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CAQH-CORE Operating Rules

CAQH - Council for Affordable Quality Healthcare
CAQH is a non profit alliance of health plans and trade associations collaborating on initiatives that simplify healthcare administration for health plans and providers.  This results in a better care experience for patients and caregivers.
CORE – Committee on Operating Rules for Information Exchange
CORE has more than 140 stakeholders that include health plans, providers, vendors, CMS and others.  Together they continuously work on operating rules that build on existing standards.

Payers are mandated by legislation to follow the operating rules.  Operating rules support standards and specify the business actions each party must adhere to in order to ensure a high volume of reliable transactions occur smoothly.  This reduces the amount of time and resources providers spend on administrative functions.

Software vendors and clearinghouses are not mandated to follow the operating rules but, this creates a good business practice.

ACA Mandated Operating Rules Compliance Dates

ACA Mandated Operating Rules Compliance Dates

January 1, 2013 Mandated Requirements
  • Eligibility for health plan — 270/271 transaction
  • Claim status transactions — 276/277 transaction
January 1, 2014 Mandated Requirements
  • Electronic funds transfer — EFT
  • Health care payment and remittance advice — 835 transaction
January 1, 2016 Mandated Requirements
  • Health claims or equivalent encounter information — 837I, 837P, 837D
  • Health care Enrollments and Maintenance — 834
  • Health plan premium payments — 820
  • Referral certification and authorization — 278
  • Health claims attachments — HL7

The final rules for the 2016 Mandated Requirements have not been finalized and published. Payers are unable to comply with the Operating Rules until they are published.

EDI 101

  • Acknowledgements Manual
  • Code lists (offsite link)
  • EDI Transactions by Payer
  • What is HIPAA?

    The Health Insurance Portability and Accountability Act of 1996. The Administrative Simplification provisions of HIPAA are intended to reduce the costs and administrative burdens of health care by making possible the standardized, electronic transmission of many transactions that are carried out manually on paper or have several different formats for each.

    There are several transactions that have been standardized as a result of HIPAA. Trading Partners are encouraged to contact their vendors about the possible use of these transactions.

    Note: Effective Monday, October 24, 2016 all Trading Partner Agreements and accompanying Business Associate Riders, entered into between Administrative Services of Kansas, Inc. and a trading partner between the dates of July 1, 2002 and June 30, 2004 are no longer in effect.

  • Implementation Guides (offsite link)
  • Life of a claim

    Life of a Claim

    Providers submitting claims to a clearinghouse may or may not be sent to the payer the same day. Clearinghouses may impose separate editing prior to submitting your claims to the payer. In this diagram the Trading Partner represents the entity responsible for submitting your claims.

    1. Claim Sent by Trading Partner
    2. Claims received by EDI System and stored in mailbox directory
    3. Transaction identified 837I, 837P, 837D
    4. Claim level editing performed
    5. Acknowledgement sent to TP mailbox
      • Rejected claims will need to be corrected and resubmitted
    6. Accepted claims sent to payer

    Once a file has been submitted by a Trading Partner the Life of a Claim process can not be interrupted.

  • The administration simplification provisions of HIPAA require the Secretary of Health and Human Services (HHS) to adopt a national standard identifier for covered health care providers. The National Provider Identifier (NPI) will be the standard identifier and CMS is developing the National Plan and Provider Enumeration System (NPPES) to identify providers and assign NPIs.

    The NPI is ten-digit number and is used to submit claim transactions to all government and non-government payers. NPI replaced existing provider numbers assigned by these entities and CMS will discontinue the UPIN enumeration process.

    Providers who are required to obtain an NPI include:

    • physicians
    • non-physician healthcare practitioners
    • other suppliers and certified providers such as institutions
    • home health agencies
    • skilled nursing facilities

    Each individual practitioner will receive one NPI. However, an organization provider may obtain an NPI for each of its subparts.

    A subpart can be considered:

    • a separate physical location of an organization health care provider
    • member of a chain
    • an organization health care provider separately licensed or certified

    For additional informational and to complete an application, visit on the Web.

  • ASK provides products and services for customers in Kansas, Northwestern Missouri, Western New York, and Northeastern New York.

    These products are designed to help Trading Partners increase the number of transactions they send electronically.

    • EDI Midwest– Learn how to send claims to over 900 additional payers.
    • ABILITY | PC-ACE® – Learn more about free claims filing software available from ASK.

User Documentation

  • Helpful Information for Providers/Vendors testing HIPAA 5010 formats:

    • It is suggested a minimum of 25, but no more than 50 claims/requests be submitted for each line of business you wish to test.
    • Test files are submitted via SFTP
    • The ISA15 should equal "T"
    • The trading partner is responsible for downloading and reviewing the acknowledgements, which are available within 1 hour after transmission. Please refer to the Acknowledgements Manual for further information. Contact the EDI Help Desk with any questions regarding testing or acknowledgments, 1-800-472-6481, opt. 1.
    • The trading partner may request production status once a test file passes with 10% or fewer errors.

    Helpful information for Vendors:

    • It is important that software vendors review the Companion Guides before sending test files. (Providers will also benefit from reviewing these documents)
    • If you wish to test as a vendor, it will work best if you are able to test with an active NPI.
    • Implementation guides (TR3’s) are maintained by Washington Publishing Company. To obtain a copy of the ANSI ASC X12N implementation guides, please visit their Web site.

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