Skip to Main Content

HIPAA SIMPLIFIED

Your online resource for healthcare regulations

DC_test_header

Claims and Encounters/Benefit Enrollment/Premium Payment/Referral and Authorization Operating Rules

In September 2015, the CAQH Committee on Operating Rules for Information Exchange (CORE®) approved the Phase IV Operating Rules for their voluntary certification process.

The Phase IV Operating Rules address the following ASC X12N transactions:

  • Health Care Claims: Institutional (835I), Professional (835P), and Dental (837D)
  • Health Care Services Review – Request for Review and Response (278)
  • Benefit Enrollment and Maintenance (834)
  • Payroll Deducted and Other Group Premium Payment for Insurance Products (820)

The Phase IV Operating Rules are as follows:

  • Phase IV CAQH CORE 450 version 4.0.0: Health Care Claim (837) Infrastructure Rule
  • Phase IV CAQH CORE 452 version 4.0.0: Health Care Services Review and Response (278) Infrastructure Rule
  • Phase IV CAQH CORE 454 version 4.0.0: Benefit Enrollment and Maintenance (834) Infrastructure Rule
  • Phase IV CAQH CORE 456 version 4.0.0: Premium Payment (820) Infrastructure Rule
  • Phase IV CAQH CORE 470 version 4.0.0: Connectivity Rule including:
    • Phase IV CAQH CORE-required Processing Mode and Payload Type Tables
    • XML Schema Specification (normative)
    • Web Services Definition Language (WSDL) Specification (normative)

For each transaction, the Phase IV Operating Rules define the following requirements:

  • Required and optional processing modes (batch, real-time)
  • Use of ASC X12 Acknowledgments for Health Care
  • Response times
  • Transaction logging and auditing
  • Reporting requirements; for example, scheduled downtimes
  • Companion guide format and flow
  • Provision of a “Safe Harbor” connectivity option, using updated specifications from those required for Phase I, II, and III.

View the Phase IV Operating Rules

View Additional Information on CAQH CORE

  • Claims And Encounters

    • Regulatory Adoption

      On July 6, 2016, the National Committee on Vital and Health Statistics (NCVHS), advisory body to the Department of Health and Human Services, recommended that the Phase IV Operating Rules not be adopted under regulatory mandate and instead supported voluntary industry adoption.  Recommendations also included; addressing inconsistencies in authentication and connectivity requirements, regulatory adoption of the acknowledgement standard as HIPAA-mandated, and transaction-specific findings and recommendations.

      To see the NCVHS recommendation, go to www.ncvhs.hhs.gov.

      Regulatory action on the Phase IV operating rules is not anticipated.

    • Voluntary Certification

      CAQH CORE offers a voluntary certification program which serves to demonstrate an entity’s conformance to the Phase IV Operating Rules.

      Change Healthcare supports the NCVHS recommendations and will not seek CORE Phase IV voluntary certification until the recommendations are addressed or further regulatory clarifications are communicated.

      View Information on CAQH CORE Voluntary Certification