Frequently Asked Questions - III. CAQH CORE Prior Authorization & Referrals (278) Data Content Rule

 

 

  1. Does the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule only address pended responses?
  2. Why is the Extended Character Set outside the scope of the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule?
  3. Why are referrals in scope for the CAQH CORE Prior Authorization & Referrals Web Portal Rule and out of scope for the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule?
  4. Is the industry required to adopt the 5010X217 278 transaction?
  5. Will limiting the scenarios for the required use of PWK01 Attachment Report Type Code and Logical Identifiers Names and Codes (LOINCs) hinder prior authorization automation and adoption of the 5010X217 278 transaction?
  6. Does the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule require entities to use LOINCs in the HI Loop?
  7. How many times does the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule state that LOINCs and the PWK loop can be repeated at the Patient Event Level and Service Event Level?
  8. To request additional documentation for a pended response, how many HR03 Industry Codes can be returned according to the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule?
  9. In Section 4.2.3 Requesting Additional Documentation for a Pended Response of the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule, how was the list of service categories determined?
  10. Are vendors who send requests on behalf of the payer able to go beyond the specificity of the list of services categories in the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule?
  11. When requesting additional documentation for a pended response for a patient with more than one service preformed for the same diagnosis, which service category would it be categorized under in the CAQH CORE Prior Authorization & Referrals (278) Data
  12. Why is there a requirement to return HCSDRC 09 (Out of Network) in the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule when this type of transaction is rejected using a AAA*35 (Error Code 35 – Out of Network)?
  13. Does last name normalization required by the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule mirror that of the Eligibility Transaction Rule requirements?
  14. Why does the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule include Date-of-Birth and DMG segments in patient identification, but not member ID?
  15. Why are all HCR03 Industry Codes included as options in CAQH CORE Prior Authorization & Referrals (278) Data Content Rule?
  16. Does the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule refer to only to the 5010X217 278 and no other transactions?
  17. When a provider receives a LOINC from the health plan, are they required to respond using the CDA standard?
Does the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule only address pended responses?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 09:55
Does the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule only address pended responses?

No, the CAQH CORE Prior Authorization and Referrals (278) Data Content Rule has requirements that apply to the data content of the 278 Inquiry and Response transactions beyond just pended responses (e.g., last name normalization; uniform and consistent use of AAA Error Codes and Action Codes, etc.)

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Why is the Extended Character Set outside the scope of the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule?
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Why are referrals in scope for the CAQH CORE Prior Authorization & Referrals Web Portal Rule and out of scope for the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 09:57
Why are referrals in scope for the CAQH CORE Prior Authorization & Referrals Web Portal Rule and out of scope for the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule?

During CAQH CORE’s extensive environmental scan period (which included multi-stakeholder interviews, provider site visits, a vendor product assessment, and an All-CORE Participant Survey), one of the biggest pain points cited involved the scenario where a prior authorization request is pended due to the need for additional information (to prove medical necessity for medical services). Another burden for providers is lack of uniformity across Web Portals, as each plan has a portal tool with inconsistent and non-uniform data requirements, field names, etc.

Based on feedback collected, the CAQH CORE Participants determined that for the use case of prior authorizations pended for the need for additional documentation to prove medical necessity, data content enhancements would be beneficial. The Subgroup developed requirements for the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule that reduce common errors that result in pends or denials and assist with communicating those errors back to the provider in an actionable and consistent manner. Given that research revealed that referrals do not often fall into this particular use case, referrals are not included in the scope of the 278 Data Content Rule.

It should be noted that excluding referrals, emergency/urgent cases from the Data Content Rule does not prevent or prohibit entities from using the 5010X217 278 Request and Response for these requests. Additionally, entities are not required to have a Web Portal to conduct a referral or use a portal for this purpose if it does not already do so.

Referral requests and prior authorizations for emergency and urgent services are not out of scope for the CAQH CORE Prior Authorization & Referrals Web Portal Rule – the rule requirements do pertain to them. The focus of the Web Portal Rule is on the system availability requirements and using standard labels and names for data fields.

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Is the industry required to adopt the 5010X217 278 transaction?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 09:59
Is the industry required to adopt the 5010X217 278 transaction?

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 urgently support electronically. The CAQH CORE Prior Authorization & Referrals (278) Data Content Rule does not require other modalities/solutions such as Web Portals to be discontinued.

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Will limiting the scenarios for the required use of PWK01 Attachment Report Type Code and Logical Identifiers Names and Codes (LOINCs) hinder prior authorization automation and adoption of the 5010X217 278 transaction?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 09:59
Will limiting the scenarios for the required use of PWK01 Attachment Report Type Code and Logical Identifiers Names and Codes (LOINCs) hinder prior authorization automation and adoption of the 5010X217 278 transaction?

While Sections 4.2.3.1 and 4.2.3.2 of the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule list types of events that, when additional medical information is required, necessitate the return of the appropriate HCR01 306 Action Code and HCR03 Industry Code and either a PWK or PWK and LOINC, the rule does not prohibit health plans and their agents from using the same methods to request additional documentation for events outside of the listed event categories. The requirements are placed on the health plan and its agent to process a limited set of use cases for when a service, procedure, etc. requires additional documentation when these types of service fall into a set of categories as defined in the rule. When procedure codes, diagnosis codes, and revenue codes fall outside these categories of service, the rule requirements do not apply, but health plans and their agent are encouraged to use the PWK segments and LOINC codes. The rule sets a floor not ceiling, therefore, health plans and their agents can go beyond the rule requirements to include additional categories of service, for example.

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Does the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule require entities to use LOINCs in the HI Loop?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 10:00
Does the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule require entities to use LOINCs in the HI Loop?

No. When a health plan requests additional documentation for a pended response, the plan and its agent must return a PWK segment and are encouraged to return a PWK segment AND a LOINC in the HI Loop. The use of LOINCs is not dependent on a CMS regulation addressing attachments. LOINCs are supported within the 5010X217 278 Request and Response TR3 and are used throughout clinical data exchange. The use of LOINCs is an option and is not required, as the use of the PWK can be used to request the additional documentation required for processing a pended prior authorization. The intent of this requirement is to allow progressive steps to be made by the industry in the adoption and use of the LOINCs.

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How many times does the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule state that LOINCs and the PWK loop can be repeated at the Patient Event Level and Service Event Level?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 10:01
How many times does the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule state that LOINCs and the PWK loop can be repeated at the Patient Event Level and Service Event Level?

The HI Loop supports up to twelve occurrences of LOINCs and the PWK Loop can be repeated up to ten times at both the Patient Event Level and the Service Level. Health plans and their agents are encouraged to use LOINCs to identify specific additional data and attachments to accommodate adjudication of the prior authorization. The use of LOINCs is an option and is not required, as the use of the PWK can be used to request the additional documentation required for processing a pended prior authorization. The intent of this requirement is to allow progressive steps to be made by the industry in the adoption and use of the LOINCs.

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To request additional documentation for a pended response, how many HR03 Industry Codes can be returned according to the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 10:01
To request additional documentation for a pended response, how many HR03 Industry Codes can be returned according to the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule?

A health plan and its agent can return up to five HR03 Industry Codes for a pended response requiring additional documentation.

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In Section 4.2.3 Requesting Additional Documentation for a Pended Response of the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule, how was the list of service categories determined?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 10:02
In Section 4.2.3 Requesting Additional Documentation for a Pended Response of the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule, how was the list of service categories determined?

To encourage movement toward a more automated and streamlined processing of the request and flagging the need for additional documentation, the rule requires that the health plan process submitted Diagnosis, Procedure, and Revenue Codes that fall into types of services that are often pended for medical necessity. The categories of services were determined and agreed to by the Prior Authorization Subgroup as the most frequently pended for additional documentation. This will allow for the industry to make progress in building logic into adjudication systems for prior authorization.

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Are vendors who send requests on behalf of the payer able to go beyond the specificity of the list of services categories in the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 10:03
Are vendors who send requests on behalf of the payer able to go beyond the specificity of the list of services categories in the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule?

Yes. Health plans and their agents are strongly encouraged to evaluate and respond to all received procedure, diagnosis, or revenue codes, not only those listed in rule. The rule does not prohibit health plans and their agents from using the same methods to request additional documentation for services outside of the listed service categories. The requirements are placed on the health plan and its agent to process a limited set of use cases for when a service, procedure, etc. requires additional documentation when these types of service fall into a set of categories as defined in the rule. The rules set a floor, not a ceiling, therefore, health plans and their agents can go above and beyond the rule requirements and include additional categories of service, for example.

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When requesting additional documentation for a pended response for a patient with more than one service preformed for the same diagnosis, which service category would it be categorized under in the CAQH CORE Prior Authorization & Referrals (278) Data

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 10:04
When requesting additional documentation for a pended response for a patient with more than one service preformed for the same diagnosis, which service category would it be categorized under in the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule? (For example, surgery, imaging, laboratory, oncology, and inpatient services that all apply to a lung cancer diagnosis.)

The X12 v5010X217 278 Technical Report 3 (TR3) supports submission of up to 12 different ICD-10 codes from 3 different X12 External Code Sources.

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Why is there a requirement to return HCSDRC 09 (Out of Network) in the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule when this type of transaction is rejected using a AAA*35 (Error Code 35 – Out of Network)?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 10:04
Why is there a requirement to return HCSDRC 09 (Out of Network) in the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule when this type of transaction is rejected using a AAA*35 (Error Code 35 – Out of Network)?

A transaction being rejected using a AAA*35 assumes that the prior authorization was rejected due to being out-of-network. While this is often true, it is not always the case. Setting up the out of network flag at the HCSDR 09 level allows for that flexibility.

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Does last name normalization required by the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule mirror that of the Eligibility Transaction Rule requirements?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 10:05
Does last name normalization required by the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule mirror that of the Eligibility Transaction Rule requirements?

Yes, Sections 3.6, 4.1 and 4.2 of the CAQH CORE Prior Authorization and Referrals (278) Data Content Rule address the use of a patient’s last name to the extent permitted by the X12 v5010X217 278 Request/Response and the requirements for providers, health plans, and their agents and are nearly identical; however, since the X12 v5010X279 270/271 Eligibility & Benefit Inquiry and Response focus is on patient verification, the requirements are slightly different; i.e., the CAQH CORE Eligibility and Benefits (270/271) Data Content Rule requires the return of the last name in the INS Loop when the last name submitted in the 270 Request is different than the last name stored by the health plan. There is nothing comparable in the 278 transactions as there are no INS Segment in the 278 Response transaction.

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Why does the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule include Date-of-Birth and DMG segments in patient identification, but not member ID?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 10:05
Why does the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule include Date-of-Birth and DMG segments in patient identification, but not member ID?

The rule expands upon the 5010X217 278 Request and Response Technical Report Type 3 (TR3) requirements while not conflicting with them to allow for the most accurate patient matching (and therefore reduction in pended requests due to related errors). The member ID is not included in the rule because it is already required by the Technical Report Type 3 (TR3).

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Why are all HCR03 Industry Codes included as options in CAQH CORE Prior Authorization & Referrals (278) Data Content Rule?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 10:06
Why are all HCR03 Industry Codes included as options in CAQH CORE Prior Authorization & Referrals (278) Data Content Rule?

The CAQH CORE Prior Authorization Subgroup and Rules Work Group participants responded to several feedback forms and straw polls to offer insight into challenges with the X12 v5010X217 278 Request/Response data content. One of the challenges widely reported with the Response is the inconsistency in the use of the HCR codes. This requirement encourages consistency and uniformity in their use. Health plans and their agents are encouraged to use all HCR codes to better return specific messages to the provider.

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Does the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule refer to only to the 5010X217 278 and no other transactions?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 10:06
Does the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule refer to only to the 5010X217 278 and no other transactions?

Yes. The CAQH CORE Prior Authorization & Referrals (278) Data Content Rule builds upon the foundational infrastructure requirements for prior authorization established by the CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule and applies only to the 5010X217 278 transaction.

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When a provider receives a LOINC from the health plan, are they required to respond using the CDA standard?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 10:07
When a provider receives a LOINC from the health plan, are they required to respond using the CDA standard?

No. The CAQH CORE Prior Authorization & Referrals (278) Data Content Rule does not require a provider to respond using the CDA standard. Response/transport method of additional documentation is mutually defined by trading partner agreement, contract, etc. between the provider and the health plan or its agent.

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