CMS-10662 ASETT_Assessment_All_Operating_Rule_Response_Attestation

Operating Rule Response/Attestation Document

Table of Contents

Introduction and Purpose .............................................................................................................................................................................................. 3
Introduction ............................................................................................................................................................................................................... 3
Purpose ...................................................................................................................................................................................................................... 3
Instructions .................................................................................................................................................................................................................... 3
All Entities Phase I ...................................................................................................................................................................................................... 4
Rule 153 – Connectivity (270/271) ........................................................................................................................................................................ 4
All Entities Phase II ..................................................................................................................................................................................................... 6
Rule 250 - Claim Status Rule (276/277) ................................................................................................................................................................. 6
Rule 270 - Eligibility and Benefits 270/271 Data Content (270/271) ..................................................................................................................... 6
All Entities Phase III .................................................................................................................................................................................................... 8
Rule 350 – Infrastructure Rules (EFT/ERA (835)) ................................................................................................................................................... 8
Health Plan – Phase I.................................................................................................................................................................................................. 9
Rule 150 – Eligibility & Benefit Batch Acknowledgement (270/271)..................................................................................................................... 9
Rule 151 – Eligibility & Benefit Real Time Acknowledgement (270/271) ............................................................................................................ 10
Rule 152 – Companion Guide (270/271) ............................................................................................................................................................. 10
Rule 153 – Connectivity (270/271) ...................................................................................................................................................................... 11
Rule 154 – Data Content (270/271) ..................................................................................................................................................................... 12
Rule 155 – Eligibility and Benefits Batch Response Time Rule (270/271) ........................................................................................................... 13
Rule 156 – Eligibility Benefits and Real Time Response Time Rule (270/271) ..................................................................................................... 14
Rule 157 – Eligibility and Benefits System Availability Rule (270/271) ................................................................................................................ 15
Health Plan - Phase II ............................................................................................................................................................................................... 17
Rule 250 - Claim Status Rule (276/277) ............................................................................................................................................................... 17
Rule 258 – Eligibility and Benefits 270/271 Normalizing Patient Last Name (270/271)...................................................................................... 20
1

Rule 259 – Eligibility and Benefits 270/271 AAA Error Code Reporting (270/271) ............................................................................................. 21
Rule 260 - Eligibility and Benefits 270/271 Data Content (270/271) ................................................................................................................... 23
Health Plan - Phase III .............................................................................................................................................................................................. 24
Rule 350 – Infrastructure Rules (EFT/ERA (835)) ................................................................................................................................................. 24
Rule 360 – CARC/RARC Uniform Use (EFT/ERA (835)) ......................................................................................................................................... 26
Rule 370 – EFT/ERA Association (EFT/ERA (835)) ................................................................................................................................................ 27
Rule 380 – EFT Enrollment Data Rule (EFT/ERA (835)) ........................................................................................................................................ 28
Rule 382 – ERA Enrollment Data Rule (EFT/ERA (835)) ....................................................................................................................................... 29
Provider - Phase I ..................................................................................................................................................................................................... 30
Rule 153 – Connectivity (270/271) ...................................................................................................................................................................... 30
Provider – Phase II ................................................................................................................................................................................................... 30
Rule 258 – Eligibility and Benefits 270/271 Normalizing Patient Last Name (270/271)...................................................................................... 30
Clearinghouse - Phase II ........................................................................................................................................................................................... 31
Rule 250 - Claim Status Rule (276/277) ............................................................................................................................................................... 31
Rule 258 – Eligibility and Benefits 270/271 Normalizing Patient Last Name (270/271)...................................................................................... 31
Rule 259 – Eligibility and Benefits 270/271 AAA Error Code Reporting (270/271) ............................................................................................. 32
Rule 260 - Eligibility and Benefits 270/271 Data Content (270/271) ................................................................................................................... 32

2

Introduction and Purpose
Introduction
HIPAA covered entities and their business associates are required to comply with the federally mandated operating rules per section 1104 of the Affordable
Care Act (ACA).
From the CAQH CORE Website: Operating Rules support a range of existing standards to make electronic transactions more predictable and consistent,
regardless of the technology. CAQH CORE has been designated by the Secretary of the Department of Health and Human Services (HHS) as the author for the
federally mandated operating rules per Section 1104 of the Affordable Care Act (ACA). 1 ACA Section 1104 applies to HIPAA covered entities and business
associates engaging in HIPAA standard transactions on behalf of covered entities. 2

Purpose
The purpose of this document is to provide a mechanism for covered entities to report whether they meet and support individual operating rule requirements
that are applicable to their organization. In addition, it instructs the covered entity to provide verification and/or an explanation as to how they meet the
individual operating rule requirements. This operating rule attestation document is for assessment purposes only.
This document is organized by Covered Entity types (All, Health Plan, Provider, Clearinghouse), Operating Rule phases (I, II, III), and Transaction types. Each
section includes a link to the published operating rule from the CAQH CORE website.

Instructions
1.

2.
3.
4.

1
2

For each transaction(s) indicated in Part C of the Artifact Request document, provide a corresponding operating rule attestation for “all entities” as well as
your covered entity type. For example, if your covered entity type is a Health Plan, and the 835 transaction is indicated in Part C of the Artifact Request
document, you will complete all of the 835 operating rule attestations marked “All” and those marked “Health Plan.”
• Clearinghouses: you must also attest to any operating rule that has been outsourced to you by another covered entity type. For example, if you
provide a real time 271 response on behalf of a health plan, you must also complete the applicable attestations related to the 271 response in the
Health Plan section.
Ensure that you select each applicable attestation response of “Yes” or “No.” If the requirement is not applicable, enter “N/A.” In addition, select a “Yes”
or “No” response to attest that the Covered Entity has uploaded documentation to the portal when applicable.
When providing corresponding attachments or documentation, indicate the name of the attachment, or document, in the comments section along with
the date it was uploaded to the portal.
Covered Entity representative’s signature, date, and comments are required at the end of each attestation. Typed names are acceptable signatures.

CAQH CORE Website: Operating Rules section of CAQH Core Website
CAQH CORE Website: Operating Rules Mandate section of CAQH Core Website

3

All Entities Phase I
Rule 153 – Connectivity (270/271)
Link to Operating Rule 153 on CAQH Core Website
Section 1 – All
Does your organization support an HTTP/S message pattern where the sender submits a message and then waits for a response from the message receiver,
according to section 1 of this rule? Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 2 – All
Does your organization support a real time single inquiry or submission according to section 2 of this rule? Yes or No (Circle One)
If you are the receiver of a real time single inquiry or submission, does your organization support providing either an error response or the corresponding ASC
X12 message response (999 or 271)? Note: the 999 is not mandated at this time. Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

4

Section 3 – All
Does your organization support a batch request submission according to section 3 (and/or its subsection(s)) of this rule? Yes or No (Circle One)
If you are the receiver of a batch submission, does your organization support providing the standard HTTP message indicating whether the request was
accepted or rejected according to section 3 (and/or its subsection(s)) of this rule? In addition, does your organization support sending files in the HTTP/S
response message or a list of available files when the sender requests the available files according to section 3 (and/or its subsection(s)) of this rule? Yes or No
(Circle One)

If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 5 – All
Does your organization support the HTTP/S protocol for security and authentication, including use of a User ID and Password, registering the IP address, and
using a digital certificate according to section 5 (and/or its subsection(s)) of this rule? Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

5

All Entities Phase II
Rule 250 - Claim Status Rule (276/277)
Link to Operating Rule 250 on CAQH Core Website
Section 4.1 – All
Does your organization support the claim status connectivity requirements according to section 4.1 of this rule? Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Rule 270 - Eligibility and Benefits 270/271 Data Content (270/271)
Link to Operating Rule 270 on CAQH Core Website
Section 4.1 – All
Does your organization support the basic conformance requirements and safe harbor Phase II connectivity according to section 4.1 (and/or its subsection(s)) of
this rule? Yes or No (Circle One)
For health plans and clearinghouses, have you implemented both envelope standards (SOAP+WSDL and HTTP MIME Multipart)?
For providers, have you implemented one of the envelope standards mentioned above? Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

6

Section 4.2 – All
Does your organization support the Envelope Specification requirements according to section 4.2 (and/or its subsection(s)) of this rule? Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement. Provide the name of which envelope specification you support.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 4.3 – All
Does your organization support the general specification requirements according to section 4.3 (and/or its subsection(s)) of this rule? Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 4.4 – All
Does your organization support the Envelope requirements according to section 4.4 (and/or its subsection(s)) of this rule? Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

7

All Entities Phase III
Rule 350 – Infrastructure Rules (EFT/ERA (835))
Link to Operating Rule 350 on CAQH Core Website
Section 4.2 – All
For providers, does your organization return a 999 to the health plan to indicate acceptance or rejection of the 835 according to section 4.2 (and/or its
subsection(s)) of this rule? Note: the 999 is not mandated at this time. Yes or No (Circle One)
For health plans, does your organization accept and process a 5010 999 from the provider according to section 4.2 (and/or its subsection(s)) of this rule? Note:
the 999 is not mandated at this time. Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

8

Health Plan – Phase I
Rule 150 – Eligibility & Benefit Batch Acknowledgement (270/271)
Link to Operating Rule 150 on CAQH Core Website
Section 1 – Health Plan
Does your organization return a 5010 271, with AAA segments that contain business errors, if the batch 270 is accepted for processing according to section 1
(and/or its subsection(s)) of this rule? Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 2 – Health Plan
If your organization returns a 5010 999 for batch 270, is it returned after the initial communications session according to section 2 of this rule? Note: the 999 is
not mandated at this time. Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

9

Rule 151 – Eligibility & Benefit Real Time Acknowledgement (270/271)
Link to Operating Rule 151 on CAQH Core Website
Section 1 – Health Plan
Does your organization return either a 999 when a 270 is functional group is rejected, or a 5010 271, with AAA segments that contain business errors, if the
real time 270 is accepted for processing according to section 1 (and/or its subsection(s)) of this rule? Note: the 999 is not mandated at this time. Yes or No
(Circle One)

If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Rule 152 – Companion Guide (270/271)
Link to Operating Rule 152 on CAQH Core Website
Health Plan
Does your organization publish a 5010 270/271 Companion Guide according to rule 152? Yes or No (Circle One)
If yes, please provide a copy.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

10

Rule 153 – Connectivity (270/271)
Link to Operating Rule 153 on CAQH Core Website
Section 4 – Health Plan
Does your organization support the required HTTP data elements and message formatting requirements according to section 4 (and/or its subsection(s)) of
this rule? Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 7 – Health Plan
Does your organization support the response message options and error notification requirements according to section 7 ((and/or its subsection(s)) of this
rule? Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports all 4
requirements above.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

11

Rule 154 – Data Content (270/271)
Link to Operating Rule 154 on CAQH Core Website
Section 1 – Health Plan
Does your organization support the eligibility response requirements, including the health plan name, patient financial responsibility, eligibility dates, and
CORE required service type codes according to section 1 (and/or its subsection(s)) of this rule? Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports all 4
requirements above.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

12

Rule 155 – Eligibility and Benefits Batch Response Time Rule (270/271)
Link to Operating Rule 155 on CAQH Core Website
Section 1 – Health Plan
Does your organization support the 270 batch mode response time requirements by returning a 271 response by 7:00 AM the following business day
according to section 1 of this rule? Yes or No (Circle One)
If yes, provide a log for one calendar month that demonstrates this.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 2 – Health Plan
Does your organization support the 999 batch mode response time requirements by providing a 999 within one hour from receipt of the batch according to
section 2 of this rule? Note: the 999 is not mandated at this time. Yes or No (Circle One)
If yes, provide a log for one calendar month that demonstrates this.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature
Date:
Comments:

13

Rule 156 – Eligibility Benefits and Real Time Response Time Rule (270/271)
Link to Operating Rule 156 on CAQH Core Website
Section 1 – Health Plan
Does your organization support the 270 real time response time requirement of 60 seconds or less according to section 1 of this rule? Yes or No (Circle One)
If yes, provide a log for one calendar month that demonstrates this.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

14

Rule 157 – Eligibility and Benefits System Availability Rule (270/271)
Link to Operating Rule 157 on CAQH Core Website
Section 1 – Health Plan
Does your organization support the system availability requirement of no less than 86 percent per calendar week according to section 1 of this rule? Yes or No
(Circle One)

If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 2 – Health Plan
Does your organization support the reporting requirements of scheduled downtime according to section 2 (and/or its subsection(s)) of this rule? Yes or No
(Circle One)

1. If yes, share with us your published regular scheduled downtime.
2. If yes, share with us an example of when you published non-routine downtime.
3. If yes, share with us an example of when you provided information pertaining to unscheduled downtime.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 3 – Health Plan
Does your organization support a published holiday schedule according to section 3 of this rule? Yes or No (Circle One)

15

Section 3 – Health Plan
If yes, share with us your published holiday schedule. You may provide the URL.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

16

Health Plan - Phase II
Rule 250 - Claim Status Rule (276/277)
Link to Operating Rule 250 on CAQH Core Website
Section 4.2 – Health Plan
For a real time 276, does your organization return a 5010 999 if the real time 276 is rejected according to section 4.2 (and/or its subsection(s)) of this rule? If
the real time 276 is accepted, do you return a 5010 277 according to section 4.2 (and/or its subsection(s)) of this rule? Note: the 999 is not mandated at this
time. Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 4.3 – Health Plan
For a batch 276, does your organization return a 5010 999 to indicate the batch 276 functional group was accepted according to section 4. (and/or its
subsection(s)) of this rule? If so, is it returned after the initial communications session according to section 4.3 (and/or its subsection(s)) of this rule? Note: the
999 is not mandated at this time. Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 4.4 – Health Plan
For a real time 276, does your organization provide a real time response within 20 seconds according to section 4.4 (and/or its subsection(s)) of this rule? Yes
or No (Circle One)

17

Section 4.4 – Health Plan
If yes, provide a log for one calendar month that demonstrates this.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 4.5 – Health Plan & Clearinghouse
For a batch 276, does your organization provide a batch 5010 277 response by 7:00 AM the following day according to section 4.5 (and/or its subsection(s)) of
this rule? This includes when it is subsequently converted to a real time 276 by a clearinghouse or switch according to section 4.5 of this rule. In addition, does
your organization provide a 5010 999 within one hour of receiving the 276 batch according to section 4.5 (and/or its subsection(s)) of this rule? Note: the 999
is not mandated at this time. Yes or No (Circle One)
If yes, provide a log for one calendar month that demonstrates this.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 4.6 – Health Plan
Does your organization support the system availability and reporting requirements according to section 4.6 (and/or its subsection(s)) of this rule? Yes or No
(Circle One)

1. If yes, share with us your published regular scheduled downtime.
2. If yes, share with us an example of when you published non-routine downtime.
3. If yes, share with us an example of when you provided information pertaining to unscheduled downtime.
4. If yes, share with us your published holiday schedule.
Uploaded to Portal: Yes or No (Circle One)

18

Section 4.6 – Health Plan
Covered Entity Representative Signature:
Date:
Comments:

Section 4.7 – Health Plan
Does your organization publish a 5010 276/277 Companion Guide according to section 4.7 (and/or its subsection(s)) of this rule? Yes or No (Circle One)
If yes, please provide a copy.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

19

Rule 258 – Eligibility and Benefits 270/271 Normalizing Patient Last Name (270/271)
Link to Operating Rule 258 on CAQH Core Website
Section 4.2 – Health Plan
Does your organization normalize the patient last name according to section 4.2 (and/or its subsection(s)) of this rule? Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 4.3 – Health Plan
Does your organization normalize the patient last name according to section 4.3 of this rule? Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

20

Rule 259 – Eligibility and Benefits 270/271 AAA Error Code Reporting (270/271)
Link to Operating Rule 259 on CAQH Core Website
Section 4.1 – Health Plan
Does your organization return a AAA segment for each error condition defined in the Error Reporting Codes & Requirements Table in 4.5? Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 4.3 – Health Plan
Does your organization support the pre-query and error reporting requirements according to section 4.3 (and/or its subsection(s)) of this rule? Yes or No (Circle
One)

If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 4.4 – Health Plan
Does your organization support the post-query and reporting requirements according to section 4.4 of this rule? Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)

21

Section 4.4 – Health Plan
Covered Entity Representative Signature:
Date:
Comments:

Section 4.5 – Health Plan
Does your organization support the error reporting code requirements according to section 4.5 of this rule? Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

22

Rule 260 - Eligibility and Benefits 270/271 Data Content (270/271)
Link to Operating Rule 260 on CAQH Core Website
Section 4.1 – Health Plan
Does your organization support the basic requirements when an individual is located in your system according to section 4.1 (and/or its subsection(s)) of this
rule? This includes the specified service type codes, health benefits coverage, patient financial responsibility, base deductible dates, and benefit specific
deductible dates. Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

23

Health Plan - Phase III
Rule 350 – Infrastructure Rules (EFT/ERA (835))
Link to Operating Rule 350 on CAQH Core Website
Section 4.1 – Health Plan
Does your organization support the Phase II Connectivity Rules, including Safe Harbor, envelope methods, and authentication according to section 4.1 of this
rule? Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 4.3 – Health Plan
Does your organization provide a dual delivery of the 835 and the proprietary remittance advice for at least 3 payment cycles according to section 4.3 of this
rule? Yes or No (Circle One)
If yes, please provide one example of a 5010 835 and the corresponding proprietary remittance advice from the past 12 months.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

24

Section 4.4 – Health Plan
Does your organization publish a 5010 835 Companion Guide according to section 4.4 (and/or its subsection(s)) of this rule? Yes or No (Circle One)
If yes, please provide a copy.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

25

Rule 360 – CARC/RARC Uniform Use (EFT/ERA (835))
Link to Operating Rule 360 on CAQH Core Website
Section 4.1 – Health Plan
Does your organization support the uniform use of CARC/RARC and NCPDP Reject Reason codes that are applicable to the four defined business scenarios
according to section 4.1 (and/or its subsection(s)) of this rule? Yes or No (Circle One)
If yes, please provide a short description in the Comments section below as to how your organization meets this requirement, including the process and
frequency of updates. Also, indicate if your organization’s internal codes are currently aligned with the applicable business scenarios and the CARC, RARC,
CAGC and NCPDP Reject Code combinations.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 4.2 – Health Plan & Clearinghouse
Does your organization have a provider facing product for manual remittance advice processing according to section 4.2 of this rule? If yes, does it display the
CARC/RARC/GACG and Scenario descriptions? Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

26

Rule 370 – EFT/ERA Association (EFT/ERA (835))
Link to Operating Rule 370 on CAQH Core Website
Section 4.1 – Health Plan
Does your organization inform the provider of the minimum CCD+ Data elements for reassociation according to section 4.1 of this rule? Yes or No (Circle One)
If yes, provide the documentation you give to providers when they enroll for EFT.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 4.2 – Health Plan
Does your organization track the elapsed time between 835 and EFT according to section 4.2 (and/or its subsection(s)) of this rule? Yes or No (Circle One)
If yes, provide a short description in the comments section below of the tracking mechanism and statistics used to meet the 90% compliance requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 4.3 – Health Plan
Does your organization have a written procedure for late/missing EFT/ERA according to section 4.3 of this rule? Yes or No (Circle One)
If yes, provide the written procedure for late/missing EFT/ERA.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

27

Rule 380 – EFT Enrollment Data Rule (EFT/ERA (835))
Link to Operating Rule 380 on CAQH Core Website
Section 4.1 – Health Plan
Skip to 4.2

Section 4.2 – Health Plan
Does your organization collect no more EFT enrollment data elements than the maximum defined and provide written instructions according to section 4.2 of
this rule? Yes or No (Circle One)
1. If yes, provide the paper based EFT enrollment form and instructions.
2. If yes, provide the URL for electronic EFT enrollment, or an example of the XML.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 4.3 – Health Plan
1.

Does your organization follow the format and flow of the Manual Paper Based Enrollment template according to section 4.3 (and/or its subsection(s)) of
this rule? Yes or No (Circle One)
2. Does your organization follow the format, flow, and data set when using an electronic EFT enrollment form, and provide instructions for initial enrollment
and changes to electronic payment according to section 4.3 (and/or its subsection(s)) of this rule? Yes or No (Circle One)
1. Information provided in 4.2 can also be used here.
2. Information provided in 4.2 can also be used here.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

28

Rule 382 – ERA Enrollment Data Rule (EFT/ERA (835))
Link to Operating Rule 382 on CAQH Core Website
Section 4.1 – Health Plan
Skip to 4.2

Section 4.2 – Health Plan
Does your organization collect no more ERA enrollment data elements than the maximum defined and provide written instructions according to section 4.2 of
this rule? Yes or No (Circle One)
1. If yes, provide the paper based ERA enrollment form and instructions.
2. If yes, provide the URL for electronic ERA enrollment, or an example of the XML.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Section 4.3 – Health Plan
1.

Does your organization follow the format, flow and data set when using a manual paper based ERA enrollment form, and provide instructions according to
section 4.3 (and/or its subsection(s)) of this rule? Yes or No (Circle One)
2. Does your organization follow the format, flow and data set when using an electronic ERA enrollment form, and provide instructions according to section
4.3 (and/or its subsection(s)) of this rule? Yes or No (Circle One)
1. Information provided in 4.2 can also be used here.
2. Information provided in 4.2 can also be used here.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

29

Provider - Phase I
Rule 153 – Connectivity (270/271)
Link to Operating Rule 153 on CAQH Core Website
Section 6 – Provider
Does your organization support the response time, time out parameters, and retransmission requirements according to section 6 of this rule? Yes or No (Circle
One)

If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Provider – Phase II
Rule 258 – Eligibility and Benefits 270/271 Normalizing Patient Last Name (270/271)
Link to Operating Rule 258 on CAQH Core Website
Section 4.1 – Provider
Does your organization store suffix name separately according to section 4.1 (and/or its subsection(s)) of this rule? Yes or No (Circle One)
If yes, provide an example 270 that contains the suffix in NM107-1039 Name Suffix data element in Loops 2100C/2100D.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

30

Clearinghouse - Phase II
Rule 250 - Claim Status Rule (276/277)
Link to Operating Rule 250 on CAQH Core Website
Section 4.5 – Health Plan & Clearinghouse
For a batch 276, does your organization provide a batch 5010 277 response by 7:00 AM the following day according to section 4.5 (and/or its subsection(s)) of
this rule? This includes when it is subsequently converted to a real time 276 by a clearinghouse or switch according to section 4.5 of this rule. In addition, does
your organization provide a 5010 999 within one hour of receiving the 276 batch according to section 4.5 (and/or its subsection(s)) of this rule? Note: the 999
is not mandated at this time. Yes or No (Circle One)
If yes, provide a log for one calendar month that demonstrates this.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Rule 258 – Eligibility and Benefits 270/271 Normalizing Patient Last Name (270/271)
Link to Operating Rule 258 on CAQH Core Website
Section 4.4 – Clearinghouse
Does your organization support section 4.2 of Phase II CORE 259 AAA Error Codes according to section 4.4 of this rule? Yes or No (Circle One)
If yes, share with us the documentation you have and/or provide us a short description in the comments section below of how your organization supports and
meets this requirement.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

31

Rule 259 – Eligibility and Benefits 270/271 AAA Error Code Reporting (270/271)
Link to Operating Rule 259 on CAQH Core Website
Section 4.2 – Clearinghouse
Does your organization support the error code description requirements according to section 4.2 of this rule? Yes or No (Circle One)
If yes, share with us an example of the text you provide that describes the error conditions.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

Rule 260 - Eligibility and Benefits 270/271 Data Content (270/271)
Link to Operating Rule 260 on CAQH Core Website
Section 4.2 – Clearinghouse
Does your organization support the display requirements according to section 4.2 of this rule? Yes or No (Circle One)
If yes, provide an example where the data is appropriately available to the end user without altering the semantic meaning of the 271 data content.
Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:

32

In accordance with the Paperwork Reduction Act (1995), no persons are required to respond to a collection of information, unless it displays a valid Office of Management and Budget
(OMB) control number. The valid OMB control number for this information collection is 0938-XXXX (Expires XX/XX/XXXX). The time required to complete this information collection
is estimated to average [10 hours] per response (4 forms x 60 minutes/form), including the time to review instructions, search existing data resources, gather the data needed, and
complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to:
Centers for Medicare & Medicaid Services
Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05
7500 Security Boulevard
Baltimore, Maryland 21244-1850
Please do not send applications, claims, payments, medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Any correspondence not
pertaining to the information collection burden approved under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have
questions or concerns regarding where to submit your documents, please contact: Cecily Austin at [email protected] or Kevin Stewart at [email protected] .

33