Frequently Asked Questions - V. General CAQH CORE Attachments Prior Authorization Operating Rule Questions

How will compliance regarding Attachments Prior Authorization Operating Rules be enforced?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 10:20
How will compliance regarding Attachments Prior Authorization Operating Rules be enforced?

In 2022, the Attachments Prior Authorization Operating Rules were published to industry for voluntary adoption. If an organization decides to pursue voluntary CORE Certification on the CAQH CORE Attachments Prior Authorization Operating Rules, they have a maximum timeframe of 180 days to complete certification testing on the rule requirement after submission of the CAQH CORE Pledge to adopt the rule. CORE-certified entities are then required to recertify every three years. Non-conformance could impact an entity’s CORE Certification status.

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Why was the X12 v6020 275 chosen instead of other options, such as v5010 or v7030?
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Why was the X12 v5010 chosen for Prior Authorization Transactions when the rule supports v6020 of the Attachments transaction?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 10:21
Why was the X12 v5010 chosen for Prior Authorization Transactions when the rule supports v6020 of the Attachments transaction?

Since v5010X217 278 is currently specified in the CAQH CORE Prior Authorization Operating Rules and is the HIPAA-mandated version, the Attachments Subgroup – Prior Authorization Use Case voted, using a consensus-driven approach including straw polls, feedback forms, and discussions, to support X12 v5010 278 for consistency across existing CAQH CORE Operating Rules.

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Is the X12 275 TR3 be available for Industry use?
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Will the CAQH CORE Attachments Prior Authorization Infrastructure Rule require providers to use the X12 275 transaction to send attachments to support a prior authorization request?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 10:22
Will the CAQH CORE Attachments Prior Authorization Infrastructure Rule require providers to use the X12 275 transaction to send attachments to support a prior authorization request?

No. Providers are not required to use non-HIPAA mandated transactions, including the X12 v6020X316 275 transaction, to send an attachment or additional documentation. If providers do choose to use X12 275 to send an attachment, they should follow the relevant operating rule requirements.

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Are providers required to send an unsolicited X12 275 transaction when sending the original X12 278 request?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 10:23
Are providers required to send an unsolicited X12 275 transaction when sending the original X12 278 request?

No. Providers are not required to send an unsolicited X12 275 to support an X12 278 prior authorization request or X12 837 claim submission. The requirements only apply in instances when the provider sends an unsolicited X12 275, but they are not required to do so.

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