Frequently Asked Questions - II. CAQH CORE Health Care Claims (837) Infrastructure Rule

  1. What was included in the CAQH CORE Infrastructure update and how did it impact the CAQH CORE Health Care Claim (837) Infrastructure Rule?
  2. When does the CAQH CORE Health Care Claim (837) Infrastructure Rule apply?
  3. How does an entity determine which version of CAQH CORE Connectivity to use when implementing the CAQH CORE Health Care Claim (837) Infrastructure Rule?
  4. If an X12 v5010 837 is received in a batch, does the X12 v5010 999 Acknowledgment or X12 v5010 277CA transaction have to be returned in a batch?
  5. Currently my organization’s EDI system only returns a positive X12 v5010 999 Acknowledgment reporting acceptance of the X12 v5010 837 submitted in Batch Processing Mode. If the Functional Group or a Transaction Set within a Functional Group is rejected
  6. Do the time frames for the CAQH CORE Health Care Claim (837) Infrastructure Rule still apply if it is an especially large batch? Do the CAQH CORE Operating Rules define the batch size?
  7. Can a clearinghouse or vendor act on behalf of a health plan for providing X12 v5010 999 Acknowledgements to X12 v5010 837 Claims?
  8. What are the CAQH CORE Health Care Claim (837) Infrastructure Rule requirements for entities to support real time and/or batch processing?
  9. Are there any requirements regarding how often X12 v5010 837 Claim transactions should be submitted? (e.g., do CAQH CORE Operating Rules either support or exclude a provider or vendor from sending daily batches of X12 v5010 837 Claim transactions?)
  10. Currently my organization’s EDI system only returns a positive X12 v5010 999 Acknowledgment reporting acceptance of the X12 v5010 837. If the Functional Group or a Transaction Set within a Functional Group is rejected, must my system be changed to com
  11. My organization’s EDI system was developed in-house and does not currently support the TA1. However, our system does support the X12 v5010 999 Acknowledgment for rejected Functional Groups. Is this conformant under the CORE 450 Health Care Clai
  12. Do the CAQH CORE Health Care Claim (837) Infrastructure Rule Real Time Acknowledgement Requirements require that my organization’s system must always return both of these types of Acknowledgements: X12 v5010 999 Acknowledgment and the X12 v5010 277CA?
  13. Is an Acknowledgement necessary if the user sends claim data in a proprietary (not an X12 837) format in a real time mode?
  14. Does my organization have to send back a response (X12 v5010 999 Acknowledgement or X12 v5010 277CA) to a submitted claim if my system is down?
  15. Will there be a difference in system availability requirements for Batch versus Real Time Processing Modes?
  16. Why did the CAQH CORE Participants increase the weekly system availability requirement from 86% to 90% system availability for the CAQH CORE Health Care Claim (837) Infrastructure Rule in 2022?
  17. Is the additional 24-hour downtime available per calendar quarter required to be taken in one 24-hour period?
  18. Is the additional 24-hour downtime per calendar quarter in addition to the weekly allocated downtime?
  19. Does the new quarterly system availability downtime requirement define calendar quarter?
  20. My organization includes system availability schedules in our Companion Guide. Does this satisfy the CAQH CORE Health Care Claim (837) Infrastructure Rule requirements for system availability reporting?
  21. Why was the Master Companion Guide Template created for entities processing healthcare claims?
  22. Why was the CAQH CORE Master Companion Guide Template updated?
  23. Does the CAQH CORE Health Care Claim (837) Infrastructure Rule required HIPAA covered entities to publish a Companion Guide if they do not currently do so?
  24. Can I combine multiple Transaction Sets in a single companion guide?
  25. The CAQH CORE Health Care Claim (837) Infrastructure Rule requires that a HIPAA-covered entity or its agent must include the entity’s requirements for coordination of benefits in their Companion Guide. What if my organization doesn’t provide for coord
  26. Why does the CAQH CORE Health Care Claim (837) Infrastructure Rule include a requirement to address COB requirements in an entity’s Companion Guide for claims?
  27. What is the coordination of benefits (COB) content I have to include in the Companion Guide per Section 4.6.1 of the CAQH CORE Health Care Claim (837) Infrastructure Rule?
What was included in the CAQH CORE Infrastructure update and how did it impact the CAQH CORE Health Care Claim (837) Infrastructure Rule?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:23
What was included in the CAQH CORE Infrastructure update and how did it impact the CAQH CORE Health Care Claim (837) Infrastructure Rule?

·       Substantive Update to System Availability Requirements. The weekly system availability requirement was updated across the CAQH CORE Infrastructure Rules including CAQH CORE Health Care Claim (837) Infrastructure Rule from 86% per calendar week to requiring systems to be available 90% per calendar week.  Additionally, a new quarterly system availability requirement was added allowing systems 24 additional downtime hours per calendar quarter, in excess of the allowable weekly system downtime or 17 hours (10% system downtime per calendar week).

·       Non-Substantive Update to CAQH CORE Connectivity. Per CAQH CORE Certification Policy, CORE-certified entities are required to comply with the most recent published version of the CAQH CORE Connectivity Rule within two years of publication. Therefore, by January 1, 2023, CAQH CORE Connectivity vC4.0.0 will be required for all CAQH CORE Infrastructure Operating Rules. To align the rule requirements with this policy, the connectivity requirement language in the CAQH CORE X Infrastructure Rule was updated to require “most recent published and CAQH CORE adopted version of the CAQH CORE Connectivity Rule.”

·       Non-Substantive Update to CAQH CORE Master Companion Guide Template. Past versions of the CAQH CORE Master Companion Guide referenced a specific version of the ASC X12N Implementation Guides, e.g., v5010. However, with the creation of new operating rules such as CAQH CORE Attachments Operating Rules which use a different X12 version, not all operating rules use the same X12 version. To align with the need to address multiple X12 versions and enable greater flexibility, references to a specific X12 version were adjusted to be modifiable in the CAQH CORE Master Companion Guide.

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When does the CAQH CORE Health Care Claim (837) Infrastructure Rule apply?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:24
When does the CAQH CORE Health Care Claim (837) Infrastructure Rule apply?

This rule applies when:

§  A provider and its agent electronically send patient-specific information or supplemental documentation (solicited or unsolicited) to a health plan and its agent to support an X12 837 Health Care Claim

§  A health plan and its agent electronically process patient-specific information or supplemental documentation and respond to a provider and its agent to support an X12 v5010 837 Health Care Claim.

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How does an entity determine which version of CAQH CORE Connectivity to use when implementing the CAQH CORE Health Care Claim (837) Infrastructure Rule?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:24
How does an entity determine which version of CAQH CORE Connectivity to use when implementing the CAQH CORE Health Care Claim (837) Infrastructure Rule?

All CAQH CORE Infrastructure Operating Rules including CAQH CORE X Infrastructure Rule most recent published and CAQH CORE adopted version of the CAQH CORE Connectivity Rule” (please see the CAQH CORE Connectivity webpage for more information).  

Per CORE Certification Policy, entities seeking CORE Certification are required at a minimum to implement the version of CORE Connectivity published two years prior from when pursuing certification testing. Optionally, entities can choose to implement any newer versions of CORE Connectivity published within the past two years and attain certification depending on testing availability.

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If an X12 v5010 837 is received in a batch, does the X12 v5010 999 Acknowledgment or X12 v5010 277CA transaction have to be returned in a batch?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:25
If an X12 v5010 837 is received in a batch, does the X12 v5010 999 Acknowledgment or X12 v5010 277CA transaction have to be returned in a batch?

The rule requirement addressing response time when an X12 v5010 837 is submitted in Batch Processing Mode by 9:00 pm ET on a business day only requires that a health plan must have the responses available by 7:00 AM by the second business day following a submission of claims. The CAQH CORE Health Care Claim (837) Infrastructure Rule does not specify whether or not the batch of responses must match exactly the batch of X12 v5010 837 claims

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Currently my organization’s EDI system only returns a positive X12 v5010 999 Acknowledgment reporting acceptance of the X12 v5010 837 submitted in Batch Processing Mode. If the Functional Group or a Transaction Set within a Functional Group is rejected

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:26
Currently my organization’s EDI system only returns a positive X12 v5010 999 Acknowledgment reporting acceptance of the X12 v5010 837 submitted in Batch Processing Mode. If the Functional Group or a Transaction Set within a Functional Group is rejected, must my system be changed to comply with the batch requirements?

Yes. Per the CAQH CORE Health Care Claim (837) Infrastructure Rule, an X12 v5010 999 Acknowledgment must be returned for all Functional Groups of any X12 v5010 837 Claim Transaction Sets whether or not the Functional Group or a Transaction Set within the Functional Group is accepted, accepted with errors, or rejected. 

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Do the time frames for the CAQH CORE Health Care Claim (837) Infrastructure Rule still apply if it is an especially large batch? Do the CAQH CORE Operating Rules define the batch size?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:26
Do the time frames for the CAQH CORE Health Care Claim (837) Infrastructure Rule still apply if it is an especially large batch? Do the CAQH CORE Operating Rules define the batch size?

The CAQH CORE Health Care Claim (837) Infrastructure Rule and CAQH CORE Connectivity Rule vC3.1.0 CAQH CORE Health Care Claim (837) Infrastructure Rule do not define batch size. The maximum size of a batch file that is accepted by a Server is outside the scope of the rules; the implementer of a Server may publish its file size limit, if any, in its Connectivity Companion Guide. Therefore, the response period for all Acknowledgements specified when an X12 v5010 837 claim is submitted in Batch Processing Mode applies to all batches. 

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Can a clearinghouse or vendor act on behalf of a health plan for providing X12 v5010 999 Acknowledgements to X12 v5010 837 Claims?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:27
Can a clearinghouse or vendor act on behalf of a health plan for providing X12 v5010 999 Acknowledgements to X12 v5010 837 Claims?

Yes. The CAQH CORE Health Care Claim (837) Infrastructure Rule defines the specific requirements that HIPAA-covered health plans or their agents and HIPAA-covered providers or their agents must satisfy. In this context, an agent is “one who agrees and is authorized to act on behalf of another, a principal, to legally bind an individual in particular business transactions with third parties pursuant to an agency relationship.” (Source: West’s Encyclopedia of American Law, edition 2, Copyright 2008 The Gale Group, Inc. All rights reserved).

The X12 v5010 999 Acknowledgement returned to an X12 v5010 837 claim submitted in Batch Processing Mode by a HIPAA-covered health plan or its agent must indicate whether a Functional Group or any included X12 v5010 837 Claim Transaction Set is accepted, accepted with errors or rejected.

An X12 v5010 999 Acknowledgement must be returned only when the Functional Group or any included X12 v5010 837 Claim Transaction Set submitted in Real Time Processing Mode without adjudication is rejected.

Any X12 v5010 999 Acknowledgement returned reporting either that the Functional Group or included X12 v5010 837 claim is accepted with errors or rejected must report each error detected to the most specific level of detail supported by the X12 v5010 999 Acknowledgement.

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What are the CAQH CORE Health Care Claim (837) Infrastructure Rule requirements for entities to support real time and/or batch processing?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:27
What are the CAQH CORE Health Care Claim (837) Infrastructure Rule requirements for entities to support real time and/or batch processing?

The CAQH CORE Health Care Claim (837) Infrastructure Rule requires that a HIPAA-covered health plan or its agent must implement the server requirements for Batch Processing Mode for the X12 v5010 837 Claim transaction as specified in the CAQH CORE Connectivity Rule vC3.1.0. Optionally, a HIPAA-covered health plan or its agent may elect to also implement the server requirements for Real Time Processing Modes as specified in the CAQH CORE Connectivity Rule vC3.1.0.

A HIPAA-covered health plan or its agent conducting the X12 v5010 837 Claim transaction is required to conform to the processing mode requirements specified in this section regardless of any other connectivity modes and methods used between trading partners. 

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Are there any requirements regarding how often X12 v5010 837 Claim transactions should be submitted? (e.g., do CAQH CORE Operating Rules either support or exclude a provider or vendor from sending daily batches of X12 v5010 837 Claim transactions?)

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:28
Are there any requirements regarding how often X12 v5010 837 Claim transactions should be submitted? (e.g., do CAQH CORE Operating Rules either support or exclude a provider or vendor from sending daily batches of X12 v5010 837 Claim transactions?)

No. The CAQH CORE Health Care Claim (837) Infrastructure Rule does not address the frequency of submission for X12 v5010 837 Claim transactions.

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Currently my organization’s EDI system only returns a positive X12 v5010 999 Acknowledgment reporting acceptance of the X12 v5010 837. If the Functional Group or a Transaction Set within a Functional Group is rejected, must my system be changed to com

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:28
Currently my organization’s EDI system only returns a positive X12 v5010 999 Acknowledgment reporting acceptance of the X12 v5010 837. If the Functional Group or a Transaction Set within a Functional Group is rejected, must my system be changed to comply with the Batch Acknowledgement Requirement?

Yes. The CAQH CORE Health Care Claim (837) Infrastructure Rule requires that the HIPAA-covered health plan or its agent must always return an X12 v5010 999 Acknowledgment for all Functional Groups, whether or not the group is rejected. This requirement allows the provider to know within a reasonable timeframe if the submitted batch of inquiries was accepted by the health plan and will be processed. Likewise, the rule also requires that the provider must always return an X12 v5010 999 Acknowledgment for all Functional Groups whether or not the group is rejected, thereby allowing timely resolution of any issues.

The X12 v5010 999 Acknowledgment must report each error detected to the most specific level of detail supported by the X12 v5010 999 Acknowledgement.

A HIPAA-covered health plan or its agent must acknowledge each claim received in any Functional Group of any X12 v5010 837 Claim Transaction Set using the X12 v5010 277CA transaction only when X12 v5010 837 Claim Transaction Set is not rejected.

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My organization’s EDI system was developed in-house and does not currently support the TA1. However, our system does support the X12 v5010 999 Acknowledgment for rejected Functional Groups. Is this conformant under the CORE 450 Health Care Clai

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:29
My organization’s EDI system was developed in-house and does not currently support the TA1. However, our system does support the X12 v5010 999 Acknowledgment for rejected Functional Groups. Is this conformant under the CORE 450 Health Care Claim (837) Infrastructure Rule requirements?

Yes. The CAQH CORE Health Care Claim (837) Infrastructure Rule addresses only the X12 v5010 999 Acknowledgment; therefore, your organization’s system must be able to return an X12 v5010 999 Acknowledgment for all Functional Groups to indicate that the functional group(s) was either accepted, accepted with errors, or rejected. If it is unable to do so, your organization will need to remediate the system to be in conformance with the CAQH CORE Operating Rule in order to become CORE-certified.

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Do the CAQH CORE Health Care Claim (837) Infrastructure Rule Real Time Acknowledgement Requirements require that my organization’s system must always return both of these types of Acknowledgements: X12 v5010 999 Acknowledgment and the X12 v5010 277CA?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:30
Do the CAQH CORE Health Care Claim (837) Infrastructure Rule Real Time Acknowledgement Requirements require that my organization’s system must always return both of these types of Acknowledgements: X12 v5010 999 Acknowledgment and the X12 v5010 277CA?

No. When an X12 v5010 837 is submitted in Real Time a HIPAA-covered health plan or its agent must only return an X12 v5010 999 Acknowledgment when the Functional Group of any X12 v5010 837 Claim Transaction Set is rejected. 

A HIPAA-covered health plan or its agent must not return an X12 v5010 999 Acknowledgment to indicate that a Functional Group or a Transaction Set is accepted or accepted with errors. 

A HIPAA-covered health plan or its agent must acknowledge each claim received in any Functional Group of any X12 v5010 837 Claim Transaction Set using the X12 v5010 277CA transaction only when X12 v5010 837 Claim Transaction Set is accepted.

Therefore, the submitter of an X12 v5010 837 Claim Transaction in Real Time will receive only one response from the HIPAA-covered health plan or its agent: an X12 v5010 999 Acknowledgment or an X12 v5010 277CA. Thus, your organization’s system must return only one of these transactions, depending on the processing results, not both.

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Is an Acknowledgement necessary if the user sends claim data in a proprietary (not an X12 837) format in a real time mode?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:30
Is an Acknowledgement necessary if the user sends claim data in a proprietary (not an X12 837) format in a real time mode?

Good business practices for electronic message exchange encourage all senders and receivers to appropriately acknowledge receipt and both acceptance/rejection and errors found in any message. Accordingly, the CAQH CORE Health Care Claim (837) Infrastructure Rule is focused on the conduct of the HIPAA-named X12 Transaction Sets and on the X12 standards as well. Thus, the CAQH CORE Health Care Claim (837) Infrastructure Rule addresses the use of the X12 v5010 999 Acknowledgment and the X12 v5010 277CA and when to use them when conducting the X12 v5010 837 Transaction Sets. Additionally, in order to become CORE-certified, an entity is required to attest to its compliance with HIPAA, which requires the use of the appropriate X12 implementation guides.

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Does my organization have to send back a response (X12 v5010 999 Acknowledgement or X12 v5010 277CA) to a submitted claim if my system is down?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:31
Does my organization have to send back a response (X12 v5010 999 Acknowledgement or X12 v5010 277CA) to a submitted claim if my system is down?

As long as your claim system is in conformance with the CAQH CORE Health Care Claim (837) Infrastructure Rule requirements, then it is not required to send back an X12 v5010 999 Acknowledgement or X12 v5010 277CA, either in real time or batch when your system is down. When your system is back up such Acknowledgements should be made available to the submitter.

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Will there be a difference in system availability requirements for Batch versus Real Time Processing Modes?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:31
Will there be a difference in system availability requirements for Batch versus Real Time Processing Modes?

No. The system availability requirements apply to Batch and Real Time Processing Modes, with no difference in system availability based on the processing mode. CAQH CORE will conduct research and environmental scans to obtain data on the feasibility of separate system availability requirements in potential future infrastructure updates, as separate requirements may make better business sense as the industry moves to more API-driven interactions between providers and health plans.

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Why did the CAQH CORE Participants increase the weekly system availability requirement from 86% to 90% system availability for the CAQH CORE Health Care Claim (837) Infrastructure Rule in 2022?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:32
Why did the CAQH CORE Participants increase the weekly system availability requirement from 86% to 90% system availability for the CAQH CORE Health Care Claim (837) Infrastructure Rule in 2022?

Each set of CAQH CORE Operating Rules includes an infrastructure rule with requirements for system availability and reporting, including the CAQH CORE Health Care Claim (837) Infrastructure Rule. In response to feedback from CAQH CORE Participants and the CAQH CORE Board, in September 2021 CAQH CORE surveyed Participating Organizations to determine where there may be consensus to update the CAQH CORE Infrastructure Operating Rule requirements to align with evolving business needs and technology. The survey focused on system availability and response time requirements across all rule sets and clear consensus emerged to update the system availability requirements across the CAQH CORE Infrastructure Rules.

 

Significant discussions occurred related to system availability needs. Ultimately, CORE Participants compromised by approving a new quarterly system availability requirement to accommodate large system migrations if weekly system availability was increased from 86% per calendar week to 90% per calendar week. With this weekly availability increase, the new quarterly system availability allows health plans and their agents to use 24 additional hours of system downtime per calendar quarter for system migrations, mitigations, and other system needs that may require additional downtime.

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Is the additional 24-hour downtime available per calendar quarter required to be taken in one 24-hour period?
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Is the additional 24-hour downtime per calendar quarter in addition to the weekly allocated downtime?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:33
Is the additional 24-hour downtime per calendar quarter in addition to the weekly allocated downtime?

Yes, the new requirement specifies an additional 24 hours available quarterly in excess of the 17 hours weekly allowable downtime, or 10% of a calendar week.

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Does the new quarterly system availability downtime requirement define calendar quarter?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:33
Does the new quarterly system availability downtime requirement define calendar quarter?

No. The new quarterly system availability requirement does not define calendar quarter. The definition of a calendar quarter is agreed upon between trading partners

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My organization includes system availability schedules in our Companion Guide. Does this satisfy the CAQH CORE Health Care Claim (837) Infrastructure Rule requirements for system availability reporting?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:34
My organization includes system availability schedules in our Companion Guide. Does this satisfy the CAQH CORE Health Care Claim (837) Infrastructure Rule requirements for system availability reporting?

Yes. HIPAA-covered health plans (or information sources), clearinghouses/switches or other intermediaries must publish their regularly scheduled system downtime in an appropriate manner (e.g., on websites or in Companion Guides). This allows the healthcare provider to better manage staffing levels. Additionally, the CAQH CORE Health Care Claim (837) Infrastructure Rule outlines requirements for reporting/publishing non-routine downtimes and unscheduled/emergency downtimes.

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Why was the Master Companion Guide Template created for entities processing healthcare claims?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:34
Why was the Master Companion Guide Template created for entities processing healthcare claims?

For many years health plans independently created companion guides that often varied in format and structure. Such variance can be confusing to trading partners and providers. CAQH CORE adapted its CAQH CORE Master Companion Guide Template for CAQH CORE Health Care Claim (837) Infrastructure Rule based on the CAQH/WEDI Best Practices Companion Guide Template, with input from multiple health plans, system vendors, provider representatives and healthcare/HIPAA industry experts. The CAQH CORE Master Companion Guide Template organizes information into several simple sections and provides for a common information flow and format, while at the same time giving health plans the flexibility to tailor the document to meet their particular needs. The CAQH CORE Master Companion Guide Template may be used for all HIPAA-mandated Transaction Sets.

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Why was the CAQH CORE Master Companion Guide Template updated?
Does the CAQH CORE Health Care Claim (837) Infrastructure Rule required HIPAA covered entities to publish a Companion Guide if they do not currently do so?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:35
Does the CAQH CORE Health Care Claim (837) Infrastructure Rule required HIPAA covered entities to publish a Companion Guide if they do not currently do so?

No. The CAQH CORE Health Care Claim (837) Infrastructure Rule do not require any entity to publish a Companion Guide if they do not already do so.

Section 4.6 of the CAQH CORE Health Care Claim (837) Infrastructure Rule CAQH CORE Health Care Claim (837) Infrastructure Rule specifies that should an entity publish a companion guide it must conform to the format/flow as defined in the CAQH CORE Master Companion Guide Template.

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Can I combine multiple Transaction Sets in a single companion guide?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:35
Can I combine multiple Transaction Sets in a single companion guide?

Yes. Entities may combine their companion guides for separate transactions into a single document. The flow and format of the CAQH CORE Master Companion Guide Template would still need to be followed, but sections would need to be repeated, tables added for each additional transaction, etc., without altering the flow and format.

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The CAQH CORE Health Care Claim (837) Infrastructure Rule requires that a HIPAA-covered entity or its agent must include the entity’s requirements for coordination of benefits in their Companion Guide. What if my organization doesn’t provide for coord

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:36
The CAQH CORE Health Care Claim (837) Infrastructure Rule requires that a HIPAA-covered entity or its agent must include the entity’s requirements for coordination of benefits in their Companion Guide. What if my organization doesn’t provide for coordination of benefits?

As stated in Section 4.6.1, Health Care Claim Companion Guide Requirements, “A HIPAA-covered entity or its agent’s Companion Guide covering the X12 v5010 837 Claim transaction must include the entity’s requirements for coordination of benefits in Section 7 and Section 10 as appropriate.” If a HIPAA-covered entity or its agent does not provide for coordination of benefits that should be disclosed in the Companion Guide. 

NOTE: The CAQH CORE Health Care Claim (837) Infrastructure Rule does not require any entity to publish a Companion Guide if they do not already do so, however if they do publish a Companion Guide, they must include the entity’s requirements for coordination of benefits per the rule requirement. 

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Why does the CAQH CORE Health Care Claim (837) Infrastructure Rule include a requirement to address COB requirements in an entity’s Companion Guide for claims?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:37
Why does the CAQH CORE Health Care Claim (837) Infrastructure Rule include a requirement to address COB requirements in an entity’s Companion Guide for claims?

Many health plans have separate processes for coordination of benefits (COB) claims and may require unique routing of the claim or variety of data that is not required on a regular claim. By providing this information in its companion guide a health plan is offering better servicing to its provider and trading partner community. 

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What is the coordination of benefits (COB) content I have to include in the Companion Guide per Section 4.6.1 of the CAQH CORE Health Care Claim (837) Infrastructure Rule?

Submitted by tfuchs@caqh.org on Mon, 04/18/2022 - 11:37
What is the coordination of benefits (COB) content I have to include in the Companion Guide per Section 4.6.1 of the CAQH CORE Health Care Claim (837) Infrastructure Rule?

Per Section 4.6.1, Health Care Claim Companion Guide Requirements, of the CAQH CORE Health Care Claim (837) Infrastructure Rule, there is no specific requirement for content in the Companion Guide; however, it states that, “a HIPAA-covered entity or its agent’s Companion Guide covering the X12 v5010 837 Claim transaction must include the entity’s requirements for coordination of benefits in Section 7 and Section 10 as appropriate.” It is the business decision of the HIPAA-covered entity to decide what COB content is most appropriate for Section 7 and 10 of its companions’ guides. A general example of COB content would be any special processing requirements, special claim routing requirements, or data elements specific to your organization. 

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