CORE 157: Eligibility and Benefits System Availability Rule Basic Guidelines

CORE 157CORE 157: Eligibility and Benefits System Availability Rule states that system availability must be no less than 86 percent per calendar week for both real time and batch processing modes. This will allow for health plan, (or other information source) clearinghouse/switch or other intermediary system updates to take place within a maximum of 24 hours per calendar week for regularly scheduled downtime.

Many healthcare providers have a need to determine an individual’s health plan coverage at the time and point of patient registration and intake, which may occur on a 24x7x365 basis or outside of the typical business day and business hours. Additionally, many institutional providers are now allocating staff resources to performing patient pre-registration activities on weekends and evenings. As a result, providers have a business need to be able to conduct health plan eligibility transactions at any time. On the other hand, health plans have a business need to take their eligibility and other systems offline periodically in order to perform the required system maintenance. This typically results in some systems not being available for timely eligibility inquiries and responses certain nights and weekends. The rule was created to address these conflicting needs.

CORE-certified health plans (or information sources), clearinghouses/switches or other intermediaries must publish their regularly scheduled system downtime in an appropriate manner (e.g., on websites or in Companion Guides). This allows the healthcare provider to better manage staffing levels. Additionally, the CAQH CORE 157 Rule outlines requirements for reporting/publishing non-routine downtimes, and unscheduled/emergency downtimes.

Does the organization have to send back an eligibility response if its system is down? As long as your organization eligibility system is in conformance with the CAQH CORE 157 Rule, then it is not required to send back an eligibility response, either in real time or batch.

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