CAQH CORE Eligibility Data Content Rules – Frequently Asked Questions
CAQH CORE Eligibility Data Content Rules (CAQH CORE 154 & 260 Rules) do not require that the X12 271 response to an X12 270 inquiry include a specified grouping of Service Type Codes (STCs), so are health plans/information sources prohibited from returning such an STC grouping in the X12 271 response? CAQH CORE Operating Rules represent a floor and not a ceiling. The CAQH CORE Eligibility & Benefits (270/271) Data Content Rules (CAQH CORE 154 & 260 Rules) do not preclude a health plan from returning additional STCs in the X12 271 Response. A health plan can return additional STCs to ensure that the provider has the level of detail required to meet its specific business needs.
The CAQH CORE Eligibility & Benefits (270/271) Data Content Rules (CAQH CORE 154 & 260 Rules) do not require support for a date range inquiry. Entities can make individual determinations on whether or not to support this type of inquiry. The CAQH CORE 154 and 260 Rules do require that health plans, vendors, and clearinghouse support X12 270 requests for benefit information at least 12 months into the past and up to the end of the current month. This requirement would include returning benefit information for the current plan period if such a request was received.
Why are some Service Type Codes (STCs) identified as “discretionary” in the CAQH CORE Eligibility Data Content Rules (CAQH CORE 154 & 260 Rules)? What information must a health plan return in response to the “discretionary” STCs? For certain STCs, the patient financial data is not required to be returned for some benefits as they are considered carve outs, too general, or are related to sensitive benefits (e.g., behavioral health). The health plan name (if available within its own system), the coverage status of the specific benefit, and the eligibility dates must be returned regardless of whether the health plan or information source is exercising its discretion to not return patient financial responsibility.
The discretionary STCs are:
1 – Medical Care
35 – Dental
88 – Pharmacy
A6 – Psychotherapy
A7 – Psychiatric – Inpatient
A8 – Psychiatric – Outpatient
AI – Substance Abuse
AL – Vision (Optometry)
MH – Mental Health
While the CAQH CORE 154 Rule includes STC 30 in the list of discretionary STCs, the CAQH CORE 260 Rule removes STC 30 from the list of discretionary codes.