1. Can I combine multiple transaction sets (i.e., X12 270/271 and X12 835) in a single companion guide?

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.

2. Does the CAQH CORE Payment & Remittance (835) Infrastructure Rule require HIPAA covered entities to publish a companion guide for the X12 v5010 835 if they do not currently do so?

No. The CAQH CORE Operating Rules do not require any entity to publish a companion guide. The CAQH CORE Payment & Remittance (835) Infrastructure Rule, Section 4.4, Health Care Claim Payment/Advice Companion Guide, specifies that, should an entity publish a company guide, it must conform to the format/flow as defined in the CAQH CORE Master Companion Guide.

3. The CAQH CORE Connectivity Rule requires publication of a Connectivity Companion Guide. Is this Companion Guide the same as the one referenced in the CAQH CORE Payment & Remittance (835) Infrastructure Rule?

Connectivity Companion Guides are entity-specific guides that outline the requirements to establish and maintain a connection with the entity. The CAQH CORE Connectivity Rule requires that all information servers (i.e., health plans and clearinghouses) publish an entity-specific Connectivity Companion Guide on their public web site.

5. We are a health plan and part of our X12 835 error handling process includes sending a proprietary paper RA in lieu of an out of balance X12 835. Do the CAQH CORE Payment & Remittance (835) Infrastructure Rules require that we discontinue this process

The CAQH CORE Payment & Remittance (835) Infrastructure Rule does not address a health plan’s internal error handling processes that may require the plan to send a paper RA to a provider in lieu of an out-of-balance X12 v5010 835.

6. My organization is a health plan that sends the X12 835 to some providers through a clearinghouse. Does the CAQH CORE Payment & Remittance (835) Infrastructure Rule require that we accept an X12 999 Acknowledgement from this clearinghouse?

The HHS Final Rule adopting the CAQH CORE Payment & Remittance Operating Rules to fulfill the ACA Section 1104 mandate does not adopt the batch acknowledgement requirements in Section 4.2 of the CAQH CORE Payment & Remittance (835) Infrastructure Rule.

7. The CAQH CORE Payment & Remittance (835) Infrastructure Rule requires that “health plans must be able to accept and process an X12 v5010 999 for a Functional Group of X12 v5010 835 transactions.” What does “processing” mean for this requirement?

The CAQH CORE Payment & Remittance (835) Infrastructure Rule does not explicitly define what it means to “process” an X12 v5010 999 Implementation Acknowledgement. Receivers of the X12 v5010 835 (i.e., providers and provider-facing clearinghouses) return an X12 v5010 999 to indicate that a Functional Group of X12 v5010 835 transactions has been accepted, accepted with errors, or rejected. Given the different scenarios that the X12 v5010 999 could be indicating, a health plan could have internal logic for how to process and respond to each scenario.

8. My organization is a provider-facing clearinghouse. Are we required by the CAQH CORE Payment & Remittance (835) Infrastructure Rule to return an X12 v5010 999 Implementation Acknowledgement to health plans that do not request to receive the X12 v5010

The CORE Payment & Remittance (835) Infrastructure Rule specifies requirements for use of the X12 v5010 999 Implementation Acknowledgement that are applicable to both senders and receivers of the X12 v5010 835. Per Section 4.2.1, Use of the X12 v5010 999 Implementation Acknowledgement for Functional Group Acknowledgement, of the CAQH CORE Payment & Remittance (835) Infrastructure Rule:

9. Does the requirement for a dual delivery period in Section 4.3 of the CAQH CORE Payment & Remittance (835) Infrastructure Rule mean that health plans must create and send a proprietary paper claim remittance advice if they do not currently do so?

No. The CAQH CORE Payment & Remittance (835) Infrastructure Rule , Section 4.3, Dual Delivery of X12 v5010 835 and Proprietary Paper Claim Remittance Advices, requires a health plan to support dual delivery of the X12 v5010 835 and proprietary paper claim remittance advices for a period of 31 days (or a minimum of 3 payments), if the health plan currently delivers proprietary paper claim remittance advices.

10. If the provider chooses not to continue the dual delivery period beyond 31 days (or a minimum of 3 payments) after the implementation of the X12 v5010 835, must the health plan stop sending proprietary paper claim remittance advices?

Per the CAQH CORE Payment & Remittance (835) Infrastructure Rule , Section 4.3, Dual Delivery of X12 v5010 835 and Proprietary Paper Claim Remittance Advices, at the end of the 31-day (or a minimum of 3 payments) dual or parallel processing period, “If the provider determines it is unable to satisfactorily implement and process the health plan‘s electronic X12 v5010 835 following the end of the initial dual delivery timeframe and/or after an agreed-to extension, both the provider and health plan may mutually agree to continue delivery

Subscribe to II. CAQH CORE Payment & Remittance (835) Infrastructure Rule