CAQH CORE 154 Eligibility & Benefits 270/271 eligibility data content rule subjects to the general CAQH CORE 260 Rule X12 270/271 requirements.
CAQH CORE 154 Eligibility & Benefits 270/271 Guidelines
- Code 52 is specific to hospital emergency services; Code 86 is general. CAQH CORE selected Code 86 so that emergency services provided in outpatient/urgent care/walk-in facilities would be included. Code 86 is what is required to be returned. When a health plan has different deductible amounts for hospital emergency medical services they may return an additional EB segment using Service Type Code 52 Hospital-Emergency Medical in addition to the EB segment using Code 86.
- Some of older health plans do not have a separate chiropractic benefit but include coverage for this benefit under the physician office visit benefit. In this situation it would be inaccurate to respond to an explicit X12 270 inquiry about chiropractic benefit with a “not- covered” code in EB01 per the CAQH CORE 154: Data Content Rule.
- How can partners respond to an explicit X12 270 inquiry for chiropractic benefit in this situation and not violate the CAQH CORE 154: Data Content Rule? In this situation the health plan or information source could use multiple EB segments in the 271 response to an explicit X12 270 code 33 inquiry. The first EB segment would be EB01 = V Cannot Process and EB03 = 33 Chiropractic. The second EB segment would be EB01 = 1 Active Coverage and EB03 = 98 Professional (Physician) Office Visit to indicate that chiropractic services in are included in the office visit benefit. Subsequent EB segments would then also be returned with the appropriate patient financial responsibility information for deductible, co-pay, co-insurance and in/out-of-network amounts if applicable.
- Is the test script for the Data Content Rule: “Extract from a valid X12 271 response transaction as defined in the CAQH CORE Rule the data indicating the name of the health plan covering the individual specified in the X12 270 eligibility inquiry,” explicitly stated in the CAQH CORE 154: Eligibility & Benefits 270/271 Data Content Rule as a provider requirement? The requirement for receivers of the X12 271 to have the systems capability to display the content of the X12 271 is stated in the CORE Certification Testing Script #2. The CAQH CORE 154: Eligibility & Benefits (270/271) Data Content Rule does not explicitly require providers and provider vendors to have this capability. However, the need for providers and provider vendors to demonstrate this display capability as a requirement of certification was discussed and agreed to by the CORE Participants. The CORE Participants felt that without requiring provider systems to display the required content, requiring the content to be provided by the health plans would not address the business need to make the information usefully available to the providers. This is the rationale for why this requirement is included in the Phase I CAQH CORE Certification Test Suite.