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Expiration 02/29/2024
Operating Rule Response/Attestation Document
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Table of Contents
Introduction and Purpose ............................................................................................................................................................................................. 3
Introduction ............................................................................................................................................................................................................... 3
Purpose ...................................................................................................................................................................................................................... 3
Instructions .................................................................................................................................................................................................................... 3
All Entities Phase I ..................................................................................................................................................................................................... 5
All Entities Phase I, Rule 153 – Eligibility and Benefits Connectivity Rule (270/271) ............................................................................................ 5
All Entities Phase II .................................................................................................................................................................................................... 7
All Entities Phase II, Rule 250 - Claim Status Rule (276/277) ................................................................................................................................. 7
All Entities Phase II, Rule 270 - Connectivity Rule (270/271 or 276/277) .............................................................................................................. 7
All Entities Phase III ................................................................................................................................................................................................. 10
All Entities Phase III, Rule 350 – Health Care Claim Payment/Advice (835) Infrastructure Rule (EFT/ERA (835)) .............................................. 10
Health Plan – Phase I ............................................................................................................................................................................................... 11
Health Plan Phase I, Rule 152 – Eligibility and Benefit Real-time Companion Guide Rule (270/271) ................................................................. 11
Health Plan Phase I, Rule 153 – Eligibility and Benefits Connectivity Rule (270/271) ......................................................................................... 11
Health Plan Phase I, Rule 154 – Eligibility and Benefits 270/271 Data Content Rule (270/271) ......................................................................... 12
Health Plan Phase I, Rule 155 – Eligibility and Benefits Batch Response Time Rule (270/271) .......................................................................... 13
Health Plan Phase I, Rule 156 – Eligibility and Benefits and Real-time Response Time Rule (270/271) ............................................................. 14
Health Plan Phase I, Rule 157 – Eligibility and Benefits System Availability Rule (270/271)............................................................................... 14
Health Plan - Phase II .............................................................................................................................................................................................. 16
Health Plan Phase II, Rule 250 - Claim Status Rule (276/277) ............................................................................................................................. 16
Health Plan Phase II, Rule 258 – Eligibility and Benefits 270/271 Normalizing Patient Last Name Rule (270/271)............................................ 19
Health Plan Phase II, Rule 259 – Eligibility and Benefits 270/271 AAA Error Code Reporting Rule (270/271) ................................................... 20
Health Plan Phase II, Rule 260 - Eligibility & Benefits Data Content Rule (270/271)........................................................................................... 22
1
Health Plan - Phase III ............................................................................................................................................................................................. 23
Health Plan Phase III, Rule 350 – Health Care Claim Payment/Advice (835) Infrastructure Rule (EFT/ERA (835)) ............................................. 23
Health Plan Phase III, Rule 360 – Uniform Use of Claim Adjustment Reason Codes and Remittance Advice Remark Codes (835) Rule ........... 24
Health Plan Phase III, Rule 370 – EFT & ERA Reassociation (CCD+/835) Rule (EFT/ERA (835)) ........................................................................... 25
Health Plan Phase III, Rule 380 – EFT Enrollment Data Rule (EFT/ERA (835)) ..................................................................................................... 26
Health Plan Phase III, Rule 382 – ERA Enrollment Data Rule (EFT/ERA 835)) ...................................................................................................... 27
Provider - Phase I..................................................................................................................................................................................................... 29
Provider Phase I, Rule 153 – Eligibility and Benefits Connectivity (270/271) ...................................................................................................... 29
Provider – Phase II ................................................................................................................................................................................................... 30
Provider Phase II, Rule 259– Eligibility and Benefits 270/271 AAA Error Code Reporting Rule (270/271) ......................................................... 30
Provider – Phase III.................................................................................................................................................................................................. 31
Provider Phase III, Rule 360 – Uniform Use of Claim Adjustment Reason Codes and Remittance Advice Remark Codes (835) Rule ................ 31
Clearinghouse - Phase II .......................................................................................................................................................................................... 32
Clearinghouse Phase II, Rule 250 - Claim Status Rule (276/277) ......................................................................................................................... 32
Clearinghouse Phase II, Rule 258 – Eligibility and Benefits 270/271 Normalizing Patient Last Name Rule (270/271) ....................................... 32
Clearinghouse Phase II, Rule 259– Eligibility and Benefits 270/271 AAA Error Code Reporting Rule (270/271) ................................................ 33
Clearinghouse Phase II, Rule 260 - Eligibility & Benefits Data Content Rule (270/271) ...................................................................................... 33
Clearinghouse - Phase III ......................................................................................................................................................................................... 34
Clearinghouse Phase III, Rule 360 – Uniform Use of Claim Adjustment Reason Codes and Remittance Advice Remark Codes (835) Rule....... 34
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 compliance review 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.
1.
2.
1
2
Instructions
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,” “No” or “NA.” In addition, select a "Yes," "No" or “NA” response to attest that the
Covered Entity has uploaded documentation to the portal, when applicable.
• A "Yes" response indicates you are compliant with the operating rule.
• A "No" response indicates you are not compliant with the operating rule.
CAQH CORE Website: Operating Rules section of CAQH Core Website
CAQH CORE Website: Operating Rules Mandate section of CAQH Core Website
3
A "NA" response indicates the operating rule does not apply to your organization. If “NA,” you must provide an explanation in the comments
section as to why it is not applicable to your organization.
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.
•
3.
4.
4
All Entities Phase I
1.
Question Set 1
All Entities Phase I, Rule 153 – Eligibility and Benefits Connectivity Rule (270/271)
Link to Operating Rule 153 on CAQH CORE Website
Section 1
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, No, or NA (Circle One, If NA, please explain)
2. 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:
Question Set 2
All Entities Phase I, Rule 153 – Eligibility and Benefits Connectivity Rule (270/271)
Link to Operating Rule 153 on CAQH CORE Website
Section 2
Does your organization support a real-time single inquiry or submission according to section 2 of this rule? Yes, No, or NA (Circle One, If NA, please
explain)
2. 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, No, or NA (Circle One, If NA, please explain)
3. 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:
1.
5
Question Set 3
All Entities Phase I, Rule 153 – Eligibility and Benefits Connectivity Rule (270/271)
Link to Operating Rule 153 on CAQH CORE Website
Section 3
Does your organization support a batch request submission according to section 3 (and/or its subsection(s)) of this rule? Yes, No, or NA (Circle One, If
NA, please explain)
2. 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? Yes, No, or NA (Circle One, If NA, please explain)
3. 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, No, or NA (Circle One, If NA, please explain)
4. 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:
1.
1.
Question Set 4
All Entities Phase I, Rule 153 – Eligibility and Benefits Connectivity Rule (270/271)
Link to Operating Rule 153 on CAQH CORE Website
Section 5
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, No, or NA (Circle One, If NA, please explain)
2. 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
All Entities Phase II
Question Set 5
All Entities Phase II, Rule 250 - Claim Status Rule (276/277)
Link to Operating Rule 250 on CAQH CORE Website
Section 4.1
Does your organization support the claim status connectivity requirements according to section 4.1 of this rule? Yes, No, or NA (Circle One, If NA,
please explain)
2. 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:
1.
1.
Question Set 6
All Entities Phase II, Rule 270 - Connectivity Rule (270/271 or 276/277)
Link to Operating Rule 270 on CAQH CORE Website
Section 4.1
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, No, or NA (Circle One, If NA, please explain)
2. For health plans and clearinghouses, have you implemented both envelope standards (SOAP+WSDL and HTTP MIME Multipart)? Yes, No, or NA (Circle
One, If NA, please explain)
3. For providers, have you implemented one of the envelope standards mentioned above? Yes, No, or NA (Circle One, If NA, please explain)
4. 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
Question Set 7
All Entities Phase II, Rule 270 - Connectivity Rule (270/271 or 276/277)
Link to Operating Rule 270 on CAQH CORE Website
Section 4.2
Does your organization support the Envelope Specification requirements according to section 4.2 (and/or its subsection(s)) of this rule? Yes, No, or NA
(Circle One, If NA, please explain)
2. 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:
1.
Question Set 8
All Entities Phase II, Rule 270 – Connectivity Rule (270/271 or 276/277)
Link to Operating Rule 270 on CAQH CORE Website
Section 4.3
Does your organization support the general specification requirements according to section 4.3 (and/or its subsection(s)) of this rule? Yes, No, or NA
(Circle One, If NA, please explain)
2. 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:
1.
8
Question Set 9
All Entities Phase II, Rule 270 – Connectivity Rule (270/271 or 276/277)
Link to Operating Rule 270 on CAQH CORE Website
Section 4.4
Does your organization support the Envelope requirements according to section 4.4 (and/or its subsection(s)) of this rule? Yes, No, or NA (Circle One, If
NA, please explain)
2. 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:
1.
9
All Entities Phase III
1.
Question Set 10
All Entities Phase III, Rule 350 – Health Care Claim Payment/Advice (835) Infrastructure Rule (EFT/ERA (835))
Link to Operating Rule 350 on CAQH CORE Website
Section 4.2
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, No, or NA (Circle One, If NA, please explain)
2. 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, No, or NA (Circle One, If NA, please explain)
3. 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:
10
Health Plan – Phase I
Question Set 11
Health Plan Phase I, Rule 152 – Eligibility and Benefit Real-time Companion Guide Rule (270/271)
Link to Operating Rule 152 on CAQH CORE Website
1. Does your organization publish a 5010 270/271 Companion Guide according to rule 152? Yes, No, or NA (Circle One, If NA, please explain)
2. If yes, please provide a copy. Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:
1.
Question Set 12
Health Plan Phase I, Rule 153 – Eligibility and Benefits Connectivity Rule (270/271)
Link to Operating Rule 153 on CAQH CORE Website
Section 4
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, No, or NA (Circle One, If NA, please explain)
2. 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:
11
1.
Question Set 13
Health Plan Phase I, Rule 153 – Eligibility and Benefits Connectivity Rule (270/271)
Link to Operating Rule 153 on CAQH CORE Website
Section 7
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, No, or NA (Circle One, If NA, please explain)
2. 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:
1.
Question Set 14
Health Plan Phase I, Rule 154 – Eligibility and Benefits 270/271 Data Content Rule (270/271)
Link to Operating Rule 154 on CAQH CORE Website
Section 1
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, No, or NA (Circle One, If NA, please explain)
2. 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
1.
Question Set 15
Health Plan Phase I, Rule 155 – Eligibility and Benefits Batch Response Time Rule (270/271)
Link to Operating Rule 155 on CAQH CORE Website
Section 1
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, No, or NA (Circle One, If NA, please explain)
2. If yes, provide a log for one calendar day that demonstrates this. Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:
1.
Question Set 16
Health Plan Phase I, Rule 155 – Eligibility and Benefits Batch Response Time Rule (270/271)
Link to Operating Rule 155 on CAQH CORE Website
Section 2
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, No, or NA (Circle One, If NA, please explain)
2. If yes, provide a log for one calendar day that demonstrates this. Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:
13
Question Set 17
Health Plan Phase I, Rule 156 – Eligibility and Benefits and Real-time Response Time Rule (270/271)
Link to Operating Rule 156 on CAQH CORE Website
Section 1
Does your organization support the 270 real-time response time requirement of 20 seconds or less according to section 1 of this rule? Yes, No, or NA
(Circle One, If NA, please explain)
2. If yes, provide a log for one calendar day that demonstrates this. Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:
1.
1.
Question Set 18
Health Plan Phase I, Rule 157 – Eligibility and Benefits System Availability Rule (270/271)
Link to Operating Rule 157 on CAQH CORE Website
Section 1
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, No, or NA (Circle One, If NA, please explain)
2. 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:
14
Question Set 19
Health Plan Phase I, Rule 157 – Eligibility and Benefits System Availability Rule (270/271)
Link to Operating Rule 157 on CAQH CORE Website
Section 2
Does your organization support the reporting requirements of downtime according to section 2 (and/or its subsection(s)) of this rule? Yes, No, or NA
(Circle One, If NA, please explain)
2. If yes, share with us your published regular scheduled downtime. Uploaded to Portal: Yes or No (Circle One)
3. If yes, share with us an example of when you published non-routine downtime. Uploaded to Portal: Yes or No (Circle One)
4. 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:
1.
Question Set 20
Health Plan Phase I, Rule 157 – Eligibility and Benefits System Availability Rule (270/271)
Link to Operating Rule 157 on CAQH CORE Website
Section 3
1. Does your organization support a published holiday schedule according to section 3 of this rule? Yes, No, or NA (Circle One, If NA, please explain)
2. 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:
15
Health Plan - Phase II
1.
Question Set 21
Health Plan Phase II, Rule 250 - Claim Status Rule (276/277)
Link to Operating Rule 250 on CAQH CORE Website
Section 4.2
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? Yes, No, or NA (Circle One, If NA, please explain)
2. 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, No, or NA (Circle One, If NA, please explain)
3. 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:
1.
Question Set 22
Health Plan Phase II, Rule 250 - Claim Status Rule (276/277)
Link to Operating Rule 250 on CAQH CORE Website
Section 4.3
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? Yes, No, or NA (Circle One, If NA, please explain)
2. 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, No, or NA (Circle One, If NA, please explain)
3. 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:
16
1.
Question Set 23
Health Plan Phase II, Rule 250 - Claim Status Rule (276/277)
Link to Operating Rule 250 on CAQH CORE Website
Section 4.4
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, No, or NA (Circle One, If NA, please explain)
2. If yes, provide a log for one calendar day that demonstrates this. Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:
1.
Question Set 24
Health Plan Phase II, Rule 250 - Claim Status Rule (276/277)
Link to Operating Rule 250 on CAQH CORE Website
Section 4.5
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. Yes, No, or NA (Circle One, If NA, please explain)
2. 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, No, or NA (Circle One, If NA, please explain)
3. If yes, provide a log for one calendar day that demonstrates this. Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:
17
Question Set 25
Health Plan Phase II, Rule 250 - Claim Status Rule (276/277)
Link to Operating Rule 250 on CAQH CORE Website
Section 4.6
Does your organization support the system availability and reporting requirements according to section 4.6 (and/or its subsection(s)) of this rule? Yes,
No, or NA (Circle One, If NA, please explain)
2. If yes, share with us your published regular scheduled downtime. Uploaded to Portal: Yes or No (Circle One)
3. If yes, share with us an example of when you published non-routine downtime. Uploaded to Portal: Yes or No (Circle One)
4. If yes, share with us an example of when you provided information pertaining to unscheduled downtime. Uploaded to Portal: Yes or No (Circle One)
5. If yes, share with us your published holiday schedule. Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:
1.
Question Set 26
Health Plan Phase II, Rule 250 - Claim Status Rule (276/277)
Link to Operating Rule 250 on CAQH CORE Website
Section 4.7
Does your organization publish a 5010 276/277 Companion Guide according to section 4.7 (and/or its subsection(s)) of this rule? Yes, No, or NA (Circle
One, If NA, please explain)
2. If yes, please provide a copy. Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:
1.
18
Question Set 27
Health Plan Phase II, Rule 258 – Eligibility and Benefits 270/271 Normalizing Patient Last Name Rule (270/271)
Link to Operating Rule 258 on CAQH CORE Website
Section 4.2
Does your organization normalize the patient last name according to section 4.2 (and/or its subsection(s)) of this rule? Yes, No, or NA (Circle One, If NA,
please explain)
2. 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:
1.
Question Set 28
Health Plan Phase II, Rule 258 – Eligibility and Benefits 270/271 Normalizing Patient Last Name Rule (270/271)
Link to Operating Rule 258 on CAQH CORE Website
Section 4.3
Does your organization normalize the patient last name according to section 4.3 of this rule? Yes, No, or NA (Circle One, If NA, please explain)
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:
1.
2.
19
Question Set 29
Health Plan Phase II, Rule 259 – Eligibility and Benefits 270/271 AAA Error Code Reporting Rule (270/271)
Link to Operating Rule 259 on CAQH CORE Website
Section 4.1
Does your organization return a AAA segment for each error condition defined in the Error Reporting Codes & Requirements Table in 4.5? Yes, No, or
NA (Circle One, If NA, please explain)
2. 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:
1.
1.
Question Set 30
Health Plan Phase II, Rule 259 – Eligibility and Benefits 270/271 AAA Error Code Reporting Rule (270/271)
Link to Operating Rule 259 on CAQH CORE Website
Section 4.3
If your organization performs a pre-query evaluation, does your organization support the error reporting requirements according to section 4.3 of this
rule? Yes, No, or NA (Circle One, If NA, please explain)
2. 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
Question Set 31
Health Plan Phase II, Rule 259 – Eligibility and Benefits 270/271 AAA Error Code Reporting Rule (270/271)
Link to Operating Rule 259 on CAQH CORE Website
Section 4.4
Does your organization support the post-query and reporting requirements according to section 4.4 of this rule? Yes, No, or NA (Circle One, If NA,
please explain)
2. 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:
1.
Question Set 32
Health Plan Phase II, Rule 259 – Eligibility and Benefits 270/271 AAA Error Code Reporting Rule (270/271)
Link to Operating Rule 259 on CAQH CORE Website
Section 4.5
Does your organization support the error reporting code requirements according to section 4.5 of this rule? Yes, No, or NA (Circle One, If NA, please
explain)
2. 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:
1.
21
1.
Question Set 33
Health Plan Phase II, Rule 260 - Eligibility & Benefits Data Content Rule (270/271)
Link to Operating Rule 260 on CAQH CORE Website
Section 4.1
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, No, or NA (Circle One, If NA, please explain)
2. 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
Health Plan - Phase III
1.
Question Set 34
Health Plan Phase III, Rule 350 – Health Care Claim Payment/Advice (835) Infrastructure Rule (EFT/ERA (835))
Link to Operating Rule 350 on CAQH CORE Website
Section 4.1
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, No, or NA (Circle One, If NA, please explain)
2. 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:
1.
Question Set 35
Health Plan Phase III, Rule 350 – Health Care Claim Payment/Advice (835) Infrastructure Rule (EFT/ERA (835))
Link to Operating Rule 350 on CAQH CORE Website
Section 4.3
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, No, or NA (Circle One, If NA, please explain)
2. 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:
23
Question Set 36
Health Plan Phase III, Rule 350 – Health Care Claim Payment/Advice (835) Infrastructure Rule (EFT/ERA (835))
Link to Operating Rule 350 on CAQH CORE Website
Section 4.4
Does your organization publish a 5010 835 Companion Guide according to section 4.4 (and/or its subsection(s)) of this rule? Yes, No, or NA (Circle One,
If NA, please explain)
2. If yes, please provide a copy. Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:
1.
1.
Question Set 37
Health Plan Phase III, Rule 360 – Uniform Use of Claim Adjustment Reason Codes and Remittance Advice Remark Codes (835) Rule
Link to Operating Rule 360 on CAQH CORE Website
Section 4.1
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, No, or NA (Circle One, If NA, please explain)
2. 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:
24
Question Set 38
Health Plan Phase III, Rule 370 – EFT & ERA Reassociation (CCD+/835) Rule (EFT/ERA (835))
Link to Operating Rule 370 on CAQH CORE Website
Section 4.1
Does your organization inform the provider of the minimum CCD+ Data elements for re-association according to section 4.1 of this rule? Yes, No, or NA
(Circle One, If NA, please explain)
2. 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:
1.
Question Set 39
Health Plan Phase III, Rule 370 – EFT & ERA Reassociation (CCD+/835) Rule (EFT/ERA (835))
Link to Operating Rule 370 on CAQH CORE Website
Section 4.2
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, No, or NA
(Circle One, If NA, please explain)
2. 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:
1.
25
Question Set 40
Health Plan Phase III, Rule 370 – EFT & ERA Reassociation (CCD+/835) Rule (EFT/ERA (835))
Link to Operating Rule 370 on CAQH CORE Website
Section 4.3
Does your organization have a written procedure for late/missing EFT/ERA according to section 4.3 of this rule? Yes, No, or NA (Circle One, If NA,
please explain)
2. 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:
1.
1.
Question Set 41
Health Plan Phase III, Rule 380 – EFT Enrollment Data Rule (EFT/ERA (835))
Link to Operating Rule 380 on CAQH CORE Website
Section 4.2
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, No, or NA (Circle One, If NA, please explain)
2. 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
Question Set 42
Health Plan Phase III, Rule 380 – EFT Enrollment Data Rule (EFT/ERA (835))
Link to Operating Rule 380 on CAQH CORE Website
Section 4.3
Does your organization provide a manual paper-based EFT enrollment method as referenced in Section 4.3 of this rule? Yes, No, or NA (Circle One, If
NA, please explain)
2. If yes, does your organization follow the format, flow, and data set, as well as all other requirements for manual paper-based enrollment according to
Section 4.3 of this rule? Yes, No, or NA (Circle One, If NA, please explain)
3. Does your organization provide an electronic EFT enrollment method as referenced in Section 4.3 of this rule? Yes, No, or NA (Circle One, If NA, please
explain)
4. If yes, does your organization follow the requirements according to Section 4.3 of this rule? Yes, No, or NA (Circle One, If NA, please explain)
5. Provide the paper-based EFT enrollment form and instructions, if applicable to your organization. Uploaded to Portal: Yes or No (Circle One)
6. 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:
1.
1.
Question Set 43
Health Plan Phase III, Rule 382 – ERA Enrollment Data Rule (EFT/ERA 835))
Link to Operating Rule 382 on CAQH CORE Website
Section 4.2
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, No, or NA (Circle One, If NA, please explain)
2. 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:
27
Question Set 44
Health Plan Phase III, Rule 382 – ERA Enrollment Data Rule (EFT/ERA 835))
Link to Operating Rule 382 on CAQH CORE Website
Section 4.3
Does your organization provide a manual paper-based ERA enrollment method as referenced in Section 4.3 of this rule? Yes, No, or NA (Circle One, If
NA, please explain)
2. If yes, does your organization follow the format, flow, and data set, as well as all other requirements for manual paper-based enrollment according to
Section 4.3 of this rule? Yes, No, or NA (Circle One, If NA, please explain)
3. Does your organization provide an electronic ERA enrollment method as referenced in Section 4.3 of this rule? Yes, No, or NA (Circle One, If NA, please
explain)
4. If yes, does your organization follow the electronic enrollment requirements according to Section 4.3 of this rule? Yes, No, or NA (Circle One, If NA,
please explain)
5. Provide the paper-based ERA enrollment form and instructions, if applicable to your organization. Uploaded to Portal: Yes or No (Circle One)
6. 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:
1.
28
Provider - Phase I
Question Set 45
Provider Phase I, Rule 153 – Eligibility and Benefits Connectivity (270/271)
Link to Operating Rule 153 on CAQH CORE Website
Section 6
Does your organization support the response time, time out parameters, and retransmission requirements according to section 6 of this rule? Yes, No,
or NA (Circle One, If NA, please explain)
2. 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:
1.
29
Provider – Phase II
Question Set 46
Provider Phase II, Rule 259– Eligibility and Benefits 270/271 AAA Error Code Reporting Rule (270/271)
Link to Operating Rule 259 on CAQH CORE Website
Section 4.2
Does your organization support the error condition requirements according to section 4.2 of this rule? Yes, No, or NA (Circle One, If NA, please explain)
If yes, does your organization display to the end user the text that uniquely describes the specific error conditions and data elements returned by the
health plan and ensures the actual wording of the displayed text accurately represents the AAA03 error code and corresponding "Error Condition
Description" as specified in the rule?" Yes, No, or NA (Circle One, If NA, please explain)
3. 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:
1.
2.
30
Provider – Phase III
Question Set 47
Provider Phase III, Rule 360 – Uniform Use of Claim Adjustment Reason Codes and Remittance Advice Remark Codes (835) Rule
Link to Operating Rule 360 on CAQH CORE Website
Section 4.2
Does your organization have a provider facing product for manual remittance advice processing according to section 4.2 of this rule? Yes, No, or NA
(Circle One, If NA, please explain)
2. If yes, does it display the CARC/RARC/GACG and Scenario descriptions? Yes, No, or NA (Circle One, If NA, please explain)
3. 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:
1.
31
Clearinghouse - Phase II
1.
Question Set 48
Clearinghouse Phase II, Rule 250 - Claim Status Rule (276/277)
Link to Operating Rule 250 on CAQH CORE Website
Section 4.5
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. Yes, No, or NA (Circle One, If NA, please explain)
2. 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, No, or NA (Circle One, If NA, please explain)
3. If yes, provide a log for one calendar day that demonstrates this. Uploaded to Portal: Yes or No (Circle One)
Covered Entity Representative Signature:
Date:
Comments:
Question Set 49
Clearinghouse Phase II, Rule 258 – Eligibility and Benefits 270/271 Normalizing Patient Last Name Rule (270/271)
Link to Operating Rule 258 on CAQH CORE Website
Section 4.4
Does your organization support section 4.2 of Phase II CORE 259 AAA Error Codes according to section 4.4 of this rule? Yes, No, or NA (Circle One, If NA,
please explain)
2. 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:
1.
32
Question Set 50
Clearinghouse Phase II, Rule 259– Eligibility and Benefits 270/271 AAA Error Code Reporting Rule (270/271)
Link to Operating Rule 259 on CAQH CORE Website
Section 4.2
Does your organization support the error condition requirements according to section 4.2 of this rule? Yes, No, or NA (Circle One, If NA, please explain)
If yes, does your organization display to the end user the text that uniquely describes the specific error conditions and data elements returned by the
health plan and ensures the actual wording of the displayed text accurately represents the AAA03 error code and corresponding "Error Condition
Description" as specified in the rule?" Yes, No, or NA (Circle One, If NA, please explain)
3. 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:
1.
2.
Question Set 51
Clearinghouse Phase II, Rule 260 - Eligibility & Benefits Data Content Rule (270/271)
Link to Operating Rule 260 on CAQH CORE Website
Section 4.2
Does your organization support the display requirements according to section 4.2 of this rule? Yes, No, or NA (Circle One, If NA, please explain)
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:
1.
2.
33
Clearinghouse - Phase III
Question Set 52
Clearinghouse Phase III, Rule 360 – Uniform Use of Claim Adjustment Reason Codes and Remittance Advice Remark Codes (835) Rule
Link to Operating Rule 360 on CAQH CORE Website
Section 4.2
Does your organization have a provider facing product for manual remittance advice processing according to section 4.2 of this rule? Yes, No, or NA
(Circle One, If NA, please explain)
2. If yes, does it display the CARC/RARC/GACG and Scenario descriptions? Yes, No, or NA (Circle One, If NA, please explain)
3. 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:
1.
34
| File Type | application/pdf |
| File Modified | 2023-11-03 |
| File Created | 2023-11-03 |