule 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?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:23
Does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule 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 (270/271) Data Content Rule does 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.

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Does the CAQH CORE Eligibility & Benefits (270/271) Data Content rule require all entities to support explicit request for each of the CORE Service Type Code? What does ‘support’ mean? What if most do not apply to my organization?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:24
Does the CAQH CORE Eligibility & Benefits (270/271) Data Content rule require all entities to support explicit request for each of the CORE Service Type Code? What does ‘support’ mean? What if most do not apply to my organization?

The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule requires all HIPAA-covered entities to be able to support an explicit inquiry for all CAQH CORE-required Service Type Codes Support as specified in §1.3.2.4 through §1.3.2.13. This means that an entity must be able to receive and respond to an explicit X12 270 Inquiry such as 33-Chiropractic. If the health plan does not include coverage for that specific Service Type Code (benefit), the health plan must respond with a X12 271 indicating that the specific Service Type Code is not covered and return all the other information required by the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule.

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Is the test script for the Eligibility & Benefits (270/271) 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

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:24
Is the test script for the Eligibility & Benefits (270/271) 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 Eligibility & Benefits (270/271) Data Content Rule as a provider requirement?

Yes. §1.3.1 of the rule delineates the requirements for providers, provider vendors, and information receivers. The health plan name must be returned (if one exists within the health plan’s or information source’s system) in EB05-1204 Plan Coverage Description. The requirement for receivers of the X12 271 Response to have the systems capability display the content of the X12 271 Response is stated in the CORE Certification Testing Script #2. The CAQH CORE 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 CAQH CORE Participants. They 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 fully available to providers. This is the rationale for why this requirement is included in the Eligibility & Benefits CORE Certification Test Suite.

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

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:25
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 the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule is the effective date of health plan coverage in operation and applicable for the individual.

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As a health plan, if I receive an X12 270 Request for a Service Type Code not required by the CAQH CORE Eligibility & Benefits Data Content (270/271) Rule and the plan does not support that Service Type Code, are we required to respond and, if so, how

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:37
As a health plan, if I receive an X12 270 Request for a Service Type Code not required by the CAQH CORE Eligibility & Benefits Data Content (270/271) Rule and the plan does not support that Service Type Code, are we required to respond and, if so, how?

Yes. If a request is submitted for a Service Type Code that is not required by the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule, and the receiving health plan does not support the Service Type Code, the health plan is required to respond as required by the X12 270/271 TR3 in §1.4.7.1.

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Is a health plan required to respond back with the health plan name in EB05 element of all EB segments sent back in the response?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:50
Is a health plan required to respond back with the health plan name in EB05 element of all EB segments sent back in the response?

No. Since the CAQH CORE Eligibility & Benefits (270/271) Data Content 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 returned. If there are variances in the health plan name for other Service Type Codes returned, the appropriate name should be returned.

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What patient financials are health plans required to provide in an X12 271 Response to an X12 270 Inquiry?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:50
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 Rule 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

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

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:51
Does an X12 271 Response that conforms to the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule 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.

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When a plan has global deductibles, can a health plan satisfy the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule to report deductibles by returning a deductible amount applicable globally to the health plan only on the EB segment with Se

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:51
When a plan has global deductibles, can a health plan satisfy the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule 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 returns a deductible amount only on the EB segment with Service Type Code 30. The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule 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 as health plan benefit coverage, this Service Type Code must be used when returning a global or universal deductible amount that applies to the health plan.

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Why does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule use Code 86 rather than 52 for emergency services?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:51
Why does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule use Code 86 rather than 52 for emergency services?

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.

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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 chiropr

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:52
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 Eligibility & Benefits (270/271) Data Content Rule. How can we respond to an explicit X12 270 Inquiry for chiropractic benefits in this situation and not violate the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule?

In this situation the health plan or information source could use multiple EB segments in the X12 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 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.

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How does the current CAQH CORE Eligibility & Benefits (270/271) Data Content Rule address network status?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:52
How does the current CAQH CORE Eligibility & Benefits (270/271) Data Content Rule address network status?

The current CAQH CORE Eligibility & Benefits (270/271) Data Content Rule requires the return of in- and out-of-network benefits in the EB12, which is a ‘Y’ or ‘N’. If it is not known if the provider is in- or out-of-network, the X12 271 Response must include the dollar amounts, coinsurance, or deductible if there is a variance.

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Have health plans 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) may be confusin

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:53
Have health plans 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) may be confusing when displayed as a 10/30 (switching to "patient responsibility representation"). Can we also display/send an additional coinsurance for the payer responsibility percentage?

The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule requires that co-insurance information be returned; however, the rules do not dictate how it is displayed by the HIS/PMS vendor. Each vendor may choose how to “display” this information; it 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.

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In the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule, it says that for several service type codes (e.g., 35-Dental, 88-Pharmacy, Or AL- Vision)), patient liability amounts (co-pay, coinsurance, deductible) are not required as they are c

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:53
In the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule, it says that for several service type codes (e.g., 35-Dental, 88-Pharmacy, Or AL- Vision)), patient liability amounts (co-pay, coinsurance, deductible) are not required as they are considered “discretionary”. 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.

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As the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule does 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 return

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:54
As the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule does 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 Rule does 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.

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Does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule require health plans to support date ranges in an X12 270 Inquiry?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:54
Does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule require health plans to support date ranges in an X12 270 Inquiry?

No. The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule does not require support for an inquiry with date ranges. Entities can make individual determinations on whether to support this type of inquiry. The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule does require that health plans, vendors, and clearinghouse support the X12 270 Inquiry 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 were received.

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Why are some Service Type Codes (STCs) identified as “discretionary” in the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule? What information must a health plan return in response to the “discretionary” STCs?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:54
Why are some Service Type Codes (STCs) identified as “discretionary” in the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule? 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. A complete list discretionary STCs can be found in §5.1 Eligibility & Benefits CORE Service Type Codes.

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If a health plan chooses not to respond with co-payment to one of the optional codes (e.g., 35-Dental, 88-Pharmacy, Or AL- Vision), does this mean it should still respond with coinsurance and deductible for these optional codes?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:55
If a health plan chooses not to respond with co-payment to one of the optional codes (e.g., 35-Dental, 88-Pharmacy, Or AL- Vision), does this mean it should still respond with coinsurance and deductible for these optional codes?

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 CAQH CORE Eligibility & Benefits (270/271) Data Content Rule Sub sections, §1.3.2.4 and §1.3.2.5, 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.

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Can CAQH CORE provide more detailed definitions for the CORE-required Service Type Codes (STCs) beyond what is provided in the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:55
Can CAQH CORE provide more detailed definitions for the CORE-required Service Type Codes (STCs) beyond what is provided in the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule?

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 a footnote of the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule. Clarification or interpretation of the definition of a STC can be obtained from X12 via its online X12 Interpretation Portal.

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When does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule require health plans/information sources to return health plan base and remaining deductible?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:56
When does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule require health plans/information sources to return health plan base and remaining deductible?

The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule requires that X12 271 Responses to both generic and explicit X12 270 Inquiries include patient financial responsibility for co-pay, co-insurance, health plan base, and remaining deductible for each STC returned with exceptions for discretionary reporting. The Rule require health plans to return the dollar amount for both the base and remaining deductible for all CORE-required STCs listed in §5.1 Eligibility & Benefits CORE Service Type Codes. The health plan may, at its discretion, elect not to return patient financial responsibility information (deductible, co-payment or co-insurance) for discretionary STCs. 

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Does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule specify that the range of dates applicable to deductibles that may be returned in an X12 271 eligibility response must be for a full year, or can the range of dates be for less than

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:56
Does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule specify that the range of dates applicable to deductibles that may be returned in an X12 271 eligibility response must be for a full year, or can the range of dates be for less than a full year?

No. The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule 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.

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Why does the Eligibility & Benefits (270/271) Data Content Rule require health plans to return patient remaining deductible information only for the current time period, when health plans are required to return the other patient benefit information fo

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:57
Why does the Eligibility & Benefits (270/271) Data Content Rule require health plans to return patient remaining deductible information only for the current time period, when health plans are required to return the other patient benefit information for a date up to 12 months in the past or the end of the current month?

The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule requires health plans to provide patient benefit coverage information in response to an X12 270 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 a date in the past. Similarly, it would not be possible for health plans to project what the remaining deductible may be on a future date.

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What are the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule requirements for health plans to return eligibility and benefit data, including coverage status and patient financial information, for benefits that are not directly administere

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:57
What are the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule requirements for health plans to return eligibility and benefit data, including coverage status and patient financial information, for benefits that are not directly administered by the health plan (e.g., pharmacy benefits, vision services, etc.)?

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 Rule identifies certain benefits as discretionary for reporting patient financial responsibility for carved out benefits. 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.).

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As a health plan, are we required to respond to explicit service type code benefit inquiries? We do not currently return patient financial responsibility information, i.e., co-pay and deductible, for several behavioral health-related benefits/services

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:58
As a health plan, are we required to respond to explicit service type code benefit inquiries? We do not currently return patient financial responsibility information, i.e., co-pay and deductible, for several behavioral health-related benefits/services that are required.

Yes. The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule requires that entities, at a minimum, return the coverage status for each specific benefit (Service Type Code) included in a X12 270 Inquiry that is required in response to an explicit inquiry. Even if you are exercising discretion to not return patient financial liability information for one of the listed “discretionary” Service Type Codes, you must return the health plan coverage status for that code in the EB01 segment in the 2110C or 2110D loop, as appropriate.

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As a health plan, does the rule require that we return patient financial responsibility (i.e., co-pay and deductible) in the X12 271 Response if we currently do not do so?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:58
As a health plan, does the rule require that we return patient financial responsibility (i.e., co-pay and deductible) in the X12 271 Response if we currently do not do so?

Yes. The CAQH CORE Eligibility & Benefits (270/271) Data Content 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 CORE-required Service Type Code of Procedure Code returned in the X12 271 Response.

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Does my organization have to return eligibility information if the requester of the information does not meet my organization's requirements for patient identification?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:58
Does my organization have to return eligibility information if the requester of the information does not meet my organization's requirements for patient identification?

The CAQH CORE Eligibility & Benefits (270/271) Operating Rules include requirements that improve patient matching rates, but do not include requirements for your organization’s policies on patient identification requirements. There are no requirements for patient matching.

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How does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule Normalizing Patient Last Name requirements propose the handling of patient last name when the beneficiary has two last names (e.g., Maria Garcia DeSanchez)?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 16:59
How does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule Normalizing Patient Last Name requirements propose the handling of patient last name when the beneficiary has two last names (e.g., Maria Garcia DeSanchez)?

The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule Last Name Normalization requirement does not address this specific scenario. Since the characters “De” are not included in the specified set of character strings to be removed, any validation of the last name performed by the health plan would naturally be against what was submitted in the Last Name data element in the X12 270 Inquiry against what the health plan maintains in its eligibility system. This is outside the scope of the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule.

If a health plan receives the subscriber ID number and the subscriber’s last name in the X12 270 Inquiry, does the health plan have to use the subscriber’s last name or can they ignore the subscriber last name when processing the X12 270 Inquiry?

The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule Last Name Normalization requirement does not require that a health plan use the patient’s last name in its search and match logic to locate an individual within its systems. When the last name is not used in the health plan’s search and match logic, the rule does not apply – and if the health plan receives the patient's unique ID number in an X12 270 Inquiry, it may use or ignore the name or other demographic data about the individual if not needed or used to uniquely locate that individual in the plan’s systems.

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What recommendations does CAQH CORE have for instances where the last name contains concatenated last name + suffix? For example, with the patient’s name comes in as JAMES C POMP II, the last name may be stored as “POMPII”. How can we tell if the last

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 17:00
What recommendations does CAQH CORE have for instances where the last name contains concatenated last name + suffix? For example, with the patient’s name comes in as JAMES C POMP II, the last name may be stored as “POMPII”. How can we tell if the last name should be “Pomp” or “Pompii?” In some cases the last names may be concatenated with suffixes and not easily identifiable.

The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule Normalizing Patient Last Name requirement includes the character string “II” in the set of specified character strings to be removed during normalization (§2.3.2.2). Additionally, the rule in §2.3.2.1 defines how to normalize the last name: “To normalize the submitted and stored last name: Remove all of the character strings specified in §2.3.2.2 when they are preceded by one of the punctuation values specified in §2.3.2.3 and followed by a space or when they are preceded by one of the punctuation values specified in §2.3.2.3 and are at the end of the data element And remove the special characters specified in §2.2.7 in the name element. If the last name as submitted and as stored is not delimiting the suffix using one of the specified punctuation values or store the suffix separately, the normalization logic will not remove the character string “II”. The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule does not specify HOW an entity must store a last name but does make recommendations on this issue in these sections.

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In reviewing the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule, I could not find any statement on how hyphenated or apostrophized last names should be handled, e.g., O'Donnell-Griswold? Should it be just Odonnell? Or is this addressed i

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 17:00
In reviewing the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule, I could not find any statement on how hyphenated or apostrophized last names should be handled, e.g., O'Donnell-Griswold? Should it be just Odonnell? Or is this addressed in another CAQH CORE Eligibility & Benefits (270/271) Data Content Rule?

The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule Last Name Normalization requirement  requires the removal of both the apostrophe and the hyphen in the O’Donnell-Griswold example cited. The normalized name would be ODONNELLGRISWOLD. §2.2.7 lists the X12-designated “special characters” of the “Basic Character Set” and the list includes both the apostrophe and the hyphen. §2.3.2.3. of the rule then says, “remove the special characters specified in §2.3.2 in the name element.”

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Can a health plan/information source return a AAA error segment that contains only the first error condition detected or must it return as many AAA segments as there are errors in the X12 270?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 17:00
Can a health plan/information source return a AAA error segment that contains only the first error condition detected or must it return as many AAA segments as there are errors in the X12 270?

A health plan/information source is required to return a AAA segment for each error condition that it detects in a X12 270 Inquiry, as described in §3.3 of the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule AAA Error Code Reporting requirement.

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Is the receiver of the X12 271 Response expected to be able to detect all AAA segment error conditions reported by the vendor/health plan and display them to an end user?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 17:01
Is the receiver of the X12 271 Response expected to be able to detect all AAA segment error conditions reported by the vendor/health plan and display them to an end user?

Yes. The receiver of the X12 271 Response, i.e., the system that originated the X12 270 Inquiry, is required to detect all combinations of error conditions from the AAA segments in the X12 271 Response, as defined in Table 3.3.5 Error Reporting Codes & Requirements of the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule AAA Error Code Reporting requirement, and to display to the receiving system’s end user text that uniquely describes the specific error condition(s) and data elements returned by the health plan in the X12 271 Response.

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When a health plan’s search criteria detects errors during its subscriber/dependent verification editing process, does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule AAA Error Code Reporting requirement specify in what loop (subscrib

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 17:01
When a health plan’s search criteria detects errors during its subscriber/dependent verification editing process, does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule AAA Error Code Reporting requirement specify in what loop (subscriber or dependent) the error should be reported?

The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule AAA Error Code Reporting requirement identifies 17 error conditions, some of which may occur in the subscriber loop and others which may occur in the dependent loop. §3.3 of the AAA Error Code Reporting requirement states that “when a health plan detects any of the specified error conditions it must return an appropriate AAA segment for each error detected and return other data elements as specified.” Thus, the health plan would determine the loop in which to return the appropriate AAA error codes required by the CAQH CORE Rule.

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Does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule AAA Error Code Reporting requirement require a health plan to validate date of birth?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 17:02
Does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule AAA Error Code Reporting requirement require a health plan to validate date of birth?

No. This rule does not require a health plan (or information source) to validate a date of birth; however, when a date of birth is validated and errors are found, the receiver of the X12 270 Inquiry is required to return an X12 271 Response as specified in the rule.

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Does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule AAA Error Code Reporting requirement require that entities use specific AAA03 error codes for specific errors?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 17:02
Does the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule AAA Error Code Reporting requirement require that entities use specific AAA03 error codes for specific errors?

Yes. The rule specifically identifies the AAA03 error codes that must be returned for each error condition, which may occur in either or both of the Subscriber or Dependent loops (refer to Rule §3.3 and the Error Reporting Codes & Requirements Table 3.3.5 of the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule AAA Error Code Reporting requirement).

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Is a health plan or information source required to return an X12 271 Response with the specified AAA error codes for each test script for the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule AAA Error Code Reporting requirement specified i

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 17:03
Is a health plan or information source required to return an X12 271 Response with the specified AAA error codes for each test script for the CAQH CORE Eligibility & Benefits (270/271) Data Content Rule AAA Error Code Reporting requirement specified in the CORE Certification test suite?

No. Due to the variability in search and match logic and the data elements used by health plans and information sources, some health plans and information sources may match the member in the X12 270 Inquiry test case rather than return the expected AAA error code in the X12 271 Response. An entity seeking CORE Certification can successfully pass the test for this rule by generating at least one X12 271 Response with an AAA Error Code for at least one of the Certification test scripts.

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How does a health plan identify the correct error condition description to return when multiple error conditions are mapped to the same code?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 17:03
How does a health plan identify the correct error condition description to return when multiple error conditions are mapped to the same code?

The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule AAA Error Code Reporting requirement, §3.2.1, What the Rule Applies To, notes that the rule defines a standard way to report errors that prevent health plans (or information sources) from responding with the eligibility information for the requested patient or subscriber. The rule requires use of a unique error code, wherever possible, for a given error condition so that the re-use of the same error code is minimized. Where this is not possible, the goal (when re-using an error code) is to return a unique combination of one or more AAA segments along with one or more of the submitted patient identifying data elements so that the provider will be able to determine as precisely as possible what data elements are in error and take the appropriate corrective action. The CAQH CORE Rule does not require error condition descriptions to be returned.

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Does this rule require specific search or match criteria logic to be used when validating member demographic data?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 17:03
Does this rule require specific search or match criteria logic to be used when validating member demographic data?

No. The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule AAA Error Code Reporting requirement does not require a health plan/information source to use any specific search and match criteria or logic.

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What must the receiver of the X12 271 Response display when receiving multiple AAA error codes?

Submitted by tfuchs@caqh.org on Wed, 04/20/2022 - 17:04
What must the receiver of the X12 271 Response display when receiving multiple AAA error codes?

The CAQH CORE Eligibility & Benefits (270/271) Data Content Rule Error Code Reporting requirement, §3., AAA Error Code Reporting, identifies basic requirements for the “receiver” of the X12 271 Response. These requirements include that the “receiver” must “display to the end user text that uniquely describes the specific error condition(s) and data elements returned by the health plan in the v5010 271.” The receiver may exercise discretion regarding the actual text to be displayed as long as the wording of the text displayed accurately represents the AAA03 Error Code and the corresponding Error Condition Description without changing the meaning and intent of the error condition description.

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