CAQH CORE 154 X12 271 Response Back Guides
CAQH CORE 154 X12 271 response with the health plan name (assuming it is available within the system[s]) in EB05 element of all EB segments sent back in the response has some notes. Since the CAQH CORE 154 Rule does not explicitly identify which EB segments are to carry the health plan name, it could appear on all or some of the EB segments returned. Therefore, the health plan should include the name of the health plan (when available) in EB05 ONLY when EB03=30 Health Benefit Plan Coverage and not return it redundantly on every other EB segment, unless the name of the health plan is different for a given service type.
Can an X12 271 response to an explicit X12 270 Inquiry containing one of the CORE-required Service Type Codes (STCs) identified in Rule Subsection 1.4 provide information about STCs beyond the requested CORE-required STC? The CAQH CORE Operating Rules represent a floor and not a ceiling. The CAQH CORE Eligibility & Benefits Data Content Rules (CAQH CORE 154 & 260 Rules) do not limit a health plan’s X12 271 response to only the explicit inquiry STC. If the explicit inquiry STC is on the list of CORE-required STCs, the CAQH CORE 154 and 260 Rules require that health plans include in their X12 271 response the required information for that STC. Additionally, the X12 271 response can include information about other STCs. For a STC that is not required by the CAQH CORE Rules, the ASC X12N v5010 270/271 TR3 requires that health plans respond with the generic inquiry response.
For health plans and information sources, the CAQH CORE Eligibility & Benefits (270/271) Data Content Rules (CAQH CORE 154 & 260Rules) require that an X12 271 response to an X12 270 inquiry include:
- Patient financials for co–insurance, co–payment, and base and remaining deductibles
- Patient financial responsibility for both in–network and out–of–network if the financial amounts are different.