General CAQH CORE FAQs

V. General CAQH CORE Operating Rules

1. For which of the HIPAA-mandated administrative healthcare transactions has CAQH CORE developed operating rules?

The CAQH CORE Operating Rules address the following HIPAA-mandated healthcare administrative transactions:

  • Phase I:
    • ASC X12N/005010X279 Health Care Eligibility Benefit Inquiry and Response (270/271) (i.e., ASC X12N v5010 270/271)
  • Phase II:
    • ASC X12N v5010 270/271 Eligibility and Benefits Inquiry/Response
    • ASC X12N v5010 276/277 Claim Status Inquiry/Response
    • ASC X12N/005010X279 Health Care Eligibility Benefit Inquiry and Response (270/271) (i.e., ASC X12N v5010 270/271)
    • ASC X12N/005010X212 Health Care Claim Status Request and Response (276/277) and associated errata (i.e., ASC X12N v5010 276/277)
  • Phase III:
    • ASC X12N/005010X221 Health Care Claim Payment/Advice (835) and associated errata (i.e., ASC X12N v5010 835)
    • Healthcare EFT Standards (NACHA CCD+ & X12N v5010 835 TR3 TRN Segment)
  • Phase IV:
    • ASC X12N/005010X221 Health Care Claim Payment/Advice (835) and associated errata (i.e., ASC X12N v5010 835)
    • ASC X12N/005010X222 Health Care Claim (837) Professional, ASC X12N/005010X223 Health Care Claim (837) Institutional, and ASC X12N/005010X224 Health Care Claim (837) Dental and their respective errata (collectively hereafter ASC X12N v5010 837 Claim)
    • ASC X12N/005010X217 Health Care Services Review – Request for Review and Response (278) and associated errata (i.e., ASC X12N v5010 278 Request and Response and referred to as prior authorization in general)
    • ASC X12N/005010X220 Benefit and Enrollment Maintenance (834) and associated errata (i.e., ASC X12N v5010 834)
    • ASC X12N/005010X218 Payroll Deducted and Other Group Premium Payment for Insurance Products (820) and associated errata (i.e., ASC X12N v5010 820)
2. Which CAQH CORE Operating Rules have been adopted by HHS to fulfill the ACA Section 1104 Federal mandate?

ACA Section 1104 requires the HHS Secretary to adopt and regularly update three sets of operating rules for the HIPAA-mandated healthcare administrative transactions:

  • The first set of Federal operating rules addresses the eligibility and claims status transactions; the compliance date for these operating rules was January 1, 2013.
  • The second set of Federal operating rules addresses the healthcare Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) transactions; the compliance date for these operating rules was January 1, 2014.
  • The third set of Federal operating rules addresses the health claims or equivalent encounter information, health plan enrollment/disenrollment, health plan premium payments, referral, certification, authorization, and health claims attachments transactions. The compliance date for these operating rules was January 1, 2016.[1]

As of January 1, 2016, HHS has adopted three phases of CAQH CORE Operating Rules to fulfill the ACA Section 1104 mandate:

  • First Set of ACA Section 1104 Mandated Operating Rules: In December 2011, HHS adopted the Phase I & Phase II CAQH CORE Eligibility & Claim Status Operating Rules to fulfill the first set of ACA-mandated operating rules, with the exception of CAQH CORE Operating Rule requirements pertaining to use of Acknowledgements.
  • Second Set of ACA Section 1104 Mandated Operating Rules: In April 2013 adopted the Phase III CAQH CORE EFT & ERA Operating Rules to fulfill the second set of ACA-mandated operating rules, with the exception of CAQH CORE Operating Rule requirements pertaining to use of Acknowledgements.
  • Third Set of ACA Section 1104 Mandated Operating Rules: Regulations on the third set of ACA-mandated operating rules have not yet been published. On September 12, 2012, HHS issued a letter concurring with the NCVHS recommendation to designate CAQH CORE as the authoring entity for the remaining ACA-mandated operating rules. From December 2013 - September 2015, the CAQH CORE Participants used the open CAQH CORE rule-making process to produce a set of operating rules for the following transactions: health claims or equivalent encounter information, health plan enrollment/disenrollment, health plan premium payments, and referral, certification and authorization. The complete set of Phase IV CAQH CORE Operating Rules was approved for voluntary implementation per the formal CAQH CORE voting process in September 2015.
    • NOTE: The Phase IV CAQH CORE Operating Rules have not been adopted by HHS for mandatory use by HIPAA-covered entities. HHS will determine if the Phase IV CAQH CORE Operating Rules will be included in any regulatory mandates. Any such considerations will include an HHS public comment period. Additionally, the Phase IV CAQH CORE Operating Rules do not include operating rules addressing the health claims attachment as HHS has not yet adopted standards for health claims attachments or indicated what standard(s) it might consider for attachments.
 

[1] NOTE: HHS has not yet published any regulations on the third set of ACA-mandated Federal operating rules. It is expected that such regulations will include an Interim Final Rule and public comment period. As such, it is anticipated that the January 1, 2016 compliance date will be adjusted.

3. What infrastructure areas do the CAQH CORE Infrastructure Operating Rules address?

The CAQH CORE Operating Rules specify two types of requirements for use of the healthcare administrative transactions: data content and infrastructure. Infrastructure requirements relate to the basic expectations for how a data exchange “system” works. The CAQH CORE Infrastructure Operating Rules address the following general infrastructure areas that apply to all of the healthcare administrative transactions:

  • Processing Mode
  • Connectivity and Security
  • System Availability
  • Response Time
  • Acknowledgements
  • Companion Guide

In addition to the above general infrastructure areas, the CAQH CORE Infrastructure Operating Rules also address the following infrastructure areas that apply to only some of the healthcare administrative transactions:

  • Requirements for ASC X12 v5010 270 patient identification matching and AAA error code reporting
  • Requirements for health plan dual delivery of the ASC X12N v5010 835 ERA and paper Remittance Advice (RA) (if the health plan currently provides a paper RA)
  • Requirements to ensure provider receipt of the CORE-required Minimum CCD+ Data required for EFT/ERA reassociation
  • Elapsed time maximums for release of the ASC X12N v5010 835 ERA and ACH CCD+ EFT transactions
  • Establishment of resolution procedures to address late/missing EFT and ERA Transactions
  • Requirements for health plan conformance with a maximum set of EFT/ERA enrollment data
  • Requirements for health plan provision of an electronic method for provider EFT/ERA enrollment
  • Timeframe requirements for data processing after successful receipt and verification of the ASC X12N v5010 820 Premium Payment and ASC X12N v5010 834 Benefit Enrollment and Maintenance transactions
4. For which healthcare administrative transactions do the CAQH CORE Operating Rules specify infrastructure requirements?

The CAQH CORE Operating Rules specify infrastructure requirements for the following healthcare administrative transactions:

  • ASC X12N v5010 270/271 Eligibility and Benefits Inquiry/Response
  • ASC X12N v5010 276/277 Claim Status Inquiry/Response
  • ASC X12N v5010 835 Claim Payment/Remittance Advice
  • ASC X12N v5010 278 Health Care Services Review - Request for Review and Response
  • ASC X12N v5010 820 Payroll Deducted and Other Group Premium Payment for Insurance Products
  • ASC X12N v5010 834 Benefit Enrollment and Maintenance
  • ASC  X12N v5010 837 Health Care Claim

For more information on the CAQH CORE infrastructure rule requirements, please see “How do the CAQH CORE infrastructure requirements vary for each of the healthcare administrative transactions?

5. For which healthcare administrative transactions do the CAQH CORE Operating Rules specify data content requirements?

Operating rules specify two types of requirements for use of the healthcare administrative transactions: data content and infrastructure. Data content requirements relate to the information contained within the transaction standard and support the exchange of essential data.

The CAQH CORE Operating Rules includes three operating rules that specify data content requirements for the ASC X12N v5010 270/271 Eligibility and Benefits Inquiry/Response and ASC X12N v5010 835 Claim Payment/Remittance Advice transactions:

For more information on the CAQH CORE 154 and 260 Rule requirements, please see Section VII and Section XIV of the CAQH CORE FAQs Part C: Phase I & II CAQH CORE Eligibility & Claim Status Operating Rules. For more information on the CAQH CORE 360 Rule requirements, please see Section IV of the CAQH CORE FAQs Part D: Phase III CAQH CORE EFT & ERA Operating Rules.

6. How do the CAQH CORE infrastructure requirements vary for each of the healthcare administrative transactions?

The CAQH CORE Operating Rules specify infrastructure requirements (e.g., connectivity, system availability, etc.) for the following healthcare administrative transactions:

  • ASC X12N v5010 270/271 Eligibility and Benefits Inquiry/Response
  • ASC X12N v5010 276/277 Claim Status Inquiry/Response
  • ASC X12N v5010 835 Claim Payment/Remittance Advice
  • ASC X12N v5010 278 Health Care Services Review - Request for Review and Response
  • ASC X12N v5010 820 Payroll Deducted and Other Group Premium Payment for Insurance Products
  • ASC X12N v5010 834 Benefit Enrollment and Maintenance
  • ASC X12N v5010 837 Health Care Claim

For each of the above transactions, the table below outlines the infrastructure areas addressed by the CAQH CORE Operating Rules[2]:

 

[2] NOTE: For each transaction, check marks indicate that the CAQH CORE Operating Rules include applicable rule requirements addressing the infrastructure area.

7. Are HIPAA-covered entities required to implement the CAQH CORE rule requirements pertaining to use of Acknowledgements to comply with the ACA Section 1104 Federal mandate?

The HHS Final Rules adopting the Phase I, II, and III CAQH CORE Operating Rules to fulfill the ACA Section 1104 Federal mandate do not adopt the CAQH CORE Operating Rule requirements pertaining to Acknowledgements. As such, HIPAA covered entities are not required to implement the acknowledgement requirements in the Phase I, II, or III CAQH CORE Operating Rules in order to meet the Federal requirements under the ACA.

This said, good business practices for electronic message exchange encourage all senders and receivers to appropriately acknowledge both receipt and acceptance/rejection with errors found in any message. Therefore, the CAQH CORE Operating Rules support the use of Acknowledgments. Additionally, entities seeking to obtain CORE Certification on any phase(s) of CAQH CORE Operating Rules must implement and conform to all of the CAQH CORE Operating Rules applicable to their stakeholder type, including those rule requirements pertaining to use of Acknowledgments.

8. What is the CAQH CORE Connectivity Safe Harbor?

The CAQH CORE Connectivity Safe Harbor is the connectivity method that application vendors, providers, healthcare clearinghouses, and health plans (or other information sources) can be assured will be supported by any HIPAA covered entity for the mandated operating rules and/or a CORE-certified entity. Supporting the CAQH CORE Connectivity Safe Harbor means the entity is capable and ready at the time of the request from a trading partner to exchange the transaction using the CAQH CORE Connectivity Rules.

Please Note: The CAQH CORE Connectivity Rules do not require entities to remove existing connections that do not match the rule requirements, nor do they require all HIPAA covered entities to use only the CAQH CORE Connectivity Safe Harbor for all new connections. In some circumstances, trading partners may decide to continue to use an existing, non-CAQH CORE connection. However, entities must implement the capability to use the CAQH CORE Connectivity Safe Harbor and be capable and ready to use it when requested.

The CAQH CORE Operating Rules Sets include three operating rules that specify the CAQH CORE Connectivity Safe Harbor requirements:

  • The Phase I CAQH CORE 153: Connectivity Rule v1.1.0 and Phase II CAQH CORE 270: Connectivity Rule v2.2.0 together specify business rules and technical specifications for the CAQH CORE Connectivity Safe Harbor for conduct of the following transactions:
    • ASC X12N v5010 270/271 Eligibility and Benefits Inquiry and Response
    • ASC X12N v5010 276/277 Claim Status Inquiry and Response
    • ASC X12N v5010 835 Claim Payment/Remittance Advice[3]
  • The Phase IV CAQH CORE 470: Connectivity Rule v4.0.0 specifies business rules and technical specifications for the CAQH CORE Connectivity Safe Harbor for the conduct of the following transactions:
    • ASC X12N v5010 278 Health Care Services Review - Request for Review and Response
    • ASC X12N v5010 820 Payroll Deducted and Other Group Premium Payment for Insurance Products
    • ASC X12N v5010 834 Benefit Enrollment and Maintenance
    • ASC X12N v5010 837 Health Care Claim

 

For more information on the CAQH CORE 153 and 270 Rule requirements, please see Section VI and Section XV of the CAQH CORE FAQs Part C: Phase I & II CAQH CORE Eligibility & Claim Status Operating Rules. For more information on the CAQH CORE 470 Rule requirements, please see Section VI of the CAQH CORE FAQs Part E: Phase IV CAQH CORE Operating Rules.

 

[3]NOTE: Section 4.1, Health Care Claim Payment/Advice Connectivity Requirements, of the CAQH CORE 350: Health Care Claim Payment/Advice (835) Infrastructure Rule requires all HIPAA covered entities to support the Phase II CORE 270 Connectivity Rule Version 2.2.0 to transmit or receive the ASC X12N v5010 835. The rule specifies that “This requirement addresses usage patterns for batch transactions, the exchange of security identifiers, and communications-level errors and acknowledgements.”

9. Do the CAQH CORE Operating Rules apply to Direct Data Entry transactions?

The CAQH CORE Operating Rules apply to HIPAA transactions, which are healthcare electronic data interchanges (EDI). As such, the operating rules do not apply to Direct Data Entry (DDE) transactions. NOTE: Per 45 CFR 162.103, Definitions, Direct Data Entry "means the direct entry of data (for example, using dumb terminals or web browsers) that is immediately transmitted into a health plan’s computer."

10. My organization is a health plan. We do not currently support some of the HIPAA-mandated transaction standards addressed by the CAQH CORE Operating Rules. Do the CAQH CORE Operating Rules require us to implement these HIPAA-mandated transactions?

The CAQH CORE Operating Rules do not require any entity to implement any of the HIPAA-mandated healthcare administrative transactions. Under the HIPAA provisions, HIPAA covered 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 of the HIPAA-mandated transaction standards. When using the HIPAA-mandated transaction standards, HIPAA covered entities must comply with any applicable federally mandated operating rules. For more information on which CAQH CORE Operating Rules have been federally mandated, please see “Which CAQH CORE Operating Rules have been adopted by HHS to fulfill the ACA Section 1104 Federal mandate?

11. My organization is a health plan. Does CAQH CORE require us to publish a companion guide if we do not currently do so?

No. The CAQH CORE Operating Rules do not require any entity to publish a companion guide if they do not already do so. However, if a HIPAA covered and/or CORE-certified entity publishes a companion guide addressing the following transactions, it must conform to the format/flow defined in the CAQH CORE v5010 Master Companion Guide Template.[4]

  • ASC X12N v5010 270/271 Eligibility and Benefits Inquiry and Response
  • ASC X12N v5010 276/277 Claim Status Inquiry and Response
  • ASC X12N v5010 835 Claim Payment/Remittance Advice
  • ASC X12N v5010 278 Health Care Services Review - Request for Review and Response
  • ASC X12N v5010 834 Benefit Enrollment and Maintenance
  • ASC X12N v5010 837 Health Care Claim
  • ASC X12N v5010 820 Payroll Deducted and Other Group Premium Payment for Insurance Products
 

[4] NOTE: HHS has not yet published any regulations adopting the Phase IV CAQH CORE Operating Rules addressing the ASC X12N v5010 278, ASC X12N v5010 834, ASC X12N v5010 837, and ASC X12N v5010 820 transactions for Federal compliance. As such, HIPAA-covered entities are not federally required to comply with these operating rules, including the CAQH CORE requirements for companion guides addressing these transactions.