1. The CAQH CORE Rules specify a maximum timeframe within which health plans must release the X12 835 for transmission. Does this also require the pick-up of the X12 835 to occur within this timeframe?

No. The CAQH CORE Payment & Remittance (CCD+/835) Reassociation Rule does not require the pick-up of the X12 v5010 835 to occur within the specified maximum timeframe for release of the X12 v5010 835.

2. The CAQH CORE Rules specifies timeframe requirements for health plans to “release for transmission” the X12 v5010 835 relative to the Effective Entry Date specified in the CCD+. How is “release for transmission” defined?

Section 4.2, Elapsed Time between Sending the v5010 X12 835 and the CCD+ Transactions, of the CAQH CORE Payment & Remittance (CCD+/835) Reassociation Rule specifies that “a health plan must release for transmission to the healthcare provider the v5010 X12 835 corresponding to the Healthcare EFT Standards:

3. Does the CAQH CORE Payment & Remittance (CCD+/835) Reassociation Rule prohibit a health plan from including additional information beyond the X12 v5010 835 TRN Reassociation Trace Number Segment (hereafter TRN Segment) in Record #7 Field #3 of the CCD

No. The CAQH CORE Payment & Remittance (CCD+/835) Reassociation Rule does not prohibit a health plan from including additional information in Record #7, Field #3, Payment Related Information, of the CCD+, understanding that entities ensure the field contains the required X12 v5010 835 TR3 TRN segment information and conforms to the NACHA Operating Rules.

4. Does the CAQH CORE Payment & Remittance (CCD+/835) Reassociation Rule specify requirements for how frequently a health plan should generate an X12 v5010 835 and corresponding claim payment?

No. The CAQH CORE Payment & Remittance (CCD+/835) Reassociation Rule does not specify how frequently a health plan must generate a claim payment and corresponding X12 v5010 835. For example, a health plan may generate claim payments on a daily, weekly, or monthly cycle.

5. If the CCD+ Effective Entry Date is a Thursday and a valid banking day, what is the earliest and latest date that the health plan can release the X12 v5010 835 and meet the elapsed time requirements of the CAQH CORE Rules?

For the example described above, if the CCD+ Effective Entry Date is Thursday, May 4 (and a valid banking day), assuming the health plan’s business days are Monday through Friday, the timeline would be the following:

6. What is the intent of the enhancement to the NACHA Operating Rules described in the CAQH CORE Payment & Remittance Reassociation Rule, Section 4.4, Cross-Industry Needs: Role of NACHA Operating Rules for the Financial Institutions to Support Health Ca

Section 4.4 of the CAQH CORE Payment & Remittance (CCD+/835) Reassociation Rule identifies several cross-industry needs identified by CAQH CORE Participants during development of the CAQH CORE Payment & Remittance Operating Rules. NACHA – The Electronic Payments Association is the organization responsible for the development and maintenance of the NACHA Operating Rules which govern the ACH Network and maintains the CCD+ standard format.

7. What data elements should health plans track to demonstrate conformance with the CAQH CORE Payment & Remittance (CCD+/835) Reassociation Rule required maximum elapsed time between release of the CCD+ and the X12 v5010 835?

Section 4.2.2 of the CAQH CORE Payment & Remittance (CCD+/835) Reassociation Rule requires that health plans track and audit the elapsed time between sending of the X12 v5010 835 and the CCD+ to ensure the elapsed time requirement is met ninety percent of the time as measured within a calendar month.

8. Does the “three business days” maximum elapsed time between release the X12 v5010 835 and the CCD+ Effective Entry Date have hour-to-hour requirements?

No. The CAQH CORE Payment & Remittance (CCD+/835) Reassociation Rule requirement for health plans to release the X12 v5010 835 “no sooner than three business days based on the time zone of the health plan prior to the CCD+ Effective Entry Date” and “No later than three business days after the CCD+ Effective Entry Date” for transmission to the provider means that a health plan must not send the corresponding X12 v5010 835:

9. When does the “three business days” maximum elapsed timeframe between release of the CCD+ and the X12 v5010 835 begin and end?

Section 4.2, Elapsed Time between Sending the X12 v5010 835 and the CCD+ Transactions, of the CAQH CORE Payment & Remittance (CCD+/835) Reassociation Rule requires health plans to release the X12 v5010 835:

  • “No sooner than three business days based on the time zone of the health plan prior to the CCD+ Effective Entry Date

And

10. What data elements should health plans track to demonstrate conformance with the requirement that health plans ensure the CCD+ Effective Entry Date and X12 v5010 835 BPR16 EFT Effective Date are the same valid banking day?

Section 4.2, Elapsed Time between Sending the X12 v5010 835 and the CCD+ Transactions, of the CAQH CORE Payment & Remittance (CCD+/835) Reassociation Rule requires that a health plan must not release the X12 v5010 835 earlier than three business days prior to the CCD+ Effective Entry Date or later than three business days after the CCD+ Effective Entry Date.

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