Eligibility And Claim Status

Eligibility And Claim Status CAQH CORE Companion Guides For Trading Partners and Providers

Eligibility And Claim Status companion guides can be independently created by health plans so they can often vary in format and structure. Such variance can be confusing to trading partners and providers. CAQH CORE adapted its CAQH CORE Master Companion Guide Template based on the CAQH/WEDI Best Practices Companion Guide Template developed jointly in 2003, with input from multiple health plans, system vendors, provider representatives and healthcare/HIPAA industry experts. The template organizes information into several simple sections and provides for a common information flow and format, while at the same time giving health plans the flexibility to tailor the document to meet their particular needs. The template covers a broad range of HIPAA-mandated transaction sets and is not specific to any one of them.

Similar to the other Phase I CAQH CORE Operating Rules, the scope of the CAQH CORE 152: Companion Guide Rule Version 1.1.0 is limited to the X12 270/271 eligibility and benefits inquiry/response transactions. Entities, may, if they wish, combine their Companion Guides for separate transactions into a single document. The flow and format of the CAQH CORE v5010 Master Companion Guide Template would still need to be followed, but sections could be repeated, tables added for the second transaction, etc., without altering said flow and format.

If completing CORE Certification testing, your organization is only required to submit to the CAQH CORE-authorized testing vendor:

  1. The Companion Guide’s table of contents
  2. A page showing your organization’s requirements for the presentation of segments, data elements and codes.

As part of CORE Certification testing, CAQH CORE-authorized testing vendors evaluate the following to determine if an entity’s Companion Guide(s) conforms to the CAQH CORE 152 & 250 Rules Companion Guide Requirements:

  • If the order of the Companion Guide table of contents matches the table in the CAQH CORE v5010 Master Companion Guide Template
  • If the Companion Guide format for specifying the X12 270/271 &/or X12 276/277 data content requirements is consistent with the format in the CAQH CORE v5010 Master Companion Guide Template

If a specific section(s) of the CAQH CORE v5010 Master Companion Guide Template is not appropriate for a particular entity’s Companion Guide, the CAQH CORE 152 and 250 Rules do allow the entity to exclude this section(s) from their guide.

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