Frequently Asked Questions - I. General CAQH CORE Payment & Remittance Operating Rules

What was included in April 2022 CAQH CORE Payment & Remittance Infrastructure Update and how does it impact CAQH CORE Infrastructure Rule?

Submitted by msingh@caqh.org on Wed, 04/20/2022 - 15:41
What was included in April 2022 CAQH CORE Payment & Remittance Infrastructure Update and how does it impact CAQH CORE Infrastructure Rule?
    • Non-Substantive Update to CAQH CORE Connectivity. Per CAQH CORE Certification Policy, CORE-certified entities are required to comply with the most recent published version of the CAQH CORE Connectivity Rule 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 X Infrastructure Rule was updated to require “most recent published and CAQH CORE adopted version of the CAQH CORE Connectivity Rule.
    • Non-Substantive Update to CAQH CORE Master Companion Guide Template. Past versions of the CAQH CORE Master Companion Guide referenced a specific version of the ASC X12N Implementation Guides, e.g., v5010. However, with the creation of new operating rules such as CAQH CORE Attachments Operating Rules which use a different X12 version, not all operating rules use the same X12 version. To align with the need to address multiple X12 versions and enable greater flexibility, references to a specific X12 version were adjusted to be modifiable in the CAQH CORE Master Companion Guide.
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What are the HIPAA-mandated Healthcare EFT Standards?

Submitted by jporras on Mon, 12/21/2020 - 08:36
What are the HIPAA-mandated Healthcare EFT Standards?

ACA Section 1104(c)(2) adds the EFT transaction to the list of electronic health care transactions for which the HHS Secretary must adopt a HIPAA standard. Specifically, ACA Section 1104 requires the HHS Secretary to promulgate a final rule to establish a HIPAA transaction standard for healthcare EFT no later than January 1, 2012, with the rule effective January 1, 2014.

In January 2012, HHS issued an Interim Final Rule with Comment (IFC) adopting the NACHA CCD+ and the X12 v5010 835 TR3 TRN Segment together as the Healthcare EFT Standards. On July 10, 2012, CMS announced that the IFC is a Final Rule now in effect. The CMS announcement notes that “we have decided not to change any of the policies established in CMS-0024-IFC.”

NOTE: The HHS Final Rule adopting the Healthcare EFT Standards does not prohibit use of other EFT transaction standards (e.g., Fedwire, card payment networks, CTX, etc.) to make electronic healthcare claim payments. However, if a provider requests that a health plan conduct EFT using the ACH Network, the health plan is required to do so.

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Who should implement the CAQH CORE Payment & Remittance Operating Rules?

Submitted by jporras on Tue, 12/08/2020 - 11:39
Who should implement the CAQH CORE Payment & Remittance Operating Rules?

The CAQH CORE EFT & ERA Operating Rules apply to all HIPAA covered entities that conduct the ASC X12 005010X221A1 Health Care Claim Payment/Advice (835) and the HIPAA-mandated Healthcare EFT Standards (NACHA CCD+ and the X12 v5010 835 TR3 TRN Segment) transactions. ACA Section 1104 requires all HIPAA covered entities to comply with the HIPAA-mandated payment and remittance operating rules. Entities acting in the role of a Business Associate of a HIPAA covered entity may also need to implement various aspects of the CAQH CORE EFT & ERA Operating Rules. The CMS website provides charts HERE to help organizations determine whether they are a HIPAA covered entity.

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