CAQH CORE 260: Eligibility & Benefits

CAQH CORE 260: Eligibility & Benefits (270/271) Data Content Rule Version 2.1.0

CAQH CORE 260: Eligibility & Benefits (270/271) Data Content Rule Version 2.1.0 requires that entities, at a minimum, return the coverage status for each specific benefit (service type) included in a X12 270 eligibility request that is required in response to an explicit inquiry. That is, even if you are exercising your company’s discretion not to return patient financial liability information for one of the listed “discretionary” service types, you must return the health plan coverage status for that code in the EB01 segment in the 2110C or 2110D loop, as appropriate.

The CAQH CORE 260 Rule requires that a health plan must return patient financial responsibility information for co-insurance, co-payment, and both base and remaining deductible (including in and out-of-network variance, if applicable) for each Service Type Code returned in the X12 271 Response.

If your organization chooses to respond with active/inactive only, then your organization should not return any of the patient liability types. As detailed in the rule’s subsections, 2.3.1, 2.3.2 and 2.3.3, the health plan may choose not to provide the patient liability information for certain service types and instead return active/inactive information only. However, if the health plan chooses to return patient liability information, it must do so for all three required patient liability types (co-payment, co-insurance and deductible) as applicable to the product.

CAQH CORE 260: Eligibility & Benefits (270/271) Data Content Rule Version 2.1.0 does not restrict the range of dates applicable to deductibles to be a full year. The CAQH CORE Rule requires that a begin date applicable to deductibles must be returned for the health plan coverage and that alternatively a range of dates may be returned. The range of dates is determined by the health plan and may be less than or greater than a full year.

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