Do the CAQH CORE Eligibility & Benefits Operating Rules apply when an entity is providing eligibility transaction services as an Application Service Provider (ASP) for providers and the entity translates the non-standard eligibility transactions in a prop

Yes. Since the CAQH CORE Eligibility & Benefits Operating Rules build on the X12 270/271 transactions, an ASP acting as a provider’s health care clearinghouse would have to comply with all the applicable CAQH CORE Eligibility Operating Rules in order to be in conformance.

3. Does my organization have to return eligibility information if the requester of the information does not meet my organization's requirements for patient identification?

The CAQH CORE Eligibility & Benefits Operating Rules include requirements that improve patient matching rates, but do not include requirements for your organization’s policies on patient identification requirements. There are no requirements for patient matching.

4. Are there any CAQH CORE Eligibility & Benefits Operating Rules requirements regarding how often eligibility transactions should be submitted?

No. The Eligibility & Benefits Operating Rules do not address the frequency of submission for eligibility inquiries; however, the Eligibility & Benefits rules require all entities to support real time processing. The frequency of submission should not be an issue since it is anticipated that eligibility inquiries can be submitted as frequently as needed by the provider. Per the CAQH CORE Eligibility & Benefits Operating Rules, a health plan is required to have its systems supporting eligibility inquiries available 86% of the time over a calendar week.

5. What are the CAQH CORE Eligibility & Benefits Rule requirements for entities to support Real Time and Batch Processing?

The CAQH CORE Eligibility & Benefits Operating Rules require that all entities support real time processing of the X12 270/271 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 CAQH CORE Eligibility & Benefits Operating Rules.

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