CAQH CORE 154 Rule (Subsection 2.6) – Explicit request for each of the CORE Service Types
CAQH CORE 154 Rule requires all CORE-certified entities to be able to support an explicit inquiry about each of the 12 CAQH CORE-required service types. Support means that an entity must be able to receive and respond to an explicit X12 270 inquiry- an inquiry for only one of the CAQH CORE-required service types, such as 33-Chiropractic. If the health plan does not include coverage for that specific service type (benefit), the health plan must respond with a X12 271 indicating that the specific service type is not covered and return all of the other information required by the CAQH CORE Rule.
CAQH CORE Rules are specific to “what” data is to be exchanged and what that data represents. Neither the CAQH CORE Rules nor the X12 270/271 Technical Report Type 3 (TR3) Implementation Guide address the displaying of information. Therefore, how the HIS/PMS vendor chooses to “display” this information, is solely under the purview and control of these IT system vendors.
Some organizations are concerned that the 90/70 type of coinsurance percentages used today (representing the percent paid by the insurer) will be confusing when displayed as a 10/30 (switching to “patient responsibility representation”). Many believe it is an industry standard for the coinsurance to be displayed as the percent paid by the insurer. If any organization must send coinsurance as member responsibility, can it also display/send an additional coinsurance for the payer responsibility percentage? The CAQH CORE 154: Eligibility & Benefits (270/271) Data Content Rule does not address how patient financial responsibility information is displayed by the provider’s system once the X12 271 is received and the data extracted. Therefore, how the HIS/PMS vendor chooses to “display” this information, is solely under the purview and control of these IT system vendors. The rule only specifies that the co-insurance is returned as the percent that is the patient’s responsibility, which is consistent with the proper use of the EB segment.