CAQH CORE 260: Eligibility & Benefits Data Content (270/271) Rule
CAQH CORE 260: Eligibility & Benefits Data Content (270/271) Rule relationship (CAQH CORE 154 & 260 Rules) in Phase I and Phase II is described below in the blog. The Phase I CAQH CORE 154: Eligibility & Benefits Data Content (270/271) Rule provides an important first step toward improving eligibility and benefits verification. It outlines a set of requirements for health plans to return base patient financial responsibility amounts related to deductible, co-pay and co-insurance for a set of 12 services in the X12 271 eligibility response transaction. It also includes requirements for vendors, clearinghouses and providers to transmit and use this financial data.
The Phase II CAQH CORE 260: Eligibility & Benefits Data Content (270/271) Rule extends and enhances the Phase I X12 271 response transaction by requiring the return of remaining deductible amounts for both the Phase I CORE-required 12 service type codes and an additional 39 other service type codes. The Phase II CAQH CORE Rule also requires, in addition to base patient financial responsibility, that year- to-date remaining or accumulated amounts be returned for explicit benefits eligibility requests. If the health plan supports X12 270 Eligibility Inquiries using diagnosis/procedure codes in addition to Service Type Codes, is it required to return comprehensive benefit level details in our X12 271 response as if the X12 270 Inquiry were a generic inquiry using Service Type Code 30 when we receive an X12 270 eligibility inquiry that includes diagnosis/procedure codes? The CAQH CORE Eligibility & Benefits (270/2711) Data Content Rules (CAQH CORE 154 & 260 Rules) do not address the use of diagnosis/procedure codes in either an X12 270 eligibility inquiry or an X12 271 response. Therefore, the health plan or information source can determine data content for an X12 271 response to such an X12 270 inquiry.
If a request is submitted for a service type that is not required by CAQH CORE Data Content (270/271) Rule, and the receiving health plan does not support the service type(s), that health plan is required to respond as required by the X12 270/271 TR3 in Section 126.96.36.199.
To learn more about HIPAA EDI and become a certified EDI Professional please visit our course schedule page.