• • Substantive Update to System Availability Requirements. The weekly system availability requirement was updated across the CAQH CORE Infrastructure Rules including CAQH CORE Claim Status (276/277) 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 Claim Status (276/277) 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.

The CAQH CORE Claim Status Operating Rules streamline the way claim status healthcare administrative information is exchanged electronically. Easier, more reliable access to this information at the point of care can reduce the amount of time providers spend on administration by checking the status of a patient claim electronically. 

The ACA-mandated CAQH CORE Claim Status Operating Rules address the following:  

*NOTE: The HHS Final Rule excludes rule requirements pertaining to use of Acknowledgments 

The CAQH CORE Claim Status Operating Rules also address standard testing, certification, and enforcement processes to ensure CAQH CORE conformance for entities seeking CORE Certification. 

The All HIPAA-covered entities are required by Federal law to adopt the CAQH CORE Claim Status Operating Rules by January 1, 2013 for the X12 276/277 claim status transaction. This includes the CAQH CORE Claim Status (276/277) Infrastructure Rule vCS.1.0.   

As the ACA Administrative Simplification provisions build on and update the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), ACA Section 1104 requires all HIPAA covered entities to comply with the ACA-mandated standards and applicable operating rules by their compliance dates.  

In December 2011, HHS adopted the  CAQH CORE Claim Status Operating Rules to fulfill the ACA Section 1104 Federal mandate, with the exception of rule requirements pertaining to use of Acknowledgements. By January 1, 2013, HIPAA covered entities must have met all technical rule requirements outlined in the CAQH CORE Claim Status Operating Rules that apply to their organizations, except implementation of the rule requirements for Acknowledgements. 

Note: CMS is the HHS designated authority on any decisions regarding interpretation, implementation, and enforcement of the regulations adopting the HIPAA and ACA Administrative Simplification standards and provisions. Within CMS, the National Standards Group (NSG) enforces the regulations addressing the HIPAA and ACA-mandated transactions, national identifiers, operating rules, health plan certification, and additional standards.  

CAQH CORE has resources and tools available at no cost to assist entities with implementation of the CAQH CORE Claim Status Operating Rules.

• CAQH CORE has developed a Claim Status Claim Status Analysis and Planning Guide to assist entities with determining with which CAQH CORE Rule requirements their organization will need to comply, which CAQH CORE Rule requirements are outsourced, and with identifying the remediation necessary to ensure conformance of outsourced functions. The Analysis & Planning Guide includes three tools:
• CAQH CORE Stakeholder & Business Type Evaluation to determine your organization’s stakeholder type(s) and understand the role of your intermediaries that conduct the eligibility transactions
• CAQH CORE Systems Inventory & Impact Assessment Worksheet to assess your organization’s external and internal systems that conduct eligibility transactions and are impacted by the CAQH CORE Operating Rules
• CAQH CORE Gap Analysis Worksheet to determine the level of system(s) remediation necessary for your organization to adopt the business requirements of the CAQH CORE Operating Rules
• CAQH CORE holds frequent education sessions with various industry partners on implementation of the CAQH CORE Operating Rules. Information on upcoming sessions and materials (both slides & audio) from past sessions is available on the CAQH website.
• CORE Certification also offers a useful resource for entities to ensure successful implementation of applicable CAQH CORE Claim Status rule requirements. CORE Certification has been embraced by many entities given its value in assisting with CAQH CORE Operating Rule adoption and ensuring the greatest ROI is achieved with trading partners. CORE Certification testing with a CAQH CORE-authorized testing vendor is available online at no cost to entities.
• For every CAQH CORE Operating Rule for a particular transaction, a CORE Certification Master Test Suite is developed that outlines all the requirements for entities seeking CORE Certification. These test suites include information about key concepts such as the role of trading partners that also apply for general adoption of the CAQH CORE Eligibility & Benefits Operating Rules, beyond CORE Certification. See Claim Status Master Test Suite to learn more.

The ACA-mandated CAQH CORE Claim Status Operating Rules require that all entities support real time processing of the X12 276/277 transactions. The CAQH CORE Operating Rules do not require entities to support batch processing if they do not currently do so. However, if entities do currently support batch processing, they must also implement and conform to all applicable batch processing requirements outlined in the ACA-mandated CAQH CORE Claim Status Operating Rules. Real time and batch requirements are addressed in the following ACA-mandated CAQH CORE Claim Status Operating Rules:

• CAQH CORE Connectivity Rule vC1.1.0
• CAQH CORE Connectivity Rule vC2.2.0
• CAQH CORE Claim Status (276/277) Infrastructure Rule vCS.1.0

No. The Claim Status rule sets do not address the frequency of submission for claim status inquiries.

However, the Claim Status rules require all entities to support real time. The frequency of submission should not be an issue since it is anticipated that claim status inquiries can be submitted as frequently as needed by the provider. Per the CAQH CORE Claim Status Operating Rules, a health plan is required to have its systems supporting claim status inquiries available 86% of the time over a calendar week.

Batch processing is optional and not required by the CAQH CORE Claim Status Operating Rules. If, however, batch processing mode is offered, conformance to applicable CAQH CORE Claim Status Operating Rules requirements must be followed.

No. Per CMS, the ACA-mandated CAQH CORE Claim Status Operating Rules would not apply to DDE transactions.

Yes. The Claim Status Infrastructure Rule requires that the health plan or information receiver must always return an ASC X12 Implementation Acknowledgement (999) 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 ASC X12 Implementation Acknowledgement (999) Functional Acknowledgement for all functional groups whether or not the group is rejected, thereby allowing timely resolution of any issues.

No. The CAQH CORE Acknowledgement Rules do not address the use of the ASC X12 Interchange Acknowledgement TA1.

Yes. 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 Claim Status Operating Rules are focused on the conduct of the HIPAA-mandated X12 276/277 transaction sets. Thus, the CAQH CORE Claim Status Infrastructure Rule only addresses the use of the X12 Implementation Acknowledgement (999) and when to use it when conducting the X12 276/277 transaction sets. Additionally, 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.

Health plans have independently created companion guides that often vary in format and structure. Such variance can be confusing to trading partners and providers. CAQH CORE adapted its CAQH CORE Master Companion Guide Template based on the CAQH/WEDI Best Practices Companion Guide Template developed jointly in 2003, with input from multiple health plans, system vendors, provider representatives and healthcare/HIPAA industry experts. The template organizes information into several simple sections and provides for common information flow and format, while at the same time giving health plans the flexibility to tailor the document to meet their needs. The template covers a broad range of HIPAA-mandated transaction sets and is not specific to any one of them.

Yes. Entities, may, if they wish, 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 could be repeated, tables added for the second transaction, etc., without altering said flow and format.

No. If completing CORE Certification testing, your organization is only required to submit to the CAQH CORE-authorized testing vendor:

1. The Companion Guide’s table of contents
2. A page showing your organization’s requirements for the presentation of segments, data elements and codes.

The CAQH CORE-authorized testing vendor will assess these documents to determine that your Companion Guide conforms to the CAQH CORE required flow and format.

The CAQH CORE Claim Status Operating Rules require health plan Companion Guides covering the X12 276/277 transactions to follow the format/flow as defined in the CAQH CORE Master Companion Guide Template.

As part of CORE Certification testing, CAQH CORE-authorized testing vendors evaluate the following to determine if an entity’s Companion Guide(s) conforms to the CAQH CORE Claim Status Companion Guide Requirements:

• If the order of the Companion Guide table of contents matches the table in the CAQH CORE Master Companion Guide Template
• If the Companion Guide format for specifying the X12 276/277 data content requirements is consistent with the format in the CAQH CORE  Master Companion Guide Template

If a specific section(s) of the CAQH CORE Master Companion Guide Template is not appropriate for a particular entity’s Companion Guide, the CAQH CORE Claim Status Infrastructure Rule does allow the entity to exclude this section(s) from their guide.

No. The CAQH CORE Operating Rules do not require any entity to publish a Companion Guide if they do not already do so. The Companion Guide Requirements specify that should an entity publish a company guide, it must conform to the format/flow as defined in the CAQH CORE Master Companion Guide Template.

CAQH CORE does not specify a minimum. However, to uniquely identify an X12 transmission, CAQH CORE recommends that entities store the ISA06, ISA08, ISA13, GS02, GS03, GS06, ST02, TRN02, and if sent in the transaction, the BHT03.

Partially. CORE-certified 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 System Availability requirements in the CAQH CORE Claim Status (276/277) Infrastructure Rule outline requirements for reporting/publishing non-routine downtimes, and unscheduled/emergency downtimes.

CAQH CORE does not define a duplicate transaction. Please refer to your own internal policies.

CAQH CORE does not define the recourse for information sources in this case.

CAQH CORE recognizes that every organization has its own record-retention policies and does not mandate a strict requirement for retention of tracking information. To support ongoing tracking of response times and performance measurement, CAQH CORE recommends that entities keep this information for at least 18 months if that is in accord with the organization’s existing policies.

Yes, whether it is an automated or manual re-send the re-send attempts cannot occur more frequently than what is specified in the CAQH CORE rule.

Such a message would represent a CAQH CORE non-conformance message. The CAQH CORE Rule does not require such a message to be either rejected or accepted by the receiver. It is the receiver's decision regarding acceptance of a non-conformance message.

No. For real time X12 276 claim status inquiries, your organization’s system must return an ASC X12 Implementation Acknowledgement (999) if the functional group is rejected, or the X12 277 response, to be conformant with this rule. CAQH CORE Rules do not address usage of the X12 Interchange Acknowledgement TA1.

Yes. Each health plan seeking CORE Certification will have to work with its clearinghouse and/or vendor to jointly complete CORE Certification for the health plan to be awarded the CORE Certification Seal. A clearinghouse or vendor would not be able to certify “generically” as a health plan and then transfer that CORE Certification to any health plan.

No. The CAQH CORE Acknowledgements Rules do not address the use of the X12 Interchange Acknowledgement TA1.

Good business practices for electronic message exchange encourage all senders and receivers to appropriately acknowledge receipt and either acceptance/rejection and errors found in any message. That said, CAQH CORE Claim Status Operating Rule Section 4.3 is focused on the conduct of the HIPAA-named X12 276/277 transaction sets, and the CAQH CORE Operating Rules are focused on the X12 as well. Thus, the CAQH CORE rule Section 4.3 only addresses the use of the ASC X12 Implementation Acknowledgements (999) and when to use it when conducting the X12 276/277 transaction sets. Additionally, to meet CORE Certification requirements, an entity is required to attest to its compliance with HIPAA, which requires the use of the appropriate X12 TR3.

Yes. Section 4.3 of the CAQH CORE Claim Status Operating Rule requires that the health plan or information receiver must always return an ASC X12 Implementation Acknowledgement (999) 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 ASC X12 Implementation Acknowledgement (999) for all functional groups, whether or not the group is rejected, thereby allowing timely resolution of any issues.

Yes. In accordance with the CAQH CORE Claim Status Operating Rule, Section 4.3, only the ASC X12 Implementation Acknowledgement (999) is required to be supported. CAQH CORE Rules do not address the use of the X12 TA1 Interchange Acknowledgement.

No. Your organization must successfully complete all required certification test scripts required by the Claim Status CORE Certification Master Test Suite to become CORE-certified.

The ASC X12 Implementation Acknowledgement (999) can be used only to acknowledge receipt, acceptance or rejection of X12 transaction sets. It is not designed to be able to report receipt and/or errors, etc. in a proprietary file format. Thus, it cannot be used to acknowledge receipt of a non-X12 transaction set.

The 20-second requirement described in the CAQH CORE Claim Status Operating Rule, Section 4.4 is the duration for the entire round-trip of the transaction. The 20 seconds begin when the X12 270 Inquiry or X12 276 Request is first submitted and ends when the X12 271 Response or X12 277 Response is delivered to the provider. All ensuing hops are included in these 20 seconds. Conformance with the rule is determined when 90 percent of all required responses are returned within the specified maximum response time as measured within a calendar month. Each HIPAA-covered entity is required to conform to the Federally mandated CAQH CORE Claim Status Operating Rules. Each HIPAA covered entity within the transaction flow is bound by the CAQH CORE rule requirements for meeting the 20-second round trip of the transaction (CAQH CORE recommends no more than 4 seconds per hop).

The CAQH CORE Claim Status Operating Rule, Section 4.4 requires HIPAA covered entities to capture, log, audit, match, and report the date, time, and control numbers from their own internal systems, and corresponding data received from their trading partners. The auditing requirement is included so that each entity will have the log of data to be used to resolve any issues or concerns. For the 20-second maximum real time response requirement, this log could also be used to identify where a bottleneck may be occurring.

Other data may be required for auditing purposes; however, this data can be determined by each entity. CAQH CORE recommends that to uniquely identify an X12 transmission, entities store the ISA06, ISA08, ISA13, GS02, GS03, GS06, ST02, TRN02, and if sent in the transaction, the BHT03. The audit log requirement was purposefully specified at a high level in each rule to enable each entity along the transaction pathway to design and develop its own process for audit handling. Additionally, the rules do not specify how long an entity is to maintain the data for auditing purposes.

Averages can be skewed by outlier responses. The number of responses returned within the specified timeframe gives a better indication of the information source’s capabilities.

No. CAQH CORE does not mandate a particular form.

Yes. Providers do not have to be CORE-certified to interact with CORE-certified payers under the CAQH CORE Rules.

The CAQH CORE Rule does not address this issue. The batch response time rule only requires that a health plan have the batch responses available by 7:00 AM the next business day following a submission of inquiries by 9:00 PM ET the previous business day. Therefore, the CAQH CORE rule does not specify whether or not the batch of X12 277 responses must match exactly the batch of X12 276 inquiries.

CAQH CORE does not define batch size. The rule states that all batch inquiries must be compliant with the rule.

Yes, CORE-certified 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 Operating rule outlines requirements for reporting/publishing non-routine downtimes and unscheduled/emergency downtimes.

As long as your claim status system is in conformance with the CAQH CORE Claim Status Operating Rule, Section 4.6, then it is not required to send back a claim status response, either in real time or batch.

Health plans have independently created Companion Guides that often vary in format and structure. Such variance can be confusing to trading partners and providers. CAQH CORE adapted its Master Companion Guide Template based on the CAQH/WEDI Best Practices Companion Guide Template developed jointly in 2003, with input from multiple health plans, system vendors, provider representatives and healthcare/HIPAA industry experts. The 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 needs. The template covers a broad range of HIPAA-adopted transaction sets and is not specific to any one of them.

Yes. Entities, may, if they wish, 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 could be repeated, tables added for the second transaction, etc., without altering said flow and format.

No. Your organization is only required to submit to the authorized testing vendor:

1. The guide’s table of contents and
2. A page showing your organization’s requirements for the presentation of segments, data elements and codes.

Your selected CAQH CORE-authorized testing vendor will assess these documents to determine that your Companion Guide conforms to the CORE required flow and format.

No. The Federally mandated CAQH CORE Claim Status Operating Rules, as adopted by HHS, do not require any entity to submit its Companion Guide to ASC X12 for review and approval prior to publication.

Entities seeking CORE Certification are required to submit to the CAQH CORE-authorized testing vendor: 1) The Companion Guide’s table of contents and 2) A page showing the organization’s requirements for the presentation of segments, data elements and codes. The CAQH CORE-authorized testing vendor will evaluate these documents to determine if they are consistent with the format in the CAQH CORE Master Companion Guide Template.

The 24 hours of additional quarterly downtime can be taken in any increment of time throughout the calendar quarter to allow for larger system upgrades, as needed.

However, to remain conformant with the federally mandated versions of the CAQH CORE Operating Rules, the additional quarterly downtime requirement of 24 hours per calendar quarter should not exceed a maximum of 7 hours in a single calendar week. This allows organizations to take advantage of the quarterly system availability requirements and remain in compliance with mandated operating rules which state system updates should take place within a maximum of 24 hours per calendar week for scheduled downtime.

All HIPAA covered entities are required to support CAQH CORE Connectivity vC1.1.0 and vC2.2.0 for the HIPAA-mandated claim status transaction (please see Mandated Operating Rules webpage for full list of federally mandated operating rules with original naming conventions).    

Additionally, all CAQH CORE Infrastructure Operating Rules require use of “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.  

NOTE: HHS will determine if updates to CAQH CORE Connectivity Rule requirements will be included in any regulatory mandates

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.

Each set of CAQH CORE Operating Rules includes an infrastructure rule with requirements for system availability and reporting, including the CAQH CORE Claim Status (276/277) 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.  

No, the 24-hour downtime can be taken in any increment of time throughout the calendar, as needed. 

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. 

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

The CAQH CORE Master Companion Guide Template was updated to align with industry need to support X12 versions beyond v5010. As such, the CAQH CORE Master Companion Guide template was updated to be version agnostic, removing explicit references to X12 v5010 from the template.