Frequently Asked Questions - Overview of Phase V CAQH CORE Operating Rules

The Phase V CAQH CORE Operating Rules apply to all HIPAA covered entities that conduct the X12/v5010X217 278 Request / Response transaction and/or utilize web portals to conduct prior authorizations.

Entities acting in the role of a Business Associate of a HIPAA covered entity may also implement various aspects of the Phase V CAQH CORE Operating Rules. The CMS website provides charts to help organizations determine whether an organization or individual is a HIPAA covered entity.

Note: Currently the Phase V CAQH CORE Operating Rules are voluntary and have not been adopted by HHS for mandatory adoption by HIPAA covered entities. HHS will determine if the new Phase V CAQH CORE Operating Rules will be included in any regulatory mandates. Any such considerations will include an HHS public comment period. While the Phase V CAQH CORE Operating Rules are currently voluntary, stakeholder entities are eligible to implement the operating rules and to pursue voluntary Phase V CORE Certification beginning in Q4 2019.

See the CAQH CORE FAQs Part B: ACA Section 1104 Mandate for Federal Operating Rules for more information on the ACA Section 1104 Administrative Simplification provisions.

The Phase V CAQH CORE Operating Rules focus on standardizing key components of the prior authorization process and closing gaps in electronic data exchange to move the industry toward a more automated adjudication of a request. These efficiencies enable shorter time to final adjudication and more timely delivery of patient care. Requirements include normalizing patient last name, returning specific additional documentation requirements in the 278 Response, using consistent data field label names for web portals, among others. Consult the specific rules for detailed requirements.

CORE Certification for the Phase V CAQH CORE Operating Rules is available. Phase V CORE Certification covers web portal usage and the 278 Request / Response transaction. The specific requirements and test scripts for Phase V CORE Certification are found in the Phase V CAQH CORE Voluntary Certification Test Suite, which was approved along with the Phase V CAQH CORE Operating Rules through the CAQH CORE voting process in May 2019. An entity seeking voluntary CORE Certification must be conformant with all Phase V CAQH CORE Operating Rules applicable to its stakeholder type in order to become CORE-certified on the Phase V CAQH CORE Operating Rules.

Voluntary CORE Certification for the Phase V CAQH CORE Operating Rules will be available in Q4 2019. Phase V CORE Certification covers web portal usage and the 278 Request / Response transaction. Entities interested in pursuing Phase V CORE Certification should review the Phase V CAQH CORE Voluntary Certification Test Suite which documents the test scripts required for Phase V CORE Certification. 

To become certified on a higher phase of CAQH CORE Operating Rules, an organization or its product/service must be CORE-certified on the earlier phases. CAQH CORE represents a phased approach to developing operating rules for healthcare administrative transactions. Each subsequent CAQH CORE phase builds and expands on the previous phase(s).

As Phase V builds on the key infrastructure requirements established by the Phase IV CAQH CORE 452 Health Care Services Review – Request for Review and Response (278) Infrastructure Rule, organizations must achieve Phase IV CORE Certification for the prior authorization (278) transaction, and other Phase IV transactions, as applicable, before being eligible to certify for Phase V.

The only exception to this policy applies to vendors and clearinghouses, given their products may only address certain transactions or rule requirements (unlike health plans and providers). Vendors/clearinghouses/practice management systems that offer only one of the applicable transaction sets may become CORE-certified on only the relevant CAQH CORE Operating Rules.

No, implementation of Phase V CAQH CORE Operating Rules is currently voluntary.

The Phase IV CAQH CORE 452 Health Care Services Review – Request for Review and Response (278) Infrastructure Rule and Phase V CAQH CORE Operating Rules for prior authorization apply when a health plan or agent uses, conducts, or processes the X12/v5010 278 transaction. The operating rules do not require any entity to conduct, use, or process the X12/v5010 278 transaction if it currently does not do so or is not required by Federal or state regulation to do so.