Frequently Asked Questions - I. General CAQH CORE Health Care Claims Operating Rules Questions

Which entities should implement the CAQH CORE Health Care Claims Operating Rules?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 12:53
Which entities should implement the CAQH CORE Health Care Claims Operating Rules?

The CAQH CORE Health Care Claims Infrastructure Rule applies to all HIPAA covered entities that conduct the following transactions:

§  X12 Interchanges containing Functional Groups of any HIPAA-mandated X12 v5010 837 Claim transaction

§  X12 Interchanges containing Functional Groups of any X12 v5010 277CA Claim Acknowledgement transaction

§  X12 Interchanges containing Functional Groups of any X12 v5010 999 Implementation Acknowledgement transaction

§  X12 v6020X313 277 Health Care Claim Request for Additional information Technical Report Type 3 (TR3) (hereafter referred to as X12 v6020X313 277)

§  X12 5010X222 Health Care Claim (837) Professional, X12 5010X223 Health Care Claim (837) 142 Institutional, and X12 5010X224 Health Care Claim (837) Dental transactions and their associated errata (collectively hereafter referenced as X12 v5010 837)

§  X12 6020X314 275 Additional Information to Support a Health Care Claim or Encounter Technical Report Type 3 (TR3) (hereafter referenced as X12 v6020X314 275)

§  X12 6020X257 824 Application Advice Technical Report Type 3 (TR3) (hereafter referenced as X12 149 v6020X257 824

NOTE: Entities acting in the role of a Business Associate of a HIPAA covered entity may also need to implement various aspects of the CAQH CORE Health Care Claim Operating Rules. The HHS website provides charts to help organizations determine whether an organization or individual is a HIPAA covered entity. Currently the CAQH CORE Health Care Claims Operating Rule is voluntary and has not been adopted by HHS for mandatory adoption by HIPAA covered entities. HHS will determine if the CAQH CORE Health Care Claim Operating Rule will be included in any regulatory mandates. While the CAQH CORE Health Care Claim Operating Rules are currently voluntary, stakeholder entities are immediately eligible to implement the operating rules and to pursue CORE Certification.

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