Phase IV CAQH CORE Operating Rules

III. CAQH CORE 452: Prior Authorization (278) 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

 

  1. If a 5010X217 278 Request is received in a batch, does the 5010X217 278 Response have to be returned in a batch?
  2. Currently my organization’s EDI system returns a positive 5010X231 999 Acknowledgment reporting acceptance of the 5010X217 278 submitted in Real Time Processing Mode. If the Functional Group is rejected, must my system be changed to comply with the Real Time requirements?
  3. Do the time frames for the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule still apply if it is an especially large batch? Do the CAQH CORE Operating Rules define the batch size?
  4. Why measure 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 5010X217 278 Request real time Responses?
  8. What are the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule requirements for entities to support real time and/or batch processing?
  9. Are there any requirements regarding how often 5010X217 278 Request and Response transactions should be submitted? (e.g., Do CAQH CORE Operating Rules either support or exclude a provider or vendor from sending daily batches of 5010X217 278 Request and Response transactions?)
  10. Currently my organization’s EDI system returns a positive 5010X231 999 Acknowledgment reporting acceptance of the 5010X217 278. If the Functional Group is rejected, must my system be changed to comply with the Batch Acknowledgement Requirements?
  11. My organization’s EDI system was developed in-house and does not currently support the TA1. However, our system does support the 5010X231 999 Acknowledgment for rejected functional groups. Is this conformant under the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule requirements?
  12. If my organization’s system is not changed to return the 5010X231 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 452 Rule Real Time Acknowledgement Requirements require that my organization’s system must always return both of these types of Acknowledgements: 5010X231 999 Acknowledgment and the 5010X217 278 Response?
  15. Is an acknowledgement necessary if the user sends prior authorization data in a proprietary (not a 5010X217 278) format in a real time mode?
  16. Are all Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule requirements with regard to acknowledgement only applicable to scenarios where my organization receives data in a 5010X217 278 format?
  17. Does my organization have to send back either a 5010X231 999 Acknowledgment or a 5010X217 278 Response to a submitted prior authorization 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 Prior Authorization (278) Infrastructure Rule require HIPAA-covered entities to publish a Companion Guide if they do not currently do so?
  21. Does the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule require health plans to request approval from ASC X12 prior to publication of their CORE-conformant Companion Guide?
  22. Can I combine multiple transaction sets in a single companion guide?
  23. Does this rule apply if my organization does not conduct the 5010X217 278 transaction?
  24. Why is there a variability in elapsed times for returning acknowledgements or responses between the CAQH CORE Infrastructure Rules?
  25. What do the updates address in the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule v4.1.0?
  26. How is a business day defined in the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule?
  27. How is a business day defined in the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule?
  28. Are entities required to adhere to state legislation pertaining to prior authorization maximum response timeframes that differ from the response timeframes established in the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule?
  29. Does the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule define ‘cancelled’ in Section 4.6.1 Time Requirement for a 5010X217 278 Response Close Out Due to a Lack of Requested Information/Documentation?
  30. Is a health plan or its agent required to close out a 5010X217 278 Request that was pended for additional clinical information/documentation after 15 business days?
  31. Do the response time requirements apply when the additional clinical information requested by the health plan to complete and finalize a 5010X217 278 Request is not submitted by the provider via an X12 transaction?
  32. How will the response timeframe requirements be enforced?
  33. Is a 5010X217 278 Request that is closed out by the health plan after 15 business days a denial?
  34. Do the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule response time requirements establish how health plans must communicate a 5010X217 278 Response close out to the provider?
  35. What CAQH CORE Connectivity Rule requirements apply to the 5010X217 278 per the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule?
1. If a 5010X217 278 Request is received in a batch, does the 5010X217 278 Response have to be returned in a batch?

The rule requirement addressing response time when a 5010X217 278 request is submitted in batch processing mode only requires that a health plan have the batch of responses available by the second business day following submission of a 5010X217 278 Request. The rule does not specify whether or not the batch of responses must match exactly the batch of 5010X217 278 requests.

2. Currently my organization’s EDI system returns a positive 5010X231 999 Acknowledgment reporting acceptance of the 5010X217 278 submitted in Real Time Processing Mode. If the Functional Group is rejected, must my system be changed to comply with the Real Time requirements?

Yes. Per the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule, a 5010X231 999 Acknowledgement must only be returned when a Functional Group or Transaction Set of a 5010X217 278 request is submitted in Real Time Processing Mode is rejected.

Therefore, the submitter of a 5010X217 278 Request in Real Time will receive only one of two possible responses from the HIPAA-covered health plan or its agent: a 5010X231 999 Acknowledgment or a 5010X217 278 Response.

3. Do the time frames for the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule still apply if it is an especially large batch? Do the CAQH CORE Operating Rules define the batch size?

The Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule and the CAQH CORE 470 Connectivity 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 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 a 5010X217 278 request claim is submitted in Batch Processing Mode applies to all batches. 

4. Why measure 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 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 5010X217 278 Request real time Responses?

Yes. The Phase IV CAQH CORE Prior Authorization (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 5010X217 278 Request submitted in Real Time processing mode is rejected or accepted.

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

  • A 5010X231 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:

  • A 5010X231 999 Acknowledgement to indicate that a Functional Group(s) or Transaction Set(s) is accepted or accepted with errors.

Therefore, the submitter of a 5010X217 278 Request in Real Time processing mode will receive only one of two possible responses from the HIPAA-covered health plan or its agent: a 5010X231 999 Acknowledgement or a 5010X217 278 Response.

8. What are the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule requirements for entities to support real time and/or batch processing?

The Phase IV CAQH CORE Prior Authorization (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 5010X217 278 Request and Response transactions as specified in the Phase IV CAQH CORE 470 Connectivity Rule. 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 5010X217 278 Request and Response transactions 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 5010X217 278 Request and Response transactions should be submitted? (e.g., Do CAQH CORE Operating Rules either support or exclude a provider or vendor from sending daily batches of 5010X217 278 Request and Response transactions?)

No. The Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule does not address the frequency of submission of 5010X217 278 Request and Response transactions in batch processing mode.  

10. Currently my organization’s EDI system returns a positive 5010X231 999 Acknowledgment reporting acceptance of the 5010X217 278. If the Functional Group is rejected, must my system be changed to comply with the Batch Acknowledgement Requirements?

Yes. The Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule requires that the HIPAA-covered health plan or its agent must always return a 5010X231 999 Acknowledgment for all Functional Groups of a 5010X217 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 a 5010X231 999 Acknowledgment for all Functional Groups of a 5010X217 278 Response, whether or not the Functional Group is rejected, thereby allowing timely resolution of any issues. 

Additional information on the return of a 5010X231 999 Acknowledgment by a HIPAA-covered entity or its agent can be found in Section 4.8.1 of the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule

11. My organization’s EDI system was developed in-house and does not currently support the TA1. However, our system does support the 5010X231 999 Acknowledgment for rejected functional groups. Is this conformant under the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule requirements?

Yes. Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule requirements address only the 5010X231 999 Acknowledgment; therefore your organization’s system must be able to return a 5010X231 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 Rule in order to become CORE-certified.

12. If my organization’s system is not changed to return the 5010X231 999 Acknowledgment, can my organization become CORE-certified?

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 the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule will test for your system’s capabilities to return the 5010X231 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 452 Rule Real Time Acknowledgement Requirements require that my organization’s system must always return both of these types of Acknowledgements: 5010X231 999 Acknowledgment and the 5010X217 278 Response?

No. When a 5010X217 278 Request is submitted in Real Time a HIPAA-covered health plan or its agent must only return a 5010X231 999 Acknowledgement to indicate that the Functional Group or Transaction Set is rejected.

A HIPAA-covered health plan or its agent must not return a 5010X231 999 Acknowledgement to indicate that a Functional Group or Transaction Set is accepted or accepted with errors.

Therefore, the submitter of a 5010X217 278 Request in Real Time will receive only one response from the HIPAA-covered health plan or its agent: a 5010X231 999 Acknowledgement or a 5010X217 278 Response. 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 prior authorization data in a proprietary (not a 5010X217 278) 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 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 Prior Authorization (278) Infrastructure Rule only addresses the use of the 5010X231 999 Acknowledgment and when to use it when conducting the 5010X217 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 ASC X12 implementation guides.

16. Are all Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule requirements with regard to acknowledgement only applicable to scenarios where my organization receives data in a 5010X217 278 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 rule only addresses the use of the 5010X231 999 Acknowledgment and when to use it when conducting the 5010X217 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 ASC X12 implementation guides.

17. Does my organization have to send back either a 5010X231 999 Acknowledgment or a 5010X217 278 Response to a submitted prior authorization if my system is down?

As long as your prior authorization system is in conformance with the CAQH CORE System Availability Rule, then it is not required to send back a either a 5010X231 999 Acknowledgment or a 5010X217 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.

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 Prior Authorization (278) Infrastructure Rule require HIPAA-covered entities to publish a Companion Guide if they do not currently do so?

No. Section 4.9 of the 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 Prior Authorization (278) Infrastructure Rule require health plans to request approval from ASC X12 prior to publication of their CORE-conformant Companion Guide?

No. The rule does 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.

22. 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.

23. Does this rule apply if my organization does not conduct the 5010X217 278 transaction?

No. Per Section 3.2 of the rule, the rule applies when a HIPAA-covered health plan or its agent uses, conducts, or processes the 5010X217 278 transaction.

Additionally, per Section 3.3, this rule does not require any entity to conduct, use, or process the 5010X217 278 transaction if it currently does not do so or is not required by Federal or state regulation to do so.

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

The 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 CAQH CORE Infrastructure Rule and its respective transaction focus.

25. What do the updates address in the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule v4.1.0?

The updates to the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule v4.1.0 focus on establishing national response time requirements at key steps in the prior authorization process to reduce the time to final adjudication for more timely delivery of patient care. Requirements when using the 5010X217 278 Request and Response include:

  • Two-business day maximum response time for a health plan to request any information/clinical documentation from a provider.
  • Two-business day maximum response time for a health plan to send a final determination, once all requested documentation has been received.
  • An optional response time requirement of 15 business days for a health plan to close out a prior authorization request if documentation requested from a provider has not been received.
  • Compliance with maximum response times is required for at least 90 percent of non-urgent/non-emergent prior authorizations within a calendar month.

NOTE: A version of the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule highlighting the substantive changes to the rule is available upon request. Please contact core@caqh.org for a copy.

26. How is a business day defined in the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule?

The Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule defines a business day as the 24 hours commencing with 12:00am (Midnight or 0000 hours) of each designated day through 11:59pm (2359 hours) of that same designated day. The actual calendar day(s) constituting business days are defined by and at the discretion of each HIPAA-covered health plan or its agent.

Historically, practice management systems were built to deliver batch transactions at scheduled times and process the transactions overnight, allowing response transactions to be available for pick up in the morning. Therefore, the definition and use of business days in the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule is both consistent with other CAQH CORE Operating Rules, and also supports practice management systems’ batch processes that are well established for other HIPAA Administrative Simplification transactions. Further, the use of ‘business days’ is normative for measuring service level agreements (SLAs), trading partner requirements etc.

27. How is a business day defined in the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule?

The Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule defines a business day as the 24 hours commencing with 12:00am (Midnight or 0000 hours) of each designated day through 11:59pm (2359 hours) of that same designated day. The actual calendar day(s) constituting business days are defined by and at the discretion of each HIPAA-covered health plan or its agent.

Historically, practice management systems were built to deliver batch transactions at scheduled times and process the transactions overnight, allowing response transactions to be available for pick up in the morning. Therefore, the definition and use of business days in the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule is both consistent with other CAQH CORE Operating Rules, and also supports practice management systems’ batch processes that are well established for other HIPAA Administrative Simplification transactions. Further, the use of ‘business days’ is normative for measuring service level agreements (SLAs), trading partner requirements etc.

28. Are entities required to adhere to state legislation pertaining to prior authorization maximum response timeframes that differ from the response timeframes established in the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule?

Yes. Healthcare providers and health plans who adopt the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule, including this update, must continue to abide by state laws that are stricter than CAQH CORE established response timeframes. While the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule aims to bring consistency to the industry so that both healthcare providers and health plans can have shared expectations and build more efficient and automated systems, the rules are currently voluntary for industry adoption and stricter state regulations must continue to be followed.

29. Does the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule define ‘cancelled’ in Section 4.6.1 Time Requirement for a 5010X217 278 Response Close Out Due to a Lack of Requested Information/Documentation?

No. The rule does not include requirements for data content and therefore do not specify definitions for a cancelled prior authorization. The health plan or its agent should respond to the 5010X217 278 Request using the most appropriate code for cancellation or close out.

30. Is a health plan or its agent required to close out a 5010X217 278 Request that was pended for additional clinical information/documentation after 15 business days?

No, Section 4.6.1 Time Requirement for a 5010X217 278 Response Close Out Due to a Lack of Requested Information/Documentation is an optional requirement that enables a health plan or its agent to close out a pended 5010X217 278 Request if the necessary information/documentation required to complete the request is not received after 15 business days. A health plan or its agent is not required to close out the prior authorization after 15 business days. The optional requirement enables health plans to electronically document that all prior authorization inquiries have been fully accounted for within their systems – in other words, every 5010X217 278 Request has a matching 5010X217 278 Response.

31. Do the response time requirements apply when the additional clinical information requested by the health plan to complete and finalize a 5010X217 278 Request is not submitted by the provider via an X12 transaction?

Yes. The Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule applies to the 5010X217 278 Request and Response. However, any back and forth between health plan and provider that is necessary to reach a final determination may be done outside the use of the 5010X217 278 transaction. Once the final determination is made, the 5010X217 278 Response transaction must be made available to the inquiring provider, either solicited or unsolicited.

 

The rule specifies that a health plan or its agent should publish processes for close out and resubmission/appeal of a 5010X217 278 Response and any other provider notification, in their companion guide, provider billing manual, or other organization policy manual to ensure business and technical processes are clearly articulated to the trading partner community.

32. How will the response timeframe requirements be enforced?

Phase IV CORE-certified entities are expected to adhere to all Phase IV CAQH CORE Operating Rule requirements. The Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule includes requirements on auditing and reporting to track and confirm conformance with the timeframe requirements. To be compliant with the response time requirements, a health plan or its agent must meet the maximum response time requirement of 90% within a calendar month, allowing exceptions for especially complex prior authorization cases, unforeseen system outages and downtimes, etc.

Additionally, non-conformance with the CAQH CORE Operating Rules can impact CORE Certification status. CAQH CORE enforcement is a complaint-driven process that requires documentation (electronic or paper) demonstrating multiple instances of non-conformance with the CAQH CORE Operating Rules at the specific phase of CORE Certification. If any entity is found to be in actual violation of a CAQH CORE Rule, their CORE Certification will be terminated and their name removed from the CAQH CORE website if the complaint is not remedied per the CAQH CORE Enforcement Policy timeline.

The Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule is not currently federally mandated. The Department of Health and Human Services (HHS) will determine if the Phase VI CAQH CORE Operating Rules are to be included in any regulatory mandates.​

33. Is a 5010X217 278 Request that is closed out by the health plan after 15 business days a denial?

No, closing out a 5010X217 278 Request does not constitute a denial of the request. Health plans should use one of the Health Care Service Decision Reason Codes (HCSDRC) such as, but not limited to, HCSDRC 07 (Administrative Cancellation), HCSDR 0P (Requested Information Not Received), or HCSDRC 0U (Additional Patient Information Required).

A footnote is included in the rule specifying that health plans should describe the processes for the close out and resubmission or appeal of a 5010X217 278 Response and any other provider notification, in their companion guide, provider billing manual, or other organization policy manual to ensure business and technical processes are clearly articulated to trading partners.

34. Do the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule response time requirements establish how health plans must communicate a 5010X217 278 Response close out to the provider?

No. The Phase IV CAQH CORE Operating Rules do not include requirements for data content and therefore do not specify how health plans must communicate the close out to the provider or its agent. However, industry best practice for a health plan or its agent to communicate a 5010X217 278 Response close out due to lack of requested information/documentation to a provider is to use one of the Health Care Service Review Decision Reason Codes (HCSDRC) such as, but not limited to, HCSDRC 07 (Administrative Cancellation), HCSDR 0P (Requested Information Not Received), or HCSDRC 0U (Additional Patient Information Required).

The rule specifies that a health plan or its agent should publish processes for close out and resubmission/appeal of a 5010X217 278 Response and any other provider notification, in their companion guide, provider billing manual, or other organization policy manual to ensure business and technical processes are clearly articulated to the trading partner community.

35. What CAQH CORE Connectivity Rule requirements apply to the 5010X217 278 per the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule?

Batch and real time requirements specified in the CAQH CORE 470 Connectivity Rule apply to the 5010X217 278 transaction. Requirements for batch and real time are identified in the CAQH CORE 470 Connectivity Rule, Section 4. As an example, the sequence diagrams below depict how the CAQH CORE 470 Connectivity Rule requirements for generic batch and real time submissions apply to the 5010X217 278 transaction.

Example 1: URL Sequence Diagram for a 5010X2117 278 Batch Transaction

Example 2: URL Sequence Diagram for a 5010X2117 278 Real Time Transaction