Phase IV CAQH CORE Operating Rules

II. CAQH CORE 450: Health Care Claim (837) Infrastructure Rule

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. If an ASC X12N v5010 837 is received in a batch, does the ASC X12C v5010 999 Acknowledgment or ASC X12N v5010 277CA transaction have to be returned in a batch?
  2. Currently my organization’s EDI system only returns a positive ASC X12C v5010 999 Acknowledgment reporting acceptance of the ASC X12N v5010 837 submitted in Batch Processing Mode. If the Functional Group or a Transaction Set within a Functional Group is rejected, must my system be changed to comply with the batch requirements?
  3. Do the time frames for the Phase IV CAQH CORE 450 Health Care Claim (837) Infrastructure Rule still apply if it is an especially large batch? Do the CAQH CORE Operating Rules define the batch size?
  4. Why measure acknowledgements availability response time conformance based on the percentage of responses returned within a specified timeframe rather than average response time?
  5. Is there a standard reporting form for the conformance reporting?
  6. If a CORE-certified entity is communicating with a non-CORE-certified entity, does the CORE-certified entity have to respond within the specified response time window?
  7. Can a clearinghouse or vendor act on behalf of a health plan for providing ASC X12C v5010 999 Acknowledgements to ASC X12N v5010 837 Claims?
  8. What are the Phase IV CAQH CORE 450 Health Care Claim (837) Infrastructure Rule requirements for entities to support real time and/or batch processing?
  9. Are there any requirements regarding how often ASC X12N v5010 837 Claim transactions should be submitted? (e.g., do CAQH CORE Operating Rules either support or exclude a provider or vendor from sending daily batches of ASC X12N v5010 837 Claim transactions?)
  10. Currently my organization’s EDI system only returns a positive ASC X12C v5010 999 Acknowledgment reporting acceptance of the ASC X12N v5010 837. If the Functional Group or a Transaction Set within a Functional Group is rejected, must my system be changed to comply with the Batch Acknowledgement Requirement?
  11. My organization’s EDI system was developed in-house and does not currently support the TA1. However, our system does support the ASC X12C v5010 999 Acknowledgment for rejected functional groups. Is this conformant under the Phase IV CAQH CORE 450 Health Care Claim (837) Infrastructure Rule requirements?
  12. If my organization’s system is not changed to return the ASC X12C v5010 999 Acknowledgment, can my organization become CORE-certified?
  13. The TA1 Interchange Acknowledgment is described in the HIPAA Implementation Guide Appendix B: EDI Control Director. Do the Phase IV CAQH CORE Operating Rules require its use?
  14. Do the CAQH CORE 450 Rule Real Time Acknowledgement Requirements require that my organization’s system must always return both of these types of Acknowledgements: ASC X12C v5010 999 Acknowledgment and the ASC X12N v5010 277CA?
  15. Is an acknowledgement necessary if the user sends claim data in a proprietary (not an ASC X12 837) format in a real time mode?
  16. Are all Phase IV CAQH CORE 450 Health Care Claim (837) Infrastructure Rule requirements with regard to acknowledgement only applicable to scenarios where my organization receives data in an ASC X12N v5010 837 format?
  17. Does my organization have to send back a response (ASC X12C v5010 999 Acknowledgement or ASC X12N v5010 277CA) to a submitted claim if my system is down?
  18. My organization includes system availability schedules in our Companion Guide. Does this satisfy the CAQH CORE Operating Rule requirements for system availability reporting?
  19. Why was the Master Companion Guide Template created?
  20. Does the Phase IV CAQH CORE 450 Rule require HIPAA covered entities to publish a Companion Guide if they do not currently do so?
  21. Does the Phase IV CAQH CORE 450 Rule require health plans to request approval from ASC X12 prior to publication of their CORE-conformant Companion Guide?
  22. If my health plan does not conduct the ASC X12N v5010 278 transaction, am I required to support the processing of this transaction?
  23. Can I combine multiple transaction sets in a single companion guide?
  24. The CAQH CORE 450 Rule requires that a HIPAA-covered entity or its agent must include the entity’s requirements for coordination of benefits in their companion guide. What if my organization doesn’t provide for coordination of benefits?
  25. Does this rule apply if my organization does not conduct the ASC X12 v5010 837 transaction?
  26. Why is there a variability in elapsed times for returning acknowledgements or responses between the four Phase IV CAQH CORE Infrastructure Rules?
  27. What is the coordination of benefits (COB) content I have to include in the Companion Guide per Section 4.6.1 of the CAQH CORE 450 Rule?
  28. Why does the Phase IV CAQH CORE 450 Claims Rule include a requirement to address COB requirements in an entity’s Companion Guide for claims?
1. If an ASC X12N v5010 837 is received in a batch, does the ASC X12C v5010 999 Acknowledgment or ASC X12N v5010 277CA transaction have to be returned in a batch?

The rule requirement addressing response time when an ASC X12N v5010 837 is submitted in batch processing mode by 9:00 pm ET on a business day only requires that a health plan must have the responses available by 7:00 AM by the second business day following a submission of claims. The CAQH CORE 450 Rule does not specify whether or not the batch of responses must match exactly the batch of ASC X12N v5010 837 claims.

2. Currently my organization’s EDI system only returns a positive ASC X12C v5010 999 Acknowledgment reporting acceptance of the ASC X12N v5010 837 submitted in Batch Processing Mode. If the Functional Group or a Transaction Set within a Functional Group is rejected, must my system be changed to comply with the batch requirements?

Yes. Per the Phase IV CAQH CORE 450 Health Care Claim (837) Infrastructure Rule, an ASC X12C v5010 999 Acknowledgment must be returned for all Functional Groups of any ASC X12N v5010 837 Claim Transaction Sets whether or not the Functional Group or a Transaction Set within the Functional Group is accepted, accepted with errors, or rejected. 

3. Do the time frames for the Phase IV CAQH CORE 450 Health Care Claim (837) Infrastructure Rule still apply if it is an especially large batch? Do the CAQH CORE Operating Rules define the batch size?

The CAQH CORE 450 Rule and the CAQH CORE 470 Rule do not define batch size. The maximum size of a batch file that is accepted by a Server is outside the scope of the rules; 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 ASC X12N v5010 837 claim is submitted in Batch Processing Mode applies to all batches. 

4. Why measure acknowledgements availability response time conformance based on the percentage of responses returned within a specified timeframe rather than average response time?

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.

5. Is there a standard reporting form for the conformance reporting?

No. The CAQH CORE Operating Rule does not mandate a particular form.

6. If a CORE-certified entity is communicating with a non-CORE-certified entity, does the CORE-certified entity have to respond within the specified response time window?

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

7. Can a clearinghouse or vendor act on behalf of a health plan for providing ASC X12C v5010 999 Acknowledgements to ASC X12N v5010 837 Claims?

Yes. The Phase IV CAQH CORE 450 Health Care Claim (837) 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).

The ASC X12C v5010 999 Acknowledgement returned to an ASC X12N v5010 837 claim submitted in Batch Processing Mode by a HIPAA-covered health plan or its agent must indicate whether a Functional Group or  any included ASC X12N v5010 837 Claim Transaction Set is accepted, accepted with errors or rejected.

An ASC X12C v5010 999 Acknowledgement must be returned only when the Functional Group or any included ASC X12N v5010 837 Claim Transaction Set submitted in Real Time Processing Mode without adjudication is rejected.

Any ASC X12C v5010 999 Acknowledgement returned reporting either that the Functional Group or included ASC X12N v5010 837 claim is accepted with errors or rejected must report each error detected to the most specific level of detail supported by the ASC X12C v5010 999 Acknowledgement.

8. What are the Phase IV CAQH CORE 450 Health Care Claim (837) Infrastructure Rule requirements for entities to support real time and/or batch processing?

The Phase IV CAQH CORE 450 Health Care Claim (837) Infrastructure Rule requires that a HIPAA-covered health plan or its agent must implement the server requirements for Batch Processing Mode for the ASC X12N v5010 837 Claim transaction as specified in the Phase IV CAQH CORE 470 Connectivity Rule. Optionally, a HIPAA-covered health plan or its agent may elect to also implement the server requirements for Real Time Processing Modes as specified in the CAQH CORE 470 Rule.

A HIPAA-covered health plan or its agent conducting the ASC X12N v5010 837 Claim transaction is required to conform to the processing mode requirements specified in this section regardless of any other connectivity modes and methods used between trading partners. 

9. Are there any requirements regarding how often ASC X12N v5010 837 Claim transactions should be submitted? (e.g., do CAQH CORE Operating Rules either support or exclude a provider or vendor from sending daily batches of ASC X12N v5010 837 Claim transactions?)

No. The Phase IV CAQH CORE 450 Health Care Claim (837) Infrastructure Rule does not address the frequency of submission for ASC X12N v5010 837 Claim transactions.

10. Currently my organization’s EDI system only returns a positive ASC X12C v5010 999 Acknowledgment reporting acceptance of the ASC X12N v5010 837. If the Functional Group or a Transaction Set within a Functional Group is rejected, must my system be changed to comply with the Batch Acknowledgement Requirement?

Yes. The Phase IV CAQH CORE 450 Health Care Claim (837) Infrastructure Rule requires that the HIPAA-covered health plan or its agent must always return an ASC X12C v5010 999 Acknowledgment for all Functional Groups, whether or not the 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 ASC X12C v5010 999 Acknowledgment for all functional groups whether or not the group is rejected, thereby allowing timely resolution of any issues.

The ASC X12C v5010 999 Acknowledgment must report each error detected to the most specific level of detail supported by the ASC X12C v5010 999 Acknowledgement.

A HIPAA-covered health plan or its agent must acknowledge each claim received in any Functional Group of any ASC X12N v5010 837 Claim Transaction Set using the ASC X12N v5010 277CA transaction only when ASC X12N v5010 837 Claim Transaction Set is not rejected.

11. My organization’s EDI system was developed in-house and does not currently support the TA1. However, our system does support the ASC X12C v5010 999 Acknowledgment for rejected functional groups. Is this conformant under the Phase IV CAQH CORE 450 Health Care Claim (837) Infrastructure Rule requirements?

Yes. The CAQH CORE 450 Rule addresses only the ASC X12C v5010 999 Acknowledgment; therefore your organization’s system must be able to return an ASC X12C v5010 999 Acknowledgment for all functional groups to indicate that the functional group(s) was either accepted, accepted with errors, or rejected. If it is unable to do so, your organization will need to remediate the system to be in conformance with the CAQH CORE Operating Rule in order to become CORE-certified.

12. If my organization’s system is not changed to return the ASC X12C v5010 999 Acknowledgment, can my organization become CORE-certified?

No. All of the Phase IV CAQH CORE Infrastructure Operating Rules include requirements for the use of the ASC X12C v5010 999 Acknowledgment. Your organization must successfully complete all of the required certification test scripts required by the Phase IV CAQH CORE Certification Test Suite to become CORE-certified. The test scripts for all of the Phase IV CAQH CORE Infrastructure Rules  will test for your system’s capabilities to return the ASC X12C v5010 999 Acknowledgment. 

13. The TA1 Interchange Acknowledgment is described in the HIPAA Implementation Guide Appendix B: EDI Control Director. Do the Phase IV CAQH CORE Operating Rules require its use?

No. The Phase IV CAQH CORE Operating Rules do not address the use of the ASC X12 Interchange Acknowledgement TA1.

14. Do the CAQH CORE 450 Rule Real Time Acknowledgement Requirements require that my organization’s system must always return both of these types of Acknowledgements: ASC X12C v5010 999 Acknowledgment and the ASC X12N v5010 277CA?

No. When an ASC X12N v5010 837 is submitted in Real Time a HIPAA-covered health plan or its agent must only return an ASC X12C v5010 999 Acknowledgment when the Functional Group of any ASC X12N v5010 837 Claim Transaction Set is rejected. 

A HIPAA-covered health plan or its agent must not return an ASC X12C v5010 999 Acknowledgment to indicate that a Functional Group or a Transaction Set is accepted or accepted with errors. 

A HIPAA-covered health plan or its agent must acknowledge each claim received in any Functional Group of any ASC X12N v5010 837 Claim Transaction Set using the ASC X12N v5010 277CA transaction only when ASC X12N v5010 837 Claim Transaction Set is accepted.

Therefore, the submitter of an ASC X12N v5010 837 Claim Transaction in Real Time will receive only one response from the HIPAA-covered health plan or its agent: an ASC X12C v5010 999 Acknowledgment or an ASC X12N v5010 277CA. Thus, your organization’s system must return only one of these transactions, depending on the processing results, not both.  

15. Is an acknowledgement necessary if the user sends claim data in a proprietary (not an ASC X12 837) format in a real time mode?

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 Phase IV CAQH CORE Operating Rules are focused on the conduct of the HIPAA-named ASC X12 transaction sets and on the ASC X12 standards as well. Thus, the Phase IV CAQH CORE 450 Health Care Claim (837) Infrastructure Rule addresses the use of the ASC X12C v5010 999 Acknowledgment and the ASC X12N v5010 277CA and when to use them when conducting the ASC X12N v5010 837 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 ASC X12 implementation guides.

16. Are all Phase IV CAQH CORE 450 Health Care Claim (837) Infrastructure Rule requirements with regard to acknowledgement only applicable to scenarios where my organization receives data in an ASC X12N v5010 837 format?

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 Phase IV CAQH CORE Rules are focused on the conduct of the HIPAA-named ASC X12 transaction sets and on the ASC X12 standards as well. Thus, the CAQH CORE 450 Rule only addresses the use of the ASC X12C v5010 999 Acknowledgment and the ASC X12N v5010 277CA and when to use them when conducting the ASC X12N v5010 837 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 ASC X12 implementation guides.

17. Does my organization have to send back a response (ASC X12C v5010 999 Acknowledgement or ASC X12N v5010 277CA) to a submitted claim if my system is down?

As long as your claim system is in conformance with the CAQH CORE System Availability requirements, then it is not required to send back an ASC X12C v5010 999 Acknowledgement or ASC X12N v5010 277CA, 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.

18. My organization includes system availability schedules in our Companion Guide. Does this satisfy the CAQH CORE Operating Rule requirements for system availability reporting?

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 Operating Rule outlines requirements for reporting/publishing non-routine downtimes and unscheduled/emergency downtimes.

19. Why was the Master Companion Guide Template created?

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 Phases I, II, III, and IV CAQH CORE 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.

20. Does the Phase IV CAQH CORE 450 Rule require HIPAA covered entities to publish a Companion Guide if they do not currently do so?

No. The Phase IV CAQH CORE Operating Rules do not require any entity to publish a Companion Guide if they do not already do so.

Section 4.6 of the Phase IV CAQH CORE 450 Rule specifies that should an entity publish a companion guide it must conform to the format/flow as defined in the CAQH CORE v5010 Master Companion Guide Template.

21. Does the Phase IV CAQH CORE 450 Rule require health plans to request approval from ASC X12 prior to publication of their CORE-conformant Companion Guide?

No. The Phase IV CAQH CORE Operating Rules do not require any entity to submit its Companion Guide to ASC 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 v5010 Master Companion Guide Template.

NOTE: Phase IV CORE Certification will be available in Summer 2016. 

22. If my health plan does not conduct the ASC X12N v5010 278 transaction, am I required to support the processing of this transaction?

Yes if your organization is a HIPAA-covered health plan; potentially if your organization is a business associate of a HIPAA-covered health plan. The terms and conditions of the Business Associate Agreement will determine your organization’s obligation to conduct these transactions. Under the HIPAA provisions, health plans are “required to have the capacity to accept and/or send (either itself, or by hiring a health care clearinghouse to accept and/or send on its behalf) a standard transaction that it otherwise conducts but does not currently support electronically” (see CMS FAQ #8121). This requirement applies to all HIPAA-mandated transaction standards.

 

NOTE: CMS is the HHS designated authority on any decisions regarding interpretation, implementation, and enforcement of the regulations adopting the HIPAA and ACA Administrative Simplification standards and provisions. Within CMS, the National Standards Group (NSG) enforces the regulations addressing the HIPAA and ACA-mandated transactions, national identifiers, operating rules, health plan certification, and additional standards. More detailed information on the provisions, as well as compliance and enforcement requirements, is available on the CMS website and via the CMS FAQs

23. Can I combine multiple transaction sets 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 would need to be repeated, tables added for each additional transaction, etc., without altering the flow and format.

24. The CAQH CORE 450 Rule requires that a HIPAA-covered entity or its agent must include the entity’s requirements for coordination of benefits in their companion guide. What if my organization doesn’t provide for coordination of benefits?

As stated in Section 4.6.1, Health Care Claim Companion Guide Requirements, “A HIPAA-covered entity or its agent’s Companion Guide covering the ASC X12N v5010 837 Claim transaction must include the entity's requirements for coordination of benefits in Section 7 and Section 10 as appropriate.” If a HIPAA-covered entity or its agent does not provide for coordination of benefits that should be disclosed in the Companion Guide. 

NOTE: The Phase IV CAQH CORE Operating Rules do not require any entity to publish a Companion Guide if they do not already do so, however if they do publish a companion guide they must include the entity's requirements for coordination of benefits per the rule requirement. 

25. Does this rule apply if my organization does not conduct the ASC X12 v5010 837 transaction?

No. Per Section 3.2 of CAQH CORE 450 Rule, the rule applies when a HIPAA-covered health plan or its agent uses, conducts, or processes the ASC X12N v5010 837 transaction.

Additionally, per Section 3.3 of CAQH CORE 450 Rule, this rule does not require any entity to conduct, use, or process the ASC X12N v5010 837 transaction if it currently does not do so or is not required by Federal or state regulation to do so.

26. Why is there a variability in elapsed times for returning acknowledgements or responses between the four Phase IV CAQH CORE Infrastructure Rules?

The four Phase IV CAQH CORE Infrastructure Rules recognize that there are different business processes for the various transactions which have different capabilities. Therefore, through the rule development process, appropriate elapsed time requirements were determined individually for each Phase IV CAQH CORE Infrastructure Rule and its respective transaction focus.

27. What is the coordination of benefits (COB) content I have to include in the Companion Guide per Section 4.6.1 of the CAQH CORE 450 Rule?

Per Section 4.6.1, Health Care Claim Companion Guide Requirements, of the CAQH CORE 450 Rule, there is no specific requirement for content in the Companion Guide; however, it states that, “a HIPAA-covered entity or its agent’s Companion Guide covering the ASC X12N v5010 837 Claim transaction must include the entity's requirements for coordination of benefits in Section 7 and Section 10 as appropriate.” It is the business decision of the HIPAA-covered entity to decide what COB content is most appropriate for Section 7 and 10 of its companion guide. A general example of COB content would be any special processing requirements, special claim routing requirements or data elements specific to your organization. 

28. Why does the Phase IV CAQH CORE 450 Claims Rule include a requirement to address COB requirements in an entity’s Companion Guide for claims?

Many health plans have separate processes for coordination of benefits (COB) claims and may require unique routing of the claim or variety of data that is not required on a regular claim. By providing this information in its companion guide a health plan is offering better servicing to its provider and trading partner community.