Frequently Asked Questions - II. CAQH CORE Payment & Remittance (835) Infrastructure Rule

  1. What was included in April 2022 CAQH CORE Infrastructure Update and how does it impact CAQH CORE Payment & Remittance Infrastructure Rule?
  2. How does an entity determine which version of CAQH CORE Connectivity to use when implementing the federally mandated CAQH CORE Payment & Remittance Infrastructure Rule?
  3. 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 mean that I can now only receive the 835 via the CAQH CORE Connectivity Safe Harbor?
  4. Does the CAQH CORE Payment & Remittance (835) Infrastructure Rule specify processing mode requirements for exchange of the X12 v5010 835?
  5. What CAQH CORE Connectivity Rule requirements apply to the X12 v5010 835 per the CAQH CORE Payment & Remittance (835) Infrastructure Rule?
  6. Does the Connectivity Rule specify a maximum number of X12 835 transactions that can be sent in a single payload?
  7. 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 Payment& Remittance (835) Infrastructure Rule to comply with Federal law?
  8. What are the CAQH CORE Payment & Remittance (835) Infrastructure Rule requirements for HIPAA covered entities to support dual delivery of the ERA and proprietary paper remittance advices?
  9. Is there a specific proprietary paper claim remittance advice format that health plans must use during the dual delivery period?
  10. 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?
  11. Does the requirement for a dual delivery period in Section 4.3 of the CAQH CORE Payment & Remittance (835) Infrastructure Rule mean that health plans must create and send a proprietary paper claim remittance advice if they do not currently do so?
  12. My organization is a provider-facing clearinghouse. Are we required by the CAQH CORE Payment & Remittance (835) Infrastructure Rule to return an X12 v5010 999 Implementation Acknowledgement to health plans that do not request to receive the X12 v5010
  13. The CAQH CORE Payment & Remittance (835) Infrastructure Rule requires that “health plans must be able to accept and process an X12 v5010 999 for a Functional Group of X12 v5010 835 transactions.” What does “processing” mean for this requirement?
  14. My organization is a health plan that sends the X12 835 to some providers through a clearinghouse. Does the CAQH CORE Payment & Remittance (835) Infrastructure Rule require that we accept an X12 999 Acknowledgement from this clearinghouse?
  15. We are a health plan and part of our X12 835 error handling process includes sending a proprietary paper RA in lieu of an out of balance X12 835. Do the CAQH CORE Payment & Remittance (835) Infrastructure Rules require that we discontinue this process
  16. Why was the CAQH CORE Master Companion Guide Template updated?
  17. The CAQH CORE Connectivity Rule requires publication of a Connectivity Companion Guide. Is this Companion Guide the same as the one referenced in the CAQH CORE Payment & Remittance (835) Infrastructure Rule?
  18. Does the CAQH CORE Payment & Remittance (835) Infrastructure Rule require HIPAA covered entities to publish a companion guide for the X12 v5010 835 if they do not currently do so?
  19. Can I combine multiple transaction sets (i.e., X12 270/271 and X12 835) in a single companion guide?
What was included in April 2022 CAQH CORE Infrastructure Update and how does it impact CAQH CORE Payment & Remittance Infrastructure Rule?

Submitted by msingh@caqh.org on Wed, 04/20/2022 - 15:45
What was included in April 2022 CAQH CORE Infrastructure Update and how does it impact CAQH CORE Payment & Remittance Infrastructure Rule?
  • References 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. To align the rule requirements with this policy, the connectivity requirement language in the CAQH CORE Payment & Remittance (835) Infrastructure Rule was updated to require “most recent published and CAQH CORE adopted version of the CAQH CORE Connectivity Rule.

  • 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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How does an entity determine which version of CAQH CORE Connectivity to use when implementing the federally mandated CAQH CORE Payment & Remittance Infrastructure Rule?

Submitted by msingh@caqh.org on Wed, 04/20/2022 - 16:04
How does an entity determine which version of CAQH CORE Connectivity to use when implementing the federally mandated CAQH CORE Payment & Remittance Infrastructure Rule?

All HIPAA-covered entities are required to support CAQH CORE Connectivity vC2.2.0 for the HIPAA-mandated EFT transaction (please see Mandated Operating Rules webpage for full list of federally mandated operating rules with original naming conventions).

Additionally, since February 2022, all CAQH CORE Infrastructure Operating Rules require use of “most recent published and CAQH CORE adopted version of the CAQH CORE Connectivity Rule” (please see the CAQH CORE Connectivity webpage for more information).

Per CORE Certification Policy, entities seeking CORE Certification are required at a minimum to implement the version of CORE Connectivity published two years prior from when pursuing certification testing. Optionally, entities can choose to implement any newer versions of CORE Connectivity published within the past two years and attain certification depending on testing availability.

NOTE: HHS will determine if updates to CAQH CORE Connectivity Rule requirements will be included in any regulatory mandates.

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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 mean that I can now only receive the 835 via the CAQH CORE Connectivity Safe Harbor?

Submitted by msingh@caqh.org on Thu, 07/14/2022 - 04:38
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 mean that I can now only receive the 835 via the CAQH CORE Connectivity Safe Harbor?

No. Section 4.1, Health Care Claim Payment/Advice Connectivity Requirements, of the CAQH CORE Payment & Remittance (835) Infrastructure Rule requires all HIPAA covered entities to support use of the CORE Connectivity Safe Harbor described in the CAQH CORE Connectivity Rule to transmit or receive the X12 v5010 835. However, the CAQH CORE Payment & Remittance (835) Infrastructure 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 Connectivity Rule.

As a “Safe Harbor”, the CAQH CORE Connectivity 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 Connectivity 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.

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Does the CAQH CORE Payment & Remittance (835) Infrastructure Rule specify processing mode requirements for exchange of the X12 v5010 835?

Submitted by msingh@caqh.org on Thu, 07/14/2022 - 04:40
Does the CAQH CORE Payment & Remittance (835) Infrastructure 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 CORE Payment & Remittance (835) Infrastructure Rule requires entities to support the use of the CORE Connectivity Safe Harbor, as described in the latest version of CAQH CORE Connectivity Rule and vC2.2.0, to send/receive the X12 v5010 835. Per Section 4.1 of the CAQH CORE Payment & Remittance (835) Infrastructure Rule, “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 Payment & Remittance (835) Infrastructure Rule requirements, entities must support batch processing of the X12 v5010 835, in conformance with the CAQH CORE Connectivity Rule requirements for batch processing mode. While the CAQH CORE Payment & Remittance (835) Infrastructure 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.

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What CAQH CORE Connectivity Rule requirements apply to the X12 v5010 835 per the CAQH CORE Payment & Remittance (835) Infrastructure Rule?

Submitted by msingh@caqh.org on Thu, 07/14/2022 - 04:41
What CAQH CORE Connectivity Rule requirements apply to the X12 v5010 835 per the CAQH CORE Payment & Remittance (835) Infrastructure Rule?

Only the batch requirements of any version of CAQH CORE Connectivity Rule apply to the X12 v5010 835. Requirements for batch retrieval (pick up) and acknowledgements are identified in the latest version of the CAQH CORE Connectivity Rule and vC2.2.0, Section 4 which specifies the request and response payload types for batch interactions. As an example, the sequence diagram below depicts how the CAQH CORE Connectivity Rule vC2.2.0 requirements for a generic batch retrieval apply to the X12 v5010 835 transaction.

Connectivity FAQ Image

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Does the Connectivity Rule specify a maximum number of X12 835 transactions that can be sent in a single payload?

Submitted by msingh@caqh.org on Thu, 07/14/2022 - 04:43
Does the Connectivity Rule specify a maximum number of X12 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 Payment & Remittance (835) Infrastructure Rule requires all health plans to support use of the CAQH CORE Connectivity Safe Harbor described in the CAQH CORE Connectivity Rule to transmit the X12 v5010 835. (NOTE: Providers are also required to support use of the CAQH CORE Connectivity Rule to receive the X12 v5010 835.)

The latest version of the CAQH CORE Connectivity Rule and vC2.2.0 neither requires nor prohibits the inclusion of multiple transaction sets, Functional Groups, or X12 Interchanges in a single payload. Section 6.1, Appendix and Definitions Used in this Rule, of the CAQH CORE Connectivity Rule defines a payload of batch files as a single submission containing either:

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

 

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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 Payment& Remittance (835) Infrastructure Rule to comply with Federal law?

Submitted by msingh@caqh.org on Thu, 07/14/2022 - 04:45
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 Payment& Remittance (835) Infrastructure Rule to comply with Federal law?

No. The August 2012 HHS Final Rule adopting the CAQH CORE Payment & Remittance Operating Rules does not adopt the Acknowledgement requirements in Section 4.2 of the CAQH CORE Payment & Remittance (835) Infrastructure 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 Payment & Remittance (835) Infrastructure Rule supports the use of Acknowledgements.

NOTE: In 2020 CAQH CORE updated its naming and versioning conventions for operating rules. Links to the original versions of the federally mandated CAQH CORE Operating Rules are available HERE. The most current versions of the CAQH CORE Payment and Remittance Operating Rules include all federally mandated requirements.

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What are the CAQH CORE Payment & Remittance (835) Infrastructure Rule requirements for HIPAA covered entities to support dual delivery of the ERA and proprietary paper remittance advices?

Submitted by msingh@caqh.org on Thu, 07/14/2022 - 04:46
What are the CAQH CORE Payment & Remittance (835) Infrastructure 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 Payment & Remittance (835) Infrastructure 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.”

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

Submitted by msingh@caqh.org on Thu, 07/14/2022 - 04:47
Is there a specific proprietary paper claim remittance advice format that health plans must use during the dual delivery period?

No. the CAQH CORE Payment & Remittance (835) Infrastructure 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 Payment & Remittance Infrastructure 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.

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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?

Submitted by msingh@caqh.org on Thu, 07/14/2022 - 04:47
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 Payment & Remittance (835) Infrastructure 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.”

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Does the requirement for a dual delivery period in Section 4.3 of the CAQH CORE Payment & Remittance (835) Infrastructure Rule mean that health plans must create and send a proprietary paper claim remittance advice if they do not currently do so?

Submitted by msingh@caqh.org on Thu, 07/14/2022 - 04:48
Does the requirement for a dual delivery period in Section 4.3 of the CAQH CORE Payment & Remittance (835) Infrastructure 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 Payment & Remittance (835) Infrastructure 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 Payment & Remittance (835) Infrastructure Rule does not require a health plan to start doing so.

NOTE: The CAQH CORE Payment & Remittance (835) Infrastructure 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.”

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My organization is a provider-facing clearinghouse. Are we required by the CAQH CORE Payment & Remittance (835) Infrastructure Rule to return an X12 v5010 999 Implementation Acknowledgement to health plans that do not request to receive the X12 v5010

Submitted by msingh@caqh.org on Thu, 07/14/2022 - 04:49
My organization is a provider-facing clearinghouse. Are we required by the CAQH CORE Payment & Remittance (835) Infrastructure Rule to return an X12 v5010 999 Implementation Acknowledgement to health plans that do not request to receive the X12 v5010 999?

The CORE Payment & Remittance (835) Infrastructure 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 Payment & Remittance (835) Infrastructure 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 Payment & Remittance (835) Infrastructure 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 Payment & Remittance Operating Rules to fulfill the ACA Section 1104 mandate does not adopt the batch acknowledgement requirements in Section 4.2 of the CAQH CORE Payment & Remittance (835) Infrastructure Rule. Conformance with the CAQH CORE Payment & Remittance (835) Infrastructure 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.

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The CAQH CORE Payment & Remittance (835) Infrastructure Rule requires that “health plans must be able to accept and process an X12 v5010 999 for a Functional Group of X12 v5010 835 transactions.” What does “processing” mean for this requirement?

Submitted by msingh@caqh.org on Thu, 07/14/2022 - 04:50
The CAQH CORE Payment & Remittance (835) Infrastructure Rule requires that “health plans must be able to accept and process an X12 v5010 999 for a Functional Group of X12 v5010 835 transactions.” What does “processing” mean for this requirement?

The CAQH CORE Payment & Remittance (835) Infrastructure 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 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 Payment & Remittance Operating Rules to fulfill the ACA Section 1104 mandate does not adopt the batch acknowledgement requirements in Section 4.2 of the CAQH CORE Payment& Remittance (835) Infrastructure Rule. Conformance with the CAQH CORE Payment & Remittance (835) Infrastructure Rule requirements regarding acknowledgements remains. Therefore, to meet the Federal requirements under the ACA entities do not have to comply with the CAQH CORE Payment & Remittance (835) Infrastructure Rule requirements for Acknowledgements.

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My organization is a health plan that sends the X12 835 to some providers through a clearinghouse. Does the CAQH CORE Payment & Remittance (835) Infrastructure Rule require that we accept an X12 999 Acknowledgement from this clearinghouse?

Submitted by msingh@caqh.org on Thu, 07/14/2022 - 04:50
My organization is a health plan that sends the X12 835 to some providers through a clearinghouse. Does the CAQH CORE Payment & Remittance (835) Infrastructure Rule require that we accept an X12 999 Acknowledgement from this clearinghouse?

The HHS Final Rule adopting the CAQH CORE Payment & Remittance Operating Rules to fulfill the ACA Section 1104 mandate does not adopt the batch acknowledgement requirements in Section 4.2 of the CAQH CORE Payment & Remittance (835) Infrastructure Rule. HIPAA covered entities do not have to comply with the CAQH CORE Payment & Remittance (835) Infrastructure 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 Payment & Remittance (835) Infrastructure Rule L 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 Payment & Remittance Infrastructure 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.
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We are a health plan and part of our X12 835 error handling process includes sending a proprietary paper RA in lieu of an out of balance X12 835. Do the CAQH CORE Payment & Remittance (835) Infrastructure Rules require that we discontinue this process

Submitted by msingh@caqh.org on Thu, 07/14/2022 - 04:51
We are a health plan and part of our X12 835 error handling process includes sending a proprietary paper RA in lieu of an out of balance X12 835. Do the CAQH CORE Payment & Remittance (835) Infrastructure Rules require that we discontinue this process?

The CAQH CORE Payment & Remittance (835) Infrastructure 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.

The CAQH CORE Payment & Remittance Infrastructure 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 three payments). Note: If a health plan does not currently deliver proprietary paper RAs, the CAQH CORE Payment & Remittance (835) Infrastructure 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.”

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

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Why was the CAQH CORE Master Companion Guide Template updated?

Submitted by msingh@caqh.org on Thu, 07/14/2022 - 04:54
Why was the CAQH CORE Master Companion Guide Template updated?

The CAQH CORE Master Companion Guide Template was updated to align with industry need to support X12 versions beyond v5010. As such, the CAQH CORE Master Companion Guide template was updated to be version agnostic, removing explicit references to X12 v5010 from the template.

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The CAQH CORE Connectivity Rule requires publication of a Connectivity Companion Guide. Is this Companion Guide the same as the one referenced in the CAQH CORE Payment & Remittance (835) Infrastructure Rule?

Submitted by msingh@caqh.org on Thu, 07/14/2022 - 04:54
The CAQH CORE Connectivity Rule requires publication of a Connectivity Companion Guide. Is this Companion Guide the same as the one referenced in the CAQH CORE Payment & Remittance (835) Infrastructure Rule?

Connectivity Companion Guides are entity-specific guides that outline the requirements to establish and maintain a connection with the entity. The CAQH CORE Connectivity 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 Payment & Remittance (835) Infrastructure 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 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 Master Companion Guide.

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 Payment & Remittance (835) Infrastructure 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 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.

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Does the CAQH CORE Payment & Remittance (835) Infrastructure Rule require HIPAA covered entities to publish a companion guide for the X12 v5010 835 if they do not currently do so?

Submitted by msingh@caqh.org on Thu, 07/14/2022 - 04:55
Does the CAQH CORE Payment & Remittance (835) Infrastructure 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. The CAQH CORE Payment & Remittance (835) Infrastructure Rule, 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 Master Companion Guide.

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

Submitted by msingh@caqh.org on Thu, 07/14/2022 - 04:57
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 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.

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