CAQH CORE HIPAA Operating Rules (Eligibility & Claim Status)
CAQH CORE HIPAA Operating Rules are mandated for all HIPAA-covered entities by the ACA (with the exception of requirements pertaining to acknowledgments). Find CAQH CORE HIPAA Operating Rules (Eligibility & Claim Status) in the form of FAQs below.
- What do the Phase I and Phase II CAQH CORE Eligibility & Claim Status Operating Rules address?
The Phase I and Phase II CAQH CORE Eligibility and Claim Status Operating Rules streamline the way eligibility/benefits and claim status healthcare administrative information is exchanged electronically. Easier, more reliable access to this information at the point of care can reduce the amount of time providers spend on administration by improving the accuracy of claims submitted, providing enhanced information on patient financial responsibility, and checking the status of a patient claim electronically.
- Why are the Phase I CAQH CORE Operating Rules only for the eligibility/benefits transactions?
The CORE Participants determined that the CAQH CORE Operating Rules could have the most immediate impact if Phase I focused on improving eligibility and benefits verification. CORE Participants decided to address only the X12 270/271 electronic data interchange (EDI) eligibility transactions in Phase I along with the necessary infrastructure needs including the use of the ASC X12 Implementation Acknowledgement (999) with later phases of CAQH CORE to include other types of transactions. Phase II CAQH CORE, for example, includes operating rules for both the X12 270/271 eligibility transaction and the X12 276/277 claims status transaction, as well as extending the use of the ASC X12 Implementation Acknowledgement (999) to the X12 276/277.
- What entities should implement the Phase I and Phase II CAQH CORE Eligibility and Claim Status Operating Rules?
As the ACA Administrative Simplification provisions build on and update the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), ACA Section 1104 requires all HIPAA covered entities to comply with the ACA–mandated standards and applicable operating rules by their compliance dates. The CMS website provides charts to help organizations determine whether an organization or individual is a HIPAA covered entity.