Do providers have to test for all of the Eligibility & Benefits Operating Rules?

Providers who wish to become  CORE-certified on the Eligibility & Benefits Operating Rule set must comply with all of the provider-specific CAQH CORE Operating Rules and complete the CORE Certification test scripts for each rule that apply to providers. Providers can satisfy the certification requirements by either using a provider/vendor's solution or a combination of a provider/vendor's solution plus some in-house work.

In terms of modifying data, are there allowable exceptions for loading the Eligibility & Benefits CORE Master Test Bed Data?

Yes, exceptions relate to the modification or non-use of some of the test data elements. In general, CORE Certification testers are not permitted to modify dates and patient demographic data. The Eligibility & Benefits CORE Master Test Bed Data also includes deductible and co-pay amounts explicitly shown as zero (0$) dollar amounts that are NOT modifiable.

When a health plan indicates it does not support dependents, is it necessary for the dependent test cases to be loaded into the health plan's eligibility system?

If a health plan indicated that it did not support Subscribers w/ Dependents then they would be taken through the tasks using the CORE Master Test Bed Cases 1 through 16, and they should not receive any data using the Cases 17 through 24.

I am a health plan. It appears that in much of the base data the member's address, city, state, zip have been included, which is currently not included in our X12 271 responses. Is this data required or is it okay if the response does not include this set

Any entity seeking CORE Certification on the Eligibility & Benefits Operating Rule set must attest that it is HIPAA compliant. Since the member address information is included in the CORE Master Test Bed Data, it is expected that health plans will not only load the address information for CORE Certification Testing but will also use it to create the appropriate HIPAA-compliant X12 271 response even though the CAQH CORE Operating Rule does not deal with the address information.

I am a health plan. My Organization’s eligibility system does not support identification of a primary care provider as specified in the CORE Master Test Bed Data, as we do not support products with primary care providers.

The primary care provider is not validated by the CAQH CORE-authorized testing vendors in any of the CORE Certification test scripts. Therefore, the primary care provider can be modified, or not used, by any health plan or information source based on its eligibility system requirements when undergoing CORE Certification Testing.

I am a health plan. The employee ID used in the CORE Master Test Bed Data does not align with my organization’s eligibility system format requirements (length/format/datatype).

The Employee ID is not validated by either of the CAQH CORE-authorized testing vendors in any of the certification test scripts. Therefore, the Employee ID can be modified, or not used, by a health plan or information source based on its eligibility system requirements for Employee ID when undergoing certification testing.

I am a health plan. Coverage level is listed in the CORE Master Test Bed Data; however it is listed for at least one test case as employee only. My organization’s eligibility system does not support employee only coverage level and instead uses individual

CAQH CORE-authorized testing vendors can accommodate a health plan or information source modifying the EB02 Coverage Level Code from EMP to IND as needed in order to load the benefit into its eligibility system. Therefore the EB02 Coverage Level Code can be modified, or not used, by any health plan or information source based on its eligibility system requirements for coverage level when undergoing CORE Certification Testing.

I am a health plan. The CORE Master Test Bed Data has specific payer names expected to be returned, e.g., “PlanA” certification payer, but my organization uses specific plan names.

The name “PlanA” appears only in the ISA/GS sender/receiver fields and the NM103 segment in the 2100A Information Source loop in the CORE Master Test Bed Data. The ISA/GS sender/receiver fields as well as the name of the Information Source in loop 2100A are not validated by the CAQH CORE-authorized testing vendors in any of the certification test scripts. Therefore, these values can be modified by any health plan or information source based on its eligibility system requirements when undergoing certification testing.

I am a health plan. My organization’s eligibility system does not support identification of a plan number as specified in the REF segment in the CORE Master Test Bed Data.

The Plan number is not validated by either of the CAQH CORE-authorized testing vendors in any of the certification test scripts. Therefore, the Plan number can be modified, or not used, by any health plan or information source based on its eligibility system requirements for Plan number when undergoing certification testing.

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