CAQH CORE 250: Claim Status Infrastructure Rule

CAQH CORE 250: Claim Status Infrastructure Rule applies when an entity uses, conducts, or processes the HIPAA-adopted X12 276/277 Health Care Claim Status Request and Response transactions.

The CAQH CORE 250: Claim Status Rule relates to the Phase I CAQH CORE Rules in the following ways:

  • The Phase I CAQH CORE Infrastructure Rules, which were created to increase access to the X12 270/271 transactions, also apply to the Claim Status Rule for the X12 276/277 HIPAA transactions. These infrastructure rules address real time and batch response times, the use of the ASC X12 Implementation Acknowledgement (999), system availability, and a common flow/format for a Companion Guide.
  • As with the other Phase II CAQH CORE Rules, general CAQH CORE policies also apply to the Phase II CAQH CORE Claim Status Rule as outlined in the Phase II CAQH CORE Policies 200-205, e.g., as in Phase I, there is CORE Certification testing for each stakeholder, a health plan exemption policy for system migration, and entities are required to test only for and meet batch rule requirements if they offer batch.
  • All CAQH CORE Rules are a minimum requirement; entities are free to offer more than what is required in the rule. Providers, vendors, clearinghouses, and health plans all need to meet appropriate aspects of the rule and all will be tested via CORE Certification testing.

Detailed infrastructure requirements for conducting Phase II CAQH CORE Claim Status transactions include compliance with the following Phase I CAQH CORE Rules:

  • Batch Acknowledgements (CAQH CORE 150)
  • Real Time Acknowledgements (CAQH CORE 151)
  • Companion Guide (CAQH CORE 152)
  • Eligibility/Benefits Batch Response Time (CAQH CORE 155)
  • Eligibility/Benefits Real Time Response Time (CAQH CORE 156)
  • System Availability (CAQH CORE 157)

Vendors and clearinghouses are only required to certify for the transaction type(s) offered (i.e., eligibility and/or claim status). As a vendor offering only claim status transaction support to company clients (company does not use the X12 270/271 eligibility transactions), is the company able to seek Phase II CORE Certification for claim status? In this case, upon successful completion of Phase II CORE Certification for claim status, the organization would receive a CORE Certification Seal for Claim Status.

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