When a provider receives a LOINC from the health plan, are they required to respond using the CDA standard?

No. The CAQH CORE Prior Authorization & Referrals (278) Data Content Rule does not require a provider to respond using the CDA standard. Response/transport method of additional documentation is mutually defined by trading partner agreement, contract, etc. between the provider and the health plan or its agent.

Does the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule refer to only to the 5010X217 278 and no other transactions?

Yes. The CAQH CORE Prior Authorization & Referrals (278) Data Content Rule builds upon the foundational infrastructure requirements for prior authorization established by the CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule and applies only to the 5010X217 278 transaction.

Why are all HCR03 Industry Codes included as options in CAQH CORE Prior Authorization & Referrals (278) Data Content Rule?

The CAQH CORE Prior Authorization Subgroup and Rules Work Group participants responded to several feedback forms and straw polls to offer insight into challenges with the X12 v5010X217 278 Request/Response data content. One of the challenges widely reported with the Response is the inconsistency in the use of the HCR codes. This requirement encourages consistency and uniformity in their use. Health plans and their agents are encouraged to use all HCR codes to better return specific messages to the provider.

Why does the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule include Date-of-Birth and DMG segments in patient identification, but not member ID?

The rule expands upon the 5010X217 278 Request and Response Technical Report Type 3 (TR3) requirements while not conflicting with them to allow for the most accurate patient matching (and therefore reduction in pended requests due to related errors). The member ID is not included in the rule because it is already required by the Technical Report Type 3 (TR3).

Does last name normalization required by the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule mirror that of the Eligibility Transaction Rule requirements?

Yes, Sections 3.6, 4.1 and 4.2 of the CAQH CORE Prior Authorization and Referrals (278) Data Content Rule address the use of a patient’s last name to the extent permitted by the X12 v5010X217 278 Request/Response and the requirements for providers, health plans, and their agents and are nearly identical; however, since the X12 v5010X279 270/271 Eligibility & Benefit Inquiry and Response focus is on patient verification, the requirements are slightly different; i.e., the CAQH CORE Eligibility and Benefits (270/271) Data Content Rule requires the r

Why is there a requirement to return HCSDRC 09 (Out of Network) in the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule when this type of transaction is rejected using a AAA*35 (Error Code 35 – Out of Network)?

A transaction being rejected using a AAA*35 assumes that the prior authorization was rejected due to being out-of-network. While this is often true, it is not always the case. Setting up the out of network flag at the HCSDR 09 level allows for that flexibility.

When requesting additional documentation for a pended response for a patient with more than one service preformed for the same diagnosis, which service category would it be categorized under in the CAQH CORE Prior Authorization & Referrals (278) Data

The X12 v5010X217 278 Technical Report 3 (TR3) supports submission of up to 12 different ICD-10 codes from 3 different X12 External Code Sources.

Are vendors who send requests on behalf of the payer able to go beyond the specificity of the list of services categories in the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule?

Yes. Health plans and their agents are strongly encouraged to evaluate and respond to all received procedure, diagnosis, or revenue codes, not only those listed in rule. The rule does not prohibit health plans and their agents from using the same methods to request additional documentation for services outside of the listed service categories. The requirements are placed on the health plan and its agent to process a limited set of use cases for when a service, procedure, etc.

In Section 4.2.3 Requesting Additional Documentation for a Pended Response of the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule, how was the list of service categories determined?

To encourage movement toward a more automated and streamlined processing of the request and flagging the need for additional documentation, the rule requires that the health plan process submitted Diagnosis, Procedure, and Revenue Codes that fall into types of services that are often pended for medical necessity. The categories of services were determined and agreed to by the Prior Authorization Subgroup as the most frequently pended for additional documentation.

To request additional documentation for a pended response, how many HR03 Industry Codes can be returned according to the CAQH CORE Prior Authorization & Referrals (278) Data Content Rule?

A health plan and its agent can return up to five HR03 Industry Codes for a pended response requiring additional documentation.

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