Phase IV CAQH CORE Operating Rules

I. Overview of Phase IV CAQH CORE Operating Rules

NOTE: Implementation of the Phase IV CAQH CORE Operating Rules is currently voluntary. HHS will determine if the Phase IV CAQH CORE Operating Rules will be included in any regulatory mandates. The Phase IV FAQs are for use by entities completing voluntary implementation of the operating rules and/or pursuing Phase IV CORE Certification which will be available in Fall 2016. 

 

1. What entities should implement the Phase IV CAQH CORE Operating Rules?

The Phase IV CAQH CORE Operating Rules apply to all HIPAA covered entities that conduct the following transactions:

  • ASC X12N 005010X222 Health Care Claim (837) Professional, ASC X12N 005010X223 Health Care Claim (837) Institutional, and ASC X12N 005010X224 Health Care Claim (837) Dental transactions and their respective errata (collectively the ASC X12N v5010 837 Claim)
  • ASC X12N 005010X217 Health Care Services Review – Request for Review and Response (278)  and associated errata
  • ASC X12N 005010X220 Benefit and Enrollment Maintenance (834) transaction
  • ASC X12N 005010X218 Payroll Deducted and Other Group Premium Payment for Insurance Products (820)

Entities acting in the role of a Business Associate of a HIPAA covered entity may also need to implement various aspects of the Phase IV CAQH CORE Operating Rules. The CMS website provides charts to help organizations determine whether an organization or individual is a HIPAA covered entity.

In addition to the above four Phase IV CAQH CORE Operating Rules for the above transactions, HIPAA covered entities and, if required, their Business Associates will have to implement enhanced connectivity requirements to be conformant with the Phase IV CAQH CORE 470 Connectivity Rule.

NOTE: Currently the Phase IV CAQH CORE Operating Rules are voluntary and have not been adopted by HHS for mandatory adoption by HIPAA covered entities. HHS will determine if the new Phase IV CAQH CORE Operating Rules will be included in any regulatory mandates. Any such considerations will include an HHS public comment period. While the Phase IV CAQH CORE Operating Rules are currently voluntary, stakeholder entities are immediately eligible to implement the operating rules and to pursue voluntary Phase IV CORE Certification. Based on the Phase IV CAQH CORE Voluntary Certification Test Suite, a CAQH CORE-authorized Testing Vendor will build the Phase IV testing site over the coming months and voluntary CORE Certification will be available in Fall 2016. Please contact CORE@caqh.org if your entity is interested in becoming an early adopter of this rule set. 

See the CAQH CORE FAQs Part B: ACA Section 1104 Mandate for Federal Operating Rules for more information on the ACA Section 1104 Administrative Simplification provisions.

2. What do the Phase IV CAQH CORE Operating Rules address?

The Phase IV CAQH CORE Operating Rules streamline the way that claims, prior authorization, benefits enrollment and maintenance, and premium payment healthcare administrative information is exchanged electronically. Easier, more reliable access to this information can reduce the amount of time providers spend on administration by requiring entities to support claims acknowledgements for submitted claims, enhancing the review and response time of prior authorization requests, enrolling employees and beneficiaries electronically, providing premium payment information to health plans, and providing a Companion Guide template to help clarify and specify the data content entities exchange electronically.

The Phase IV CAQH CORE Operating Rules address the following:

Scope of Phase IV Operating Rules

3. Will CORE Certification be offered for the Phase IV CAQH CORE Operating Rules?

Voluntary CORE Certification for the Phase IV CAQH CORE Operating Rules is now available. Phase IV CORE Certification covers four healthcare business transactions: healthcare claims; prior authorization; employee premium payment; and enrollment and disenrollment in a health plan. The specific requirements and test scripts for Phase IV CORE Certification are found in the Phase IV CAQH CORE Voluntary Certification Test Suite, which was approved along with the Phase IV CAQH CORE Operating Rules through the CAQH CORE voting process in September 2015. To become Phase IV CORE-certified, stakeholders are required to test for the X12 837 and X12 278 transactions, if applicable. Testing for the X12 820 and X12 834 employer-based transactions is optional for Phase IV CORE Certification.

4. When will CORE Certification be offered for the Phase IV CAQH CORE Operating Rules?

Voluntary CORE Certification for the Phase IV CAQH CORE Operating Rules is now available. Phase IV CORE Certification covers four healthcare business transactions: healthcare claims; prior authorization; employee premium payment; and enrollment and disenrollment in a health plan. Entities interested in pursuing Phase IV CORE Certification should review the Phase IV CAQH CORE Voluntary Certification Test Suite which documents the test scripts required for Phase IV CORE Certification.