CAQH CORE 154 Eligibility & Benefits 270/271 eligibility data content subjects to the Phase I and general CAQH CORE 260 Rule rule requirements for the X12 270/271.
CAQH CORE 154 Eligibility & Benefits 270/271 Notes
- The CAQH CORE 154 Eligibility & Benefits (270/271) Data Content Rule Version 1.1.0 does not require that a DTP segment be used. The DTP segment in the X12 270 may be used to request a benefit coverage date 12 months in the past or up to the end of the current month.
- The CAQH CORE 154 Rule does not require that a DTP segment be used. However, the X12 270 may use the DTP segment to request a benefit coverage date up to 12 months in the past or up to the end of the current month.
- A provider may submit an inquiry asking about eligibility for a health plan for either past or future dates. However, a health plan is not required by the CAQH CORE Rule to report eligibility dates older than 12 months in the past or beyond the end of the current month. When the health plan does not support such an inquiry, it is required to return the X12 271 with the appropriate AAA segment indicating the dates of service requested are outside of its reporting period.
- The use of code “346” for Plan Begin Date in the X12 271 response required by CAQH CORE means the effective date of health plan coverage actually in operation and in force for the individual.
- An X12 271 response from a health plan does not guarantee that the health plan will reimburse the provider for health services if a claim is submitted.
- Many health plans have a single deductible that applies to all benefits provided under that health plan. When this is the situation, a health plan should return a deductible amount only on the EB segment with Service Type Code 30. The CAQH CORE 154: Eligibility & Benefits (270/271) Data Content Rule Version 1.1.0 requires the use of code “C” Deductible in EB01-1390 Eligibility or Benefit Information data element and use of EB07-782 Monetary Amount to indicate the dollar amount of the deductible for the type of service specified in EB03-1365 service type code. Since Service Type Code 30 is defined to mean health plan benefit coverage, this is the service type code that must be used when returning a global or universal deductible amount that applies to the health plan.