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 Summer 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.