Frequently Asked Questions - II. CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule

·       Substantive Update to System Availability Requirements. The weekly system availability requirement was updated across the CAQH CORE Infrastructure Rules including CAQH CORE x Infrastructure Rule from 86% per calendar week to requiring systems to be available 90% per calendar week.  Additionally, a new quarterly system availability requirement was added allowing systems 24 additional downtime hours per calendar quarter, in excess of the allowable weekly system downtime or 17 hours (10% system downtime per calendar week).

·       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.

All CAQH CORE Infrastructure Operating Rules including CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule 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.

No. Per Section 3.2 of CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule, the rule applies when a HIPAA-covered health plan or its agent uses, conducts, or processes an X12 v5010 278 transaction.

Additionally, per Section 3.3 of CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule, this rule does not require any entity to conduct, use, or process an X12 v5010 278 transaction if it currently does not do so or is not required by Federal or state regulation to do so.

Since February 2022, all CAQH CORE Infrastructure Operating Rules including CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule require use of the most current CAQH CORE published and adopted version of the CAQH CORE Connectivity Rule” (please see the CAQH CORE Connectivity web page to find the most recent published and adopted version of the CAQH CORE Connectivity Rule).

The CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule requirement addressing response time when an X12 v5010X217 278 request is submitted in Batch Processing Mode by 9:00 pm ET on a business day only requires that a health plan have the batch of responses available by 7:00 am ET by the third business day following submission of an X12 v5010 278 Request. The rule does not specify whether the batch of responses must match exactly the batch of X12 v5010 278 requests.

Yes. Per the CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule, an X12 v5010 999 Acknowledgement must only be returned when a Functional Group or Transaction Set of an X12 v5010X217 278 Request is submitted in Real Time Processing Mode is rejected.

Therefore, the submitter of an X12 v5010X217 278 Request transaction in Real Time will receive only one of two responses from the HIPAA-covered health plan or its agent: an X12 v5010 999 Acknowledgment or an X12 v5010X217 278 Response.

The CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule and the CAQH CORE Connectivity Rule vC3.1.0 do not define batch size. The maximum size of a batch file that is accepted by a Server is outside the scope of the rule; the implementer of a Server may publish its file size limit, if any, in its Connectivity Companion Guide. Therefore, the response time frame for all Acknowledgements specified when an X12 v5010 278 Request transaction is submitted in Batch Processing Mode applies to all batches. 

Averages can be skewed by outlier responses. The percentage of responses returned within the specified timeframe gives a better indication of the entity’s capabilities.

No. The CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule does not mandate a particular form.

Yes. An entity, e.g., a provider, does not have to be certified by CAQH CORE to interact with a CORE-certified entity, e.g., a health plan, under the CAQH CORE Operating Rules.

Yes. The CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule defines the specific requirements that HIPAA-covered health plans or their agents and HIPAA-covered providers or their agents must satisfy. In this context, an agent is “one who agrees and is authorized to act on behalf of another, a principal, to legally bind an individual in particular business transactions with third parties pursuant to an agency relationship.” (Source: West’s Encyclopedia of American Law, edition 2, Copyright 2008 The Gale Group, Inc. All rights reserved).

Importantly, the response that a HIPAA-covered health plan or its agent returns is dependent on whether the X12 v5010 278 Request submitted in Real Time processing mode is rejected or accepted.

A HIPAA-covered health plan or its agent must return:

• An X12 v5010 999 Acknowledgement to indicate that a Functional Group(s) or Transaction Set(s) is rejected.

A HIPAA-covered health plan or its agent must not return:

• An X12 v5010 999 Acknowledgement to indicate that a Functional Group(s) or Transaction Set(s) is accepted or accepted with errors.

Therefore, the submitter of an X12 v5010 278 Request in Real Time processing mode will receive only one of two possible responses from the HIPAA-covered health plan or its agent: an X12 v5010 999 Acknowledgement or an X12 v5010 278 Response.

The CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule requires that a HIPAA-covered health plan or its agent must implement the server requirements for either Real Time Processing Mode OR Batch Processing Mode for the X12 v5010 278 Request and Response transactions as specified in the CAQH CORE Connectivity Rule vC3.1.0. Optionally, a HIPAA-covered health plan or its agent may elect to implement both Real Time and Batch Processing Modes.

A HIPAA-covered health plan or its agent conducting the X12 v5010 278 Request and Response transactions is required to conform to the processing mode requirements specified in Section 4.1, Health Care Services Review- Request and Response Processing Mode Requirements, regardless of any other connectivity modes and methods used between trading partners.

No. The CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule does not address the frequency of submission of X12 v5010 278 Request and Response transactions in Batch Processing Mode.

Yes. The CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule requires that the HIPAA-covered health plan or its agent must always return an X12 v5010 999 Acknowledgment for all Functional Groups of an X12 v5010 278 Request, whether or not the Functional Group is rejected. This requirement allows the provider to know within a reasonable timeframe if the submitted batch of inquiries was accepted by the health plan and will be processed. Likewise, the rule also requires that the provider must always return an X12 v5010 999 Acknowledgment for all Functional Groups of an X12 v5010 278 Response, whether or not the Functional Group is rejected, thereby allowing timely resolution of any issues. 

Additional information on the return of an X12 v5010 999 Acknowledgment by a HIPAA-covered entity or its agent can be found in Section 4.7.1 of the CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule. 

Yes. CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule requirements address only the X12 v5010 999 Acknowledgment; therefore, your organization’s system must be able to return an X12 v5010 999 Acknowledgment for all Functional Groups. If it is unable to do so, your organization will need to remediate the system to be in conformance with the CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule requirements to become CORE-certified.

No. Your organization must successfully complete all of the required certification test scripts required by the CAQH CORE Prior Authorization & Referrals Certification Test Suite to become CORE-certified. The test scripts for the CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule will test for your system’s capabilities to return the X12 v5010 999 Acknowledgment. 

No. The CAQH CORE Prior Authorization and Referrals (278) Operating Rules do not address the use of the X12 Interchange Acknowledgement TA1.

No. When an X12 278 Request is submitted in Real Time, a HIPAA-covered health plan or its agent must only return an X12 v5010 999 Acknowledgement to indicate that the Functional Group or Transaction Set is rejected.

A HIPAA-covered health plan or its agent must not return an X12 v5010 999 Acknowledgement to indicate that a Functional Group or Transaction Set is accepted or accepted with errors.

Therefore, the submitter of an X12 v5010 278 Request in Real Time will receive only one response from the HIPAA-covered health plan or its agent: an X12 v5010 999 Acknowledgement or an X12 v5010 278 Response. Thus, your organization’s system must return only one of these transactions, depending on the processing results, not both.

Good business practices for electronic message exchange encourage all senders and receivers to appropriately acknowledge receipt and both acceptance/rejection and errors found in any message. Accordingly, the CAQH CORE Prior Authorization and Referrals (278) are focused on the conduct of the HIPAA-named X12 Transaction Sets and on the X12 standards as well. Thus, the CAQH CORE Prior Authorization and Referrals (278) Infrastructure Rule only addresses the use of the X12 v5010 999 Acknowledgment and when to use it when conducting the X12 v5010 278 Transaction Sets. Additionally, in order to become CORE-certified, an entity is required to attest to its compliance with HIPAA, which requires the use of the appropriate X12 implementation guides.

Yes. Good business practices for electronic message exchange encourage all senders and receivers to appropriately acknowledge receipt and both acceptance/rejection and errors found in any message. Accordingly, the CAQH CORE Prior Authorization & Referrals (278) Operating Rules are focused on the conduct of the HIPAA-named X12 Transaction Sets and on the X12 standards as well. Thus, the CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule only addresses the use of the X12 v5010 999 Acknowledgment and when to use it when conducting the X12 v5010 278 Transaction Sets. Additionally, to become CORE-certified, an entity is required to attest to its compliance with HIPAA, which requires the use of the appropriate X12 implementation guides.

If your prior authorization system is in conformance with the CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule System Availability Requirements, then it is not required to send back a either an X12 v5010 999 Acknowledgment or an X12 v5010 278 Response, either in real time or batch when your system is down. When your system is back up, such Acknowledgements should be made available to the submitter.

No. When an X12 278 Request is submitted in Real Time a HIPAA-covered health plan, or its agent must only return an X12 v5010 999 Acknowledgement to indicate that the Functional Group or Transaction Set is rejected.

A HIPAA-covered health plan or its agent must not return an X12 v5010 999 Acknowledgement to indicate that a Functional Group or Transaction Set is accepted or accepted with errors.

Therefore, the submitter of an X12 v5010 278 Request in Real Time will receive only one response from the HIPAA-covered health plan or its agent: an X12 v5010 999 Acknowledgement or an X12 v5010 278 Response. Thus, your organization’s system must return only one of these transactions, depending on the processing results, not both.

No. The system availability requirements apply to Batch and Real Time Processing Modes, with no difference in system availability based on the processing mode. CAQH CORE will conduct research and environmental scans to obtain data on the feasibility of separate system availability requirements in potential future infrastructure updates, as separate requirements may make better business sense as the industry moves to more API-driven interactions between providers and health plans.

Each set of CAQH CORE Operating Rules includes an infrastructure rule with requirements for system availability and reporting, including the CAQH CORE X Infrastructure Rule. In response to feedback from CAQH CORE Participants and the CAQH CORE Board, in September 2021 CAQH CORE surveyed Participating Organizations to determine where there may be consensus to update the CAQH CORE Infrastructure Operating Rule requirements to align with evolving business needs and technology. The survey focused on system availability and response time requirements across all rule sets and clear consensus emerged to update the system availability requirements across the CAQH CORE Infrastructure Rules.

Significant discussions occurred related to system availability needs. Ultimately, CORE Participants compromised by approving a new quarterly system availability requirement to accommodate large system migrations if weekly system availability was increased from 86% per calendar week to 90% per calendar week. With this weekly availability increase, the new quarterly system availability allows health plans and their agents to use 24 additional hours of system downtime per calendar quarter for system migrations, mitigations, and other system needs that may require additional downtime.

No, the 24-hour downtime can be taken in any increment of time throughout the calendar, as needed.

Yes, the new requirement specifies an additional 24 hours available quarterly in excess of the 17 hours weekly allowable downtime, or 10% of a calendar week.

No. The new quarterly system availability requirement does not define calendar quarter. The definition of a calendar quarter is agreed upon between trading partners.

Yes. HIPAA-covered health plans (or information sources), clearinghouses/switches, or other intermediaries must publish their regularly scheduled system downtime in an appropriate manner (e.g., on websites or in Companion Guides). This allows the healthcare provider to better manage staffing levels. Additionally, the CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule outlines requirements for reporting/publishing non-routine downtimes and unscheduled/emergency downtimes.

For many years health plans independently created companion guides that often varied in format and structure. Such variance can be confusing to trading partners and providers. CAQH CORE adapted its CAQH CORE Master Companion Guide Template for CAQH CORE Prior Authorization & Referrals (278) Operating Rules based on the CAQH/WEDI Best Practices Companion Guide Template, with input from multiple health plans, system vendors, provider representatives and healthcare/HIPAA industry experts. The CAQH CORE Master Companion Guide Template organizes information into several simple sections and provides for a common information flow and format, while at the same time giving health plans the flexibility to tailor the document to meet their particular needs. The CAQH CORE Master Companion Guide Template may be used for all HIPAA-mandated Transaction Sets.

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.

No. Section 4.8 of the CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule specifies that should an entity publish a Companion Guide, it must conform to the format/flow as defined in the CAQH CORE Master Companion Guide Template.

No. The CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule does not require any entity to submit its Companion Guide to X12 for review and approval prior to publication. 

Entities seeking CORE Certification are required to submit to the CAQH CORE-authorized Testing Vendor: 1) The Companion Guide’s table of contents and 2) A page showing the organization’s requirements for the presentation of segments, data elements, and codes. The CAQH CORE-authorized Testing Vendor will evaluate these documents to determine if they are consistent with the format in the CAQH CORE Master Companion Guide Template.

Yes. For compliance with CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule Requirement 4.9 Use of CAQH CORE Master Companion Guide Template, entities may 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 would need to be repeated, tables added for each additional transaction, etc., without altering the flow and format.