Eligibility & Claim Status Operating Rules

Eligibility & Claim Status Operating Rules: Service Type Codes (STCs)

Eligibility & Claim Status Operating Rules define some Service Type Codes (STCs) as “discretionary” in the CAQH CORE Eligibility & Benefits (270/271) Data Content Rules (CAQH CORE 154 & 260 Rules). 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.

Eligibility & Claim Status Operating Rules cannot change or modify the meaning or definition of any X12 standard or code. To assist the industry with a common understanding of some of the CORE-required STCs, CAQH CORE developed supplemental descriptions. These supplemental descriptions are for guidance only to aid in a common industry understanding of the STCs, as noted in Footnote #2 in Table of the rule. Clarification or interpretation of the definition of a Service Type Code can be obtained from ASC X12 via its online ASC X12 Interpretation Portal.

Eligibility & Claim Status Operating 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.

Health plans that have carved out certain benefits to another entity may not have the patient financial data available to respond to an X12 270 inquiry. The CAQH CORE Eligibility & Benefits (270/271) Data Content Rules (CAQH CORE 154 & 260 Rules) identify certain benefits as discretionary for reporting patient financial responsibility for carved out benefits. In the situation that a health plan has carved out benefit to another entity, the health plan has the discretion of reporting the patient financial data. This does not preempt the requirement for a health plan to return the other required data in the X12 271 response (i.e. health plan name, status, etc.).

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