Data Content Rules (CAQH CORE 154 & 260 Rules) – Health Plans Requirements
Data Content Rules (CAQH CORE 154 & 260 Rules) require health plans to address the situation where a patient’s benefit coverage changes from the time of the X12 270 Inquiry to the date of service. True or false? Actually the CAQH CORE Eligibility & Benefits Data Content Rules do not require that the X12 271 response contain final coverage information which is not subject to change. The X12 271 response data is current as of the date of the X12 271 response. There is no guarantee that the information reported in any given X12 271 response will not change. Changes to coverage can occur due to factors outside the control of the health plan. Any X12 271 response received from a health plan should not be construed to be a guarantee that the health plan will reimburse the provider for health services if a claim is submitted.
When do the Data Content Rules (CAQH CORE 154 & 260 Rules) CAQH CORE Eligibility & Benefits (270/271) require health plans/information sources to return health plan base and remaining deductible? The CAQH CORE Eligibility & Benefits (270/271) Data Content Rules require that X12 271 responses to both generic and explicit X12 270 inquiries include patient financial responsibility for co-pay, co-insurance, and health plan base and remaining deductible for each Service Type Code (STC) returned with exceptions for discretionary reporting. The CAQH CORE Eligibility & Benefits Data Content Rules require health plans to return the dollar amount for both the base and remaining deductible for all CORE-required STCs listed in Table 4.1.1.1 in CAQH CORE 260 Rule. The health plan may, at its discretion, elect not to return patient financial responsibility information (deductible, co-payment or co-insurance) for nine discretionary STCs. Appendix 1 in CAQH CORE 260 Rule, Section 6.1 specifies all of the CAQH CORE STCs and identifies for which codes return of patient financial responsibility information is mandatory or discretionary.