Phase III CAQH CORE EFT & ERA Operating Rules

III. CAQH CORE 350: Health Care Claim Payment/Advice (835) Infrastructure Rule

  1. Why develop an infrastructure rule for exchange of the ASC X12 Health Care Claim Payment/Advice (835) transaction?
  2. What are the CAQH CORE 350 Rule connectivity requirements for transmission of the X12 Health Care Claim Payment/Advice (835) transaction?
  3. What CAQH CORE Connectivity Rule requirements apply to the X12 v5010 835 per the CAQH CORE 350 Rule?
  4. What are the CAQH CORE 350 Rule requirements for HIPAA covered entities to support dual delivery of the ERA and proprietary paper remittance advices?
  5. Does the CAQH CORE 350 Rule require HIPAA covered entities to publish a companion guide for the X12 v5010 835 if they do not currently do so?
  6. Can I combine multiple transaction sets (i.e., X12 270/271 and X12 835) in a single companion guide?
  7. Is there a specific proprietary paper claim remittance advice format that health plans must use during the dual delivery period?
  8. If the provider chooses not to continue the dual delivery period beyond 31 days (or a minimum of 3 payments) after the implementation of the X12 v5010 835, must the health plan stop sending proprietary paper claim remittance advices?
  9. Does the requirement for a dual delivery period in Section 4.3 of the CAQH CORE 350 Rule mean that health plans must create and send a proprietary paper claim remittance advice if they do not currently do so?
  10. My health plan provides the X12 v5010 835 via an online application only, do the CAQH CORE 350 Rule requirements apply?
  11. Are HIPAA covered entities required to implement the requirements in Section 4.2, Health Care Claim Payment/Advice Batch Acknowledgement Requirements, of the CAQH CORE 350 Rule to comply with the ACA Section 1104 Federal mandate?
  12. I am a provider organization that currently receives the X12 v5010 835 via manual download from a health plan’s web portal. Does the connectivity requirement specified in Section 4.1 of the CAQH CORE 350 Rule mean that my organization can now only receive the X12 v5010 835 via the CAQH CORE Connectivity Safe Harbor?
  13. Section 4.1 of the CAQH CORE 350 Rule requires entities to support the CAQH CORE 270: Connectivity Rule Version 2.2.0 to send/receive the X12 v5010 835. The CAQH CORE 270 Rule requires health plans and clearinghouses to publish a Connectivity Companion Guide. Is this Connectivity Companion Guide the same as the health care claim payment/advice Companion Guide referenced in Section 4.4 of the CAQH CORE 350 Rule?
  14. My organization is a provider-facing clearinghouse. Are we required by the CAQH CORE 350 Rule to return an X12 v5010 999 Implementation Acknowledgement to health plans that do not request to receive the X12 v5010 999?
  15. Does the CAQH CORE 350 Rule specify processing mode requirements for exchange of the X12 v5010 835?
  16. Per Section 4.2 of the CAQH CORE 350 Rule, “health plans must be able to accept and process an X12 v5010 999 for a Functional Group of X12 v5010 835 transactions.” Does the CAQH CORE 350 Rule explicitly define what “processing” means for this requirement?
  17. The CAQH CORE 350 Rule requires entities to support the requirements for batch processing of the X12 v5010 835 specified in the CAQH CORE 270: Connectivity Rule Version 2.2.0. In Section 4.2.2.1 of the CAQH CORE 270 Rule the payload value for the Batch Results Retrieval Request is specified as “minOccurs=’0’.” Does this value mean that entities are not required to include a Payload in the request?
  18. Does the CAQH CORE 350 Rule require health plans to support transmission of the X12 v5010 835 to providers via the public Internet?
  19. My organization is a health plan that sends the X12 v5010 835 to some providers through a clearinghouse acting as a business associate of the provider. Does the CAQH CORE 350 Rule require that we accept an X12 v5010 999 Implementation Acknowledgement from this clearinghouse?
  20. My organization is a health plan. As part of our X12 v5010 835 error handling process, we currently send a proprietary paper remittance advice (RA) in lieu of an out of balance X12 v5010 835. Does the CAQH CORE 350 Rule require that we discontinue this error handling process after the dual-delivery period has ended?
  21. The CAQH CORE 350 Rule requires health plans to support the CAQH CORE 270: Connectivity Rule to transmit the X12 v5010 835. Our organization is a health plan that currently transmits several X12 v5010 835 transactions in a single payload. Does the CAQH CORE 270 Rule specify a maximum number of X12 v5010 835 transactions that can be sent in a single payload?
  22. The CAQH CORE 350 Rule requires health plans to support the CAQH CORE 270: Connectivity Rule to transmit the X12 v5010 835. Our organization is a health plan that currently limits the size of the batch X12 v5010 835 file sent in a single payload to prevent problems with the receiver’s system performance. Does the CAQH CORE 270 Rule prohibit health plans from setting a maximum limit for the size of the X12 v5010 835 batch file sent in a single payload?
1. Why develop an infrastructure rule for exchange of the ASC X12 Health Care Claim Payment/Advice (835) transaction?

Continuing to build on Phase I & Phase II CAQH CORE Eligibility & Claim Status Operating Rules, the CORE Participants determined that the CAQH CORE Operating Rules should be extended to include rules around the health care claim payment/advice transaction to allow the industry to leverage its investment in the Phase I and Phase II CAQH CORE infrastructure rules and apply them to conducting the HIPAA-mandated ASC X12 005010X221A1 Health Care Claim Payment/Advice (835) transaction. Benefits to the industry in applying these CAQH CORE infrastructure rules to the X12 v5010 835 will provide for:

  • Less staff time spent on phone calls and websites
  • Increased ability to conduct targeted follow-up
  • More accurate and efficient processing of claim payments

2. What are the CAQH CORE 350 Rule connectivity requirements for transmission of the X12 Health Care Claim Payment/Advice (835) transaction?

CAQH CORE 350: Health Care Claim Payment/Advice (835) Infrastructure Rule requires health plans to support the Phase II CAQH CORE 270: Connectivity Rule Version 2.2.0 to transmit the X12 v5010 835 ERA to providers. The CAQH CORE 153: Connectivity Rule, Version 1.1.0 and the CAQH CORE 270: Connectivity Rule, Version 2.2.0 together specify business rules and technical specifications for the CAQH CORE Connectivity “Safe Harbor”. The CAQH CORE Safe Harbor is the connectivity method that application vendors, providers, and health plans (or other information sources) can be assured will be supported by any HIPAA covered entity. Supporting the CAQH CORE Safe Harbor means the entity is capable and ready at the time of the request from a trading partner to exchange the transaction using the CORE Connectivity Rules. The CAQH CORE 350 Rule does not require trading partners to remove existing connections that do not match the rule, nor does is it require that all covered entities use only this method for all new connections. In some circumstances, you and your trading partners may decide to continue to use your current connection; however, you must implement the capability to use the CAQH CORE Connectivity Safe Harbor and be capable and ready to use it when requested.

3. What CAQH CORE Connectivity Rule requirements apply to the X12 v5010 835 per the CAQH CORE 350 Rule?

Only the batch requirements of the CAQH CORE 270: Connectivity Rule apply to the X12 v5010 835. Requirements for batch retrieval (pick up) and acknowledgements are identified in the CAQH CORE 270 Rule, Section 4. Additionally, CAQH CORE 270 Rule, Table 4.4.4.3.2 in Section 4.4.3, Enumeration of Processing Mode and Payload Type Fields, specifies the request and response payload types for batch interactions. As an example, the sequence diagram below depicts how the CAQH CORE 270 Rule requirements for a generic batch retrieval apply to the X12 v5010 835 transaction.

For further guidance on the CAQH CORE 270 Rule please see Section XV. CAQH CORE 270: Connectivity Rule of the CAQH CORE FAQs Part C: CAQH CORE Eligibility & Claim Status Operating Rules.

4. What are the CAQH CORE 350 Rule requirements for HIPAA covered entities to support dual delivery of the ERA and proprietary paper remittance advices?

Section 4.3 of the CAQH CORE 350 Rule includes a requirement for a “dual or parallel processing period” during which providers can continue to receive proprietary paper remittance advices as well as the HIPAA-mandated X12 v5010 835 standard transaction while they test the use of the X12 v5010 835 standard and associated operating rules. At the end of the dual or parallel processing period, “If the provider determines it is unable to satisfactorily implement and process the health plan‘s electronic X12 v5010 835 following the end of the initial dual delivery timeframe and/or after an agreed-to extension, both the provider and health plan may mutually agree to continue delivery of the proprietary paper claim remittance advices.”

5. Does the CAQH CORE 350 Rule require HIPAA covered entities to publish a companion guide for the X12 v5010 835 if they do not currently do so?

No. The CAQH CORE Operating Rules do not require any entity to publish a companion guide. CAQH CORE 350, Section 4.4, Health Care Claim Payment/Advice Companion Guide, specifies that, should an entity publish a company guide, it must conform to the format/flow as defined in the CAQH CORE v5010 Master Companion Guide Template.

6. Can I combine multiple transaction sets (i.e., X12 270/271 and X12 835) in a single companion guide?

Yes. Entities, may, if they wish, combine their companion guides for separate transactions into a single document. The flow and format of the CAQH CORE v5010 Master Companion Guide Template would still need to be followed, but sections could be repeated, tables added for the second transaction, etc., without altering said flow and format.

7. Is there a specific proprietary paper claim remittance advice format that health plans must use during the dual delivery period?

No. Section 4.3 of the CAQH CORE 350 Rule includes a requirement for a dual or parallel processing period during which providers can continue to receive proprietary paper claim remittance advice(s) as well as the HIPAA-mandated X12 v5010 835 standard format while they test the use of the X12 v5010 835 standard. The CAQH CORE 350 Rule does not define what type of a document constitutes a proprietary paper claim remittance advice or address the method used to deliver the proprietary paper claim remittance advice.

8. If the provider chooses not to continue the dual delivery period beyond 31 days (or a minimum of 3 payments) after the implementation of the X12 v5010 835, must the health plan stop sending proprietary paper claim remittance advices?

Per the CAQH CORE 350 Rule, Section 4.3, Dual Delivery of X12 v5010 835 and Proprietary Paper Claim Remittance Advices, at the end of the 31-day (or a minimum of 3 payments) dual or parallel processing period, “If the provider determines it is unable to satisfactorily implement and process the health plan‘s electronic X12 v5010 835 following the end of the initial dual delivery timeframe and/or after an agreed-to extension, both the provider and health plan may mutually agree to continue delivery of the proprietary paper claim remittance advices.” The rule also notes, “At the provider‘s discretion, the provider may elect to not receive the proprietary paper claim remittance advices, to choose a shorter time period, or to discontinue receiving the proprietary paper claim remittance advices before the end of the specified timeframe by notifying the health plan of this decision.”

9. Does the requirement for a dual delivery period in Section 4.3 of the CAQH CORE 350 Rule mean that health plans must create and send a proprietary paper claim remittance advice if they do not currently do so?

No. The CAQH CORE 350 Rule, Section 4.3, Dual Delivery of X12 v5010 835 and Proprietary Paper Claim Remittance Advices, requires a health plan to support dual delivery of the X12 v5010 835 and proprietary paper claim remittance advices for a period of 31 days (or a minimum of 3 payments), if the health plan currently delivers proprietary paper claim remittance advices. If a health plan does not currently deliver proprietary paper claim remittance advices, the CAQH CORE 350 Rule does not require a health plan to start doing so.

NOTE: The CAQH CORE 350 Rule does not require health plans to continue to deliver proprietary paper claim remittance advices after the dual delivery period ends. However, “If the provider determines it is unable to satisfactorily implement and process the health plan‘s electronic X12 v5010 835 following the end of the initial dual delivery timeframe and/or after an agreed-to extension, both the provider and health plan may mutually agree to continue delivery of the proprietary paper claim remittance advices.”

10. My health plan provides the X12 v5010 835 via an online application only, do the CAQH CORE 350 Rule requirements apply?

The CAQH CORE Operating Rules apply to HIPAA transactions, which are healthcare electronic data interchanges (EDI); as such, the CAQH CORE 350 Rule does not apply when the X12 v5010 835 is provided via Direct Data Entry. However, CAQH CORE 350 Rule, Section 4.1, Health Care Claim Payment/Advice Connectivity Requirements requires health plans and other information sources to support the CAQH CORE 270: Connectivity Rule Version 2.2.0 to transmit the X12 v5010 835 ERA to providers. Thus while health plans may continue to offer the X12 v5010 835 via DDE, use of a website only to provide the X12 v5010 835 to providers does not satisfy the connectivity requirements of the CAQH CORE 350 Rule.

For further guidance on the CAQH CORE 270 Rule please see Section XV. CAQH CORE 270: Connectivity Rule of the CAQH CORE FAQs Part C: CAQH CORE Eligibility & Claim Status Operating Rules.

11. Are HIPAA covered entities required to implement the requirements in Section 4.2, Health Care Claim Payment/Advice Batch Acknowledgement Requirements, of the CAQH CORE 350 Rule to comply with the ACA Section 1104 Federal mandate?

No. The August 2012 HHS Final Rule adopting the CAQH CORE EFT & ERA Operating Rules does not adopt the Acknowledgement requirements in Section 4.2 of the CAQH CORE 350 Rule. The Final Rule does note that, “without Acknowledgements, it is difficult for the sender to know whether the intended recipient received the transmission, which often results in the sender repeatedly querying the intended receiver as to the status of the transmission...until such time as the {Health and Human Services} Secretary adopts a standard for Acknowledgments, we support the industry’s ongoing voluntary use of Acknowledgements and encourage even more widespread use.” The CAQH CORE 350 Rule supports the use of Acknowledgements.

12. I am a provider organization that currently receives the X12 v5010 835 via manual download from a health plan’s web portal. Does the connectivity requirement specified in Section 4.1 of the CAQH CORE 350 Rule mean that my organization can now only receive the X12 v5010 835 via the CAQH CORE Connectivity Safe Harbor?

No. Section 4.1, Health Care Claim Payment/Advice Connectivity Requirements, of the CAQH CORE 350 Rule requires all HIPAA covered entities to support use of the CORE Connectivity Safe Harbor described in the CAQH CORE 270: Connectivity Rule Version 2.2.0 to transmit or receive the X12 v5010 835. However, the CAQH CORE 350 Rule does not prohibit entities from using other connectivity methods to conduct the X12 v5010 835 or require entities to remove existing connections that do not match the CAQH CORE 270 Rule.

As a “Safe Harbor”, the CAQH CORE 270 Rule specifies connectivity methods that application vendors, providers, and health plans can be assured will be supported by any HIPAA covered entity and/or a CORE-certified entity. Supporting the CAQH CORE Connectivity Safe Harbor means that the entity is capable and ready to exchange data using the CAQH CORE 270 Rule at the time a request is made by a trading partner. The CORE Safe Harbor allows for an automated EDI-based process to conduct the X12 v5010 835 rather than a manual download process. In some circumstances, you and your trading partners may decide to continue to use your existing connection transmit or receive the X12 v5010 835, as permitted by the CAQH CORE Connectivity Safe Harbor. However, you must implement the capability to use the CAQH CORE Connectivity Safe Harbor and be capable and ready to use it when requested by a trading partner.

For further guidance on the CAQH CORE 270 Rule please see Section XV. CAQH CORE 270: Connectivity Rule of the CAQH CORE FAQs Part C: CAQH CORE Eligibility & Claim Status Operating Rules.

13. Section 4.1 of the CAQH CORE 350 Rule requires entities to support the CAQH CORE 270: Connectivity Rule Version 2.2.0 to send/receive the X12 v5010 835. The CAQH CORE 270 Rule requires health plans and clearinghouses to publish a Connectivity Companion Guide. Is this Connectivity Companion Guide the same as the health care claim payment/advice Companion Guide referenced in Section 4.4 of the CAQH CORE 350 Rule?

Connectivity Companion Guides are entity-specific guides that outline the requirements to establish and maintain a connection with the entity. Section 4.3.7, Publication of Entity Specific Connectivity Guide, of the CAQH CORE 270 Rule requires that all information servers (i.e., health plans and clearinghouses) publish an entity-specific Connectivity Companion Guide on their public web site. The Connectivity Companion Guide must include the entity’s detailed specifications for the CAQH CORE Connectivity Safe Harbor as well as all custom extensions to the CAQH CORE Connectivity Safe Harbor and/or additional non-CAQH CORE connectivity methods supported by the entity. Per the requirements in Section 4.1, Health Care Claim Payment/Advice Connectivity Requirements, of the CAQH CORE 350 Rule, the Connectivity Companion Guide must also include the entity’s connectivity requirements for transmitting the X12 v5010 835.

Beyond the Connectivity Companion Guide, health plans and clearinghouses can also choose to publish a Companion Guide describing the specifics of how the entity implements a particular HIPAA-mandated transaction standard. Health plan and clearinghouse Companion Guides often vary in format and structure, which can be confusing to trading partners and providers. To address this issue, the CAQH CORE Operating Rules require that entity Companion Guides follow the flow and format defined in the CAQH CORE v5010 Master Companion Guide Template.

The CAQH CORE Operating Rules do not require any entity to publish a Companion Guide if they do not already do so. However, per Section 4.4, Health Care Claim Payment/Advice Companion Guide, of the CAQH CORE 350 Rule, if a health plan or clearinghouse chooses to publish a Companion Guide for the X12 v5010 835 transaction, it must conform to the format/flow as defined in the CAQH CORE v5010 Master Companion Guide Template.

If a health plan or clearinghouse chooses to publish an X12 v5010 835 Companion Guide, it may choose to include the Connectivity Companion Guide in the X12 v5010 835 Companion Guide or choose to publish it separately.

14. My organization is a provider-facing clearinghouse. Are we required by the CAQH CORE 350 Rule to return an X12 v5010 999 Implementation Acknowledgement to health plans that do not request to receive the X12 v5010 999?

The CAQH CORE 350 Rule specifies requirements for use of the X12 v5010 999 Implementation Acknowledgement that are applicable to both senders and receivers of the X12 v5010 835. Per Section 4.2.1, Use of the X12 v5010 999 Implementation Acknowledgement for Functional Group Acknowledgement, of the CAQH CORE 350 Rule:

  • Receivers of the X12 v5010 835 (i.e., providers and provider-facing clearinghouses) must return an X12 v5010 999 for each Functional Group of X12 v5010 835 transactions indicating that the Functional Group was either accepted, accepted with errors, or rejected and must also specify for each included X12 v5010 835 transaction set that the transaction set was either accepted, accepted with errors, or rejected.
  • Senders of the X12 v5010 835 (i.e., health plans and health plan-facing clearinghouses) must be able to accept and process an X12 v5010 999 for a Functional Group of X12 v5010 835 transactions.

Good business practices for electronic message exchange encourage all senders and receivers to appropriately acknowledge both receipt and acceptance/rejection with errors found in any message. Therefore, the CAQH CORE 350 Rule requires that receivers of the X12 v5010 835 return an X12 v5010 999 to all trading partner senders, including those that do not explicitly request to receive the X12 v5010 999.

NOTE: The HHS Final Rule adopting the CAQH CORE EFT & ERA Operating Rules to fulfill the ACA Section 1104 mandate does not adopt the batch acknowledgement requirements in Section 4.2 of the CAQH CORE 350 Rule. Conformance with the CAQH CORE 350 Rule requirements regarding acknowledgements remains. Therefore, to meet the Federal requirements under the ACA entities do not have to comply with the rule requirements for Acknowledgements.

15. Does the CAQH CORE 350 Rule specify processing mode requirements for exchange of the X12 v5010 835?

Yes. Section 4.1, Health Care Claim Payment/Advice Connectivity Requirements, of the CAQH CORE 350 Rule requires entities to support the use of the CORE Connectivity Safe Harbor, as described in the CAQH CORE 270: Connectivity Rule Version 2.2.0, to send/receive the X12 v5010 835. Per Section 4.1, “This requirement addresses usage patterns for batch transactions, the exchange of security identifiers, and communications-level errors and acknowledgements.”

To comply with the CAQH CORE 350 Rule requirements, entities must support batch processing of the X12 v5010 835, in conformance with the CAQH CORE 270 Rule requirements for batch processing mode. While the CAQH CORE 350 Rule does not require the exchange of the X12 v5010 835 in real time, it does not prohibit it. Therefore, conducting the X12 v5010 835 in real time could be mutually agreed to between trading partners.

For further guidance on the CAQH CORE 270 Rule please see Section XV. CAQH CORE 270: Connectivity Rule of the CAQH CORE FAQs Part C: CAQH CORE Eligibility & Claim Status Operating Rules.

16. Per Section 4.2 of the CAQH CORE 350 Rule, “health plans must be able to accept and process an X12 v5010 999 for a Functional Group of X12 v5010 835 transactions.” Does the CAQH CORE 350 Rule explicitly define what “processing” means for this requirement?

No. The CAQH CORE 350 Rule does not explicitly define what it means to “process” an X12 v5010 999 Implementation Acknowledgement. Receivers of the X12 v5010 835 (i.e., providers and provider-facing clearinghouses) return an X12 v5010 999 to indicate that a Functional Group of X12 v5010 835 transactions has been accepted, accepted with errors, or rejected. Given the different scenarios that the X12 v5010 999 could be indicating, a health plan could have internal logic for how to process and respond to each particular scenario. For example, a health plan might determine that processing an X12 v5010 999 indicating a rejection would lead to correction of errors and resending of the Functional Group of X12 v5010 835s.

NOTE: The HHS Final Rule adopting the CAQH CORE EFT & ERA Operating Rules to fulfill the ACA Section 1104 mandate does not adopt the batch acknowledgement requirements in Section 4.2 of the CAQH CORE 350 Rule. Conformance with the CAQH CORE 350 Rule requirements regarding acknowledgements remains. Therefore, to meet the Federal requirements under the ACA entities do not have to comply with the CAQH CORE 350 Rule requirements for Acknowledgements.

17. The CAQH CORE 350 Rule requires entities to support the requirements for batch processing of the X12 v5010 835 specified in the CAQH CORE 270: Connectivity Rule Version 2.2.0. In Section 4.2.2.1 of the CAQH CORE 270 Rule the payload value for the Batch Results Retrieval Request is specified as “minOccurs=’0’.” Does this value mean that entities are not required to include a Payload in the request?

Yes. Section 4.2.2.1, CORE Phase II Connectivity XML Schema Specification (normative), of the CAQH CORE 270 Rule specifies a value of minOccurs=”0” for the Payload element because the Batch Results Retrieval Request does not always require a payload (e.g., if there is no batch available for retrieval). As the intent of the Batch Results Retrieval Request is to pick up a batch (or batches) and not to deliver a payload, the Batch Results Retrieval Request may have only a SOAP envelope and no payload.

Please Note: The CAQH CORE 350 Rule does not prohibit entities from using other connectivity methods to conduct the X12 v5010 835 or require entities to remove existing connections that do not match the CAQH CORE 270 Rule.

For further guidance on the CAQH CORE 270 Rule please see Section XV. CAQH CORE 270: Connectivity Rule of the CAQH CORE FAQs Part C: CAQH CORE Eligibility & Claim Status Operating Rules.

18. Does the CAQH CORE 350 Rule require health plans to support transmission of the X12 v5010 835 to providers via the public Internet?

Yes. Section 4.1, Health Care Claim Payment/Advice Connectivity Requirements, of the CAQH CORE 350 Rule requires health plans and other information sources to support the CAQH CORE 270: Connectivity Rule Version 2.2.0 to transmit the X12 v5010 835 ERA to providers. (NOTE: Other connectivity methods can also be used.) The CAQH CORE 270 Rule requires entities to support delivery of the X12 v5010 835 via the public Internet using HTTP with SSL as the minimum security for the communications channel with specific envelopes, metadata, and submitter authentication methods.

Please Note: The CAQH CORE 350 Rule does not prohibit entities from using other connectivity methods to transmit the X12 v5010 835 nor require entities to remove existing connections that do not match the CAQH CORE 270 Rule.

For further guidance on the CAQH CORE 270 Rule please see Section XV. CAQH CORE 270: Connectivity Rule of the CAQH CORE FAQs Part C: CAQH CORE Eligibility & Claim Status Operating Rules.

19. My organization is a health plan that sends the X12 v5010 835 to some providers through a clearinghouse acting as a business associate of the provider. Does the CAQH CORE 350 Rule require that we accept an X12 v5010 999 Implementation Acknowledgement from this clearinghouse?

NOTE: The HHS Final Rule adopting the CAQH CORE EFT & ERA Operating Rules to fulfill the ACA Section 1104 mandate does not adopt the batch acknowledgement requirements in Section 4.2 of the CAQH CORE 350 Rule. HIPAA covered entities do not have to comply with the CAQH CORE 350 Rule requirements for Acknowledgements to meet the Federal requirements under the ACA.

Good business practices for electronic message exchange encourage all senders and receivers to appropriately acknowledge both receipt and acceptance/rejection with errors found in any message. Therefore, the CAQH CORE 350 Rule specifies requirements for use of the X12 v5010 999 Implementation Acknowledgement that apply to both senders and receivers of the X12 v5010 835, although conformance with these requirements remains under the ACA Federal mandate.

Per Section 4.2.1, Use of the X12 v5010 999 Implementation Acknowledgement for Functional Group Acknowledgement, of the CAQH CORE 350 Rule:

  • Receivers of the X12 v5010 835 (i.e., providers and clearinghouses acting as a business associate of a provider) must return an X12 v5010 999 for each Functional Group of X12 v5010 835 transactions indicating that the Functional Group was either accepted, accepted with errors, or rejected and must also specify for each included X12 v5010 835 transaction set that the transaction set was either accepted, accepted with errors, or rejected.
  • Senders of the X12 v5010 835 (i.e., health plans and clearinghouses acting as a business associate of a health plan) must be able to accept and process an X12 v5010 999 for a Functional Group of X12 v5010 835 transactions.
20. My organization is a health plan. As part of our X12 v5010 835 error handling process, we currently send a proprietary paper remittance advice (RA) in lieu of an out of balance X12 v5010 835. Does the CAQH CORE 350 Rule require that we discontinue this error handling process after the dual-delivery period has ended?

The CAQH CORE 350 Rule does not address a health plan’s internal error handling processes that may require the plan to send a paper RA to a provider in lieu of an out-of-balance X12 v5010 835.

Section 4.3, Dual Delivery of X12 v5010 835 and Proprietary Paper Claim Remittance Advices, of the CAQH CORE 350 Rule requires health plans that currently deliver a proprietary paper RA to support a dual or parallel processing period during which providers can continue to receive proprietary paper RAs while they test the use of the X12 v5010 835 standard and associated operating rules. The required timeframe for the dual delivery period is 31 days (or a minimum of 3 payments). Note: If a health plan does not currently deliver proprietary paper RAs, the CAQH CORE 350 Rule does not require the plan to start doing so.

At the end of the dual delivery period, “both the provider and health plan may mutually agree to continue delivery of the proprietary paper claim remittance advices.” Additionally, “at the provider’s discretion, the provider may elect to not receive the proprietary paper claim remittance advices, to choose a shorter time period, or to discontinue receiving the proprietary paper claim remittance advices before the end of the specified timeframe by notifying the health plan of this decision.”

Please Note: The CAQH CORE 350 Rule builds on the ASC X12 v5010 835 transaction standard. In addition to complying with the CAQH CORE 350 Rule requirements, health plans must also comply with the ASC X12N v5010 835 TR3 implementation guide when using the X12 v5010 835. Therefore, health plans should ensure that the balancing requirements specified in the ASC X12N v5010 835 TR3 implementation guide are met. Information related to the meaning, use, and interpretation of ASC X12 Standards, Guidelines, and Technical Reports, including implementation guideline for the ASC X12N v5010 835, can be obtained from ASC X12 via its online ASC X12 Interpretation Portal.

21. The CAQH CORE 350 Rule requires health plans to support the CAQH CORE 270: Connectivity Rule to transmit the X12 v5010 835. Our organization is a health plan that currently transmits several X12 v5010 835 transactions in a single payload. Does the CAQH CORE 270 Rule specify a maximum number of X12 v5010 835 transactions that can be sent in a single payload?

No. Section 4.1, Health Care Claim Payment/Advice Connectivity Requirements, of the CAQH CORE 350 Rule requires all health plans to support use of the CAQH CORE Connectivity Safe Harbor described in the CAQH CORE 270: Connectivity Rule Version 2.2.0 to transmit the X12 v5010 835. (NOTE: Providers are also required to support use of the CAQH CORE 270 Rule to receive the X12 v5010 835.)

The CAQH CORE 270 Rule neither requires nor prohibits the inclusion of multiple transaction sets, Functional Groups, or ASC X12 Interchanges in a single payload. Section 6.1, Appendix and Definitions Used in this Rule, of the CAQH CORE 270 Rule defines a payload of batch files as a single submission containing either:

  • One X12 Interchange containing one Functional Group containing one X12 transaction set consisting of more than one business transaction. OR
  • More than one ASC X12 Interchange, each of which may contain one or more Functional Groups, each of which may contain one or more ASC X12 transaction sets.

Information sources of the X12 v5010 835 (i.e., health plans and clearinghouses/vendors acting as a business associate of a health plan) may choose to include multiple X12 v5010 835s in a single payload or send each X12 v5010 835 transaction in separate payloads.

22. The CAQH CORE 350 Rule requires health plans to support the CAQH CORE 270: Connectivity Rule to transmit the X12 v5010 835. Our organization is a health plan that currently limits the size of the batch X12 v5010 835 file sent in a single payload to prevent problems with the receiver’s system performance. Does the CAQH CORE 270 Rule prohibit health plans from setting a maximum limit for the size of the X12 v5010 835 batch file sent in a single payload?

No. Section 4.1, Health Care Claim Payment/Advice Connectivity Requirements, of the CAQH CORE 350 Rule requires all health plans to support use of the CAQH CORE Connectivity Safe Harbor described in the CAQH CORE 270: Connectivity Rule Version 2.2.0 to transmit the X12 v5010 835. (NOTE: Providers are also required to support use of the CAQH CORE 270 Rule to receive the X12 v5010 835).

Section 3.6, Outside the Scope of this Rule, of the CAQH CORE 270 Rule specifies that the maximum size of a batch file accepted by a server is out of scope of the CAQH CORE 270 Rule. This applies both when batch files are “pushed” by the health plan to the provider (i.e., the health plan acts as a server) and when the provider sends a request to receive available files (i.e., the provider is acting minimally as a client). The CAQH CORE 270 Rule does require entities that conduct batch processing to have the capability to receive and process large batch transaction files (see Section 4.3.5.2). However, per Section 4.3.5, Capacity Plan, of the CAQH CORE 270 Rule, the maximum number of transaction sets to be included in a large batch file is an issue to be negotiated between trading partners. 

Senders of the X12 v5010 835 (i.e., health plans and clearinghouses/vendors acting as a business associate of a health plan) should work with their trading partners to establish reasonable limits for the maximum size of batch files that can be supported by their trading partners. Any system size limitations should be specified in an entity’s Connectivity Companion Guide. For additional guidance on the Connectivity Companion Guide required by the CAQH CORE 270 Rule see “Is this Connectivity Companion Guide the same as the health care claim payment/advice Companion Guide referenced in Section 4.4 of the CAQH CORE 350 Rule?