CAQH CORE Operating Rules for Eligibility and Claims Status

Operating rules for eligibility and claims status went into effect on January 1, 2013. They make it easier for providers to determine:

  • Whether a patient is eligible for coverage (transaction 270/271)
  • The status of a health care claim submitted to a health insurer (transaction 276/277)

Eligibility Operating Rule Requirements

Eligibility operating rules require health plans to:

  • Respond in real time to providers’ eligibility questions with a patient’s financial information, including:
  • Deductibles, co-pays, coinsurance, in/out of network variances
  • Coverage information for specific service types
  • Provide secure access to eligibility information over the Internet

Claims Status Operating Rule Requirements

Health plans must furnish real-time online access to claims status information, meaning that providers can better estimate cash flow while spending less time on phone calls.

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