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.