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Eligibility / Claim Status Operating Rules

Phase I

The CAQH Committee on Operating Rules for Information Exchange (CORE®) developed the Phase I Operating Rules for their voluntary Phase I certification program.  The Phase I rules were originally developed to address the 4010 version of the Health Care Eligibility Benefit Inquiry and Response (270/271). The Phase I rules were updated to align with the 5010 version of the 270/271 and were adopted by CORE in March 2011.

The Phase I Operating Rules are as follows:

  • Phase I CAQH CORE 150 version 1.1.0: Eligibility and Benefit Batch Acknowledgment Rule
  • Phase I CAQH CORE 152 version 1.1.0: Eligibility and Benefit Real Time Companion Guide Rule and CAQH CORE v5010 Master Companion Guide Template
  • Phase I CAQH CORE 153 version 1.1.0: Eligibility and Benefits Connectivity Rule
  • Phase I CAQH CORE 154 version 1.1.0: Eligibility and Benefits 270/271 Data Content Rule
  • Phase I CAQH CORE 155 version 1.1.0: Eligibility and Benefits Batch Response Time Rule
  • Phase I CAQH CORE 156 version 1.1.0: Eligibility and Benefits Real Time Response Rule
  • Phase I CAQH CORE 157 version 1.1.0: Eligibility and Benefits System Availability Rule 

The Phase I Operating Rules include requirements for:

  • View the Phase II Operating Rules
  • Real-time and batch response times
  • System availability
  • Use of the ASC X12 Acknowledgments for Health Care
  • Eligibility Benefits Response content
  • Companion guide format and flow
  • Provision of a “Safe Harbor” connectivity option

View the Phase I Operating Rules

Phase II

CORE developed the Phase II Operating Rules for their voluntary Phase II certification program.  The Phase II rules were originally developed to address version 4010 of the Health Care Eligibility Benefit Inquiry and Response (270/271) and the Health Care Claim Status Request and Response (276/277). The Phase II rules were updated to align with the 5010 version of the 270/271 and the 276/277 and were adopted by CORE in March 2011.

The Phase II Operating Rules are as follows:

  • Phase II CAQH CORE 250 version 2.1.0: Claim Status Rule and CAQH CORE v5010 Master Companion Guide Template
  • Phase II CAQH CORE 258 version 2.1.0: Normalizing Patient Last Name Rule
  • Phase II CAQH CORE 259 version 2.1.0: AAA Error Code Reporting Rule
  • Phase II CAQH CORE 260 version 2.1.0: Eligibility Data Content Rule
  • Phase II CAQH CORE 270 version 2.2.0: Connectivity Rule

The Phase II rules:

  • Apply the following Phase I requirements to the 276/277 transaction:
    • Response time
    • System availability
    • Companion guide format and flow
  • Revise the “safe harbor” connectivity specification and applied them to the 276/277 transaction
  • Expand the data content requirements of the 271 response
  • Standardize AAA error code reporting within the 271 response relating to patient identification
  • Set rules for normalizing patient names sent in the 270 request and prior to performing patient lookup

View the Phase II Operating Rules

View Additional Information on CAQH CORE

  • Eligibility / Claim Status

    • Regulatory Adoption

      On August 10, 2012 the Department of Health and Human Services published the Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transactions; Interim Final Rule which required HIPAA covered entities to conform to a subset of the CAQH CORE Phase III Operating Rules.

      Although this Interim Final Rule adopted the majority of the CORE Phase I and II Operating Rules, it excluded rules referencing acknowledgments and CORE certification.

      All Change Healthcare products and services comply with the Eligibility and Claim Status Operating Rules IFC.

      View the Change Healthcare Operating Rules Readiness Document

    • Voluntary Certification

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

      The federally issued Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transactions; Interim Final Rule excluded rules referencing acknowledgments and CORE certification.

      Change Healthcare is Phase I and II certified for Real-time and Batch Transaction Processing and Data Hosting Services.

      View Information on CAQH CORE Voluntary Certification

    • Related Documentation