Phase IV CAQH CORE Operating Rules

The rule requirement addressing response time when an ASC X12N v5010 834 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 ASC X12N v5010 834. The CAQH CORE 454 Rule does not specify whether or not the batch of responses must match exactly the batch of ASC X12N v5010 834 submissions.

Yes. Per the Phase IV CAQH CORE 454 Benefit Enrollment and Maintenance (834) Infrastructure Rule, a HIPAA-covered health plan or its agent must return an ASC X12C v5010 999 Acknowledgment to indicate that a Functional Group(s) or Transaction Set(s) is accepted, accepted with errors, or rejected and must report each error detected to the most specific level of detail supported by the ASC X12C v5010 999 Acknowledgement.

The Phase IV CAQH CORE 454 Benefit Enrollment and Maintenance (834) 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 an ASC X12N v5010 834 benefit enrollment 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 Operating 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 Phase IV CAQH CORE 454 Benefit Enrollment and Maintenance (834) Infrastructure Rule defines the specific requirements that HIPAA-covered health plans 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).

Please note that a HIPAA-covered health plan or its agent must return an ASC X12C v5010 999 Acknowledgment to indicate that a Functional Group(s) or Transaction Set(s) is accepted, accepted with errors, or rejected and must report each error detected to the most specific level of detail supported by the ASC X12C v5010 999 Acknowledgment.

The Phase IV CAQH CORE 454 Benefit Enrollment and Maintenance (834) 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 834 transaction as specified in the Phase IV CAQH CORE 470 Connectivity Rule. Optionally, a HIPAA-covered health plan or its agent may elect to implement the server requirements for Real Time Processing Mode for the ASC X12N v5010 834 transaction as specified in the Phase IV CAQH CORE 470 Connectivity Rule.   

A HIPAA-covered health plan or its agent may also elect to implement the client requirements as specified in the CAQH CORE 470 Rule in addition to implementing the server requirements. When a HIPAA-covered health plan or its agent elects to implement the client requirements as specified in the  CAQH CORE 470 Rule it must comply with all requirements specified in Sections 4.2, 4.3, 4.4, 4.5, 4.6, 5 and all respective Subsections.

A HIPAA-covered health plan or its agent conducting the ASC X12N v5010 834 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.

No. The Phase IV CAQH CORE 454 Benefit Enrollment and Maintenance (834) Infrastructure Rule does not address the frequency of submission of ASC X12N v5010 834 transactions in batch processing mode. 

Yes. The Phase IV CAQH CORE 454 Benefit Enrollment and Maintenance (834) 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 Functional Group is rejected. This requirement allows the submitter of the enrollment and maintenance transaction(s) to know within a reasonable timeframe if the submitted batch of enrollment and maintenance transaction(s) was accepted by the health plan and will be processed. 

Yes. The Phase IV CAQH CORE 454 Benefit Enrollment and Maintenance (834) Infrastructure Rule requirements address 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 Rule in order to 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 454 Benefit Enrollment and Maintenance (834) Infrastructure Rule will test for your system’s capabilities to return the ASC X12C v5010 999 Acknowledgment. 

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

Yes. When a HIPAA-covered health plan or its agent receives a Functional Group of the ASC X12N v5010 834 it must return an ASC X12C v5010 999 Acknowledgment to indicate that the Functional Group or Transaction Set(s) is accepted, accepted with errors, or rejected.  

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 454 Benefit Enrollment and Maintenance (834) Infrastructure Rule only addresses the use of the ASC X12C v5010 999 Acknowledgment and when to use it when a HIPAA-covered Health Plan conducts the ASC X12 v5010 834 transaction. 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.

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 454 Rule only addresses the use of the ASC X12C v5010 999 Acknowledgment and when to use it when a HIPAA-covered Health Plan conducts the ASC X12N v5010 834 transaction. 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.

As long as your system is in conformance with the CAQH CORE System Availability Rule, then it is not required to send back an ASC X12C v5010 999 Acknowledgment 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.

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 submitting entity to better manage staffing levels and expectations for delivery of the ASC X12 v5010 834 transaction. Additionally, the CAQH CORE Operating 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 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.

No. Section 4.9 of the Phase IV CAQH CORE 454 Operating 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.

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. 

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.

As stated in the Phase IV CAQH CORE 454 Benefit Enrollment and Maintenance Infrastructure Rule, Section 4.1, Benefit Enrollment and Maintenance Processing Mode Requirements, a HIPAA-covered health plan is not required to implement the client requirements, but “may also elect to implement the client requirements as specified in the Phase IV CAQH CORE 470 Connectivity Rule v4.0.0 in addition to implementing the server requirements. When a HIPAA-covered health plan or its agent elects to implement the client requirements as specified in the Phase IV CAQH CORE 470 Connectivity Rule v4.0.0 it must comply with all requirements specified in Sections 4.2, 4.3, 4.4, 4.5, 4.6, 5 and all respective Subsections.”

A health plan may wish to implement the client requirements for the conduct of the 834 transaction for a variety of reasons.  One example may include managed care entities with which the health plan has partnered and therefore may conduct a pull (or fetch) of the 834 transaction from the health plan rather than the health plan pushing it out to these entities.

No. Per Section 3.2 of CAQH CORE 454 Rule, the rule applies when a HIPAA-covered health plan or its agent uses, conducts, or processes the ASC X12N v5010 834 transaction.

Additionally, per Section 3.3 of CAQH CORE 454 Rule, this rule does not require any entity to conduct, use, or process the ASC X12N v5010 834 transaction if it currently does not do so or is not required by Federal or state regulation to do so.

The intent of this requirement is to ensure that the health plan updates its internal enrollment application systems on a timely basis. Thus when a provider tries to verify eligibility or submits a claim, the health plan can base its response or claim processing on more timely data which may reduce claim rejection/denial, coordination of benefit or other issues. 

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.

Yes. As stated in Section 4.1 of the CAQH CORE 454 Rule, “when a HIPAA-covered health plan or its agent elects to implement the client requirements as specified in the Phase IV CAQH CORE 470 Connectivity Rule v4.0.0 it must comply with all requirements specified in Sections 4.2, 4.3, 4.4, 4.5, 4.6, 5 and all respective Subsections.”

As stated in Section 3 of the CAQH CORE 454 Rule, the rule only “applies when a HIPAA-covered health plan or its agent uses, conducts, or processes the ASC X12N v5010 834 transaction.” If something other than an ASC X12N v5010 834 is received or transmitted, e.g., an Excel spreadsheet, an XML document, or a proprietary file, etc., then the CAQH CORE 454 Rule does not apply.