Federally Mandated

  • Regulatory Adoption

    Two federal regulations mandate compliance with the following CAQH® CORE® Operating Rules, as required under the Patient Protection and Affordable Care Act of 2010:

    • On July 8, 2011 the Department of Health and Human Services published Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transactions Interim Final Rule.  This Rule requires non-retail pharmacy HIPAA-covered entities to conform to the CAQH® CORE® Eligibility & Benefit Rules (at the time, Phase I and II), excluding the Acknowledgment provisions, for the following ASC X12N transactions:
      • X12/005010X279A1 Eligibility Benefit Inquiry and Response (270/271)
      • X12/005010X212 Health Care Claim Status Request and Response (276/277)
    • The regulation also deemed that the operating rules within the NCPDP Telecommunication Standard D.0, the HIPAA-named pharmacy standard, as operating rules for the pharmacy industry.
    • The Interim Final Rule established a compliance date of January 1, 2013, with an enforcement discretionary period ending March 31, 2013. 
    • View the Regulation
    • On August 10, 2012, the Department of Health and Human Services published Administrative Simplification: Adoption of Operating Rules for Health Care Electronic Funds Transfer (EFT) and Remittance Advice Transactions Final Rule.  This Rule requires HIPAA-covered entities to conform to the CAQH® CORE® Payment & Remittance Advice Rules (at the time, Phase III), excluding the Acknowledgment provisions, for the following transactions:
      • X12/005010X221A1 Health Care Claim Payment Advice (835)
      • Automated Clearing House (ACH) CCD+ Electronic Funds Transfer (EFT) transaction.
    • The Final Rule established a compliance date of January 1, 2014. 
    • View the Regulation

    See also https://www.caqh.org/core/operating-rules-mandate

    These Operating Rules were originally issued as Phase I, Phase II, and Phase III rules.  CAQH CORE reorganized their rules by transactions in 2020. Rule content and requirements did not change. For more information, see https://www.caqh.org/core/new-operating-rule-structure.

    All applicable Change Healthcare products and services comply with these regulations.

  • Eligibility & Benefits Operating Rules

    The CAQH® CORE® Eligibility & Benefits Operating Rules pertain to the X12/005010X279A1 Eligibility Benefit Inquiry and Response (270/271) transaction.

    The Eligibility & Benefit Operating Rules are:

    • Eligibility & Benefits (270/271) Infrastructure Rule vEB.1.0
      Requirements for processing mode (real-Time/batch), response time, system availability and downtime notification, logging, and companion guide format and flow.
    • Eligibility & Benefits (270/271) Data Content Rule vEB.1.0
      Requirements for responding to explicit service type inquiries, reporting patient financials (deductibles, co-payment, co-insurance), and plan/benefit related dates, name normalization, and AAA error reporting.
    • Connectivity Rule vC2.2.0
      Technical requirements for support of connectivity Safe Harbor, including XML and WSDL schemas.
      NOTE: This rule has known security vulnerabilities. see Connectivity Rule vC.4.4.0 on the Voluntary Adoption page for details.
  • Claim Status Operating Rules

    The CAQH® CORE® Claim Status Operating Rules pertain to the X12/005010X212 Health Care Claim Status Request and Response (276/277) transaction.

    The Claim Status Operating Rules are:

    • Claim Status (276/277) Infrastructure Rule vCS.1.0
      Requirements for processing mode (real-Time/batch), response time, system availability and downtime notification, logging, and companion guide format and flow.
    • Connectivity Rule vC2.2.0
      Technical requirements for support of connectivity Safe Harbor, including XML and WSDL schemas. 
      NOTE: This rule has known security vulnerabilities; see Connectivity Rule vC.4.4.0 on the Voluntary Adoption page for details.
  • Payment & Remittance Operating Rules

    The CAQH® CORE® Payment and Remittance Operating Rules pertain to:

    • The X12/005010X221A1 Health Care Claim Payment Advice (835) transaction
    • The Automated Clearing House (ACH) CCD+ Electronic Funds Transfer (EFT) transaction.

    The Payment and Remittance Operating Rules are:

    • Payment & Remittance (835) Infrastructure Rule vPR.1.0
      Requirements for processing mode (real-Time/batch), response time, system availability and downtime notification, logging, and companion guide format and flow.
    • Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule vPR.1.0
      Required usage combinations of Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) in the 835 by business scenario; requirements to display code descriptions in remittance product user interfaces.  Code combinations are updated three times per year.
    • Payment & Remittance (CCD+/835) Reassociation Rule vPR.1.0
      Required data to be carried in both the CCD+ and 835 for purposes of reassociating an EFT payment with the electronic remittance advice (835); maximum timeframe between issuance of the CCD+ and ERA, and requirements for communicating problem resolution procedures.
    • Payment & Remittance EFT Enrollment Data Rule vPR.1.0
      Requirements for provision of online EFT enrollment; prescribed format and flow of online and paper-based enrollment forms and related instructional materials. EFT Enrollment Data Sets are assessed yearly for necessary updates.
    • Payment & Remittance ERA Enrollment Data Rule vPR.1.0
      Requirements for provision of online ERA (835) enrollment; prescribed format and flow of online and paper-based enrollment forms and related instructional materials. ERA Enrollment Data Sets are assessed yearly for necessary updates.
    • Connectivity Rule vC2.2.0
      Technical requirements for support of connectivity Safe Harbor, including XML and WSDL schemas. NOTE: This rule has known security vulnerabilities.
      NOTE This rule has known security vulnerabilities; see Connectivity Rule vC.4.4.0 on the Voluntary Adoption page for details.
  • Voluntary Certification

    CAQH® CORE® offers a voluntary certification program which serves to demonstrate an entity’s conformance to all of its Operating Rules.

    Change Healthcare has achieved voluntary certification for the Eligibility & Benefits Operating Rules, the Claim Status Operating Rules (Phase I and II, at the time of certification), and the Payment & Remittance Operating Rules (Phase III at the time of certification).

    See Change Healthcare Accreditations & Certifications for additional information.

X12 manages the exclusive copyright to all X12 standards, publications, and products; see https://x12.org/products/ip-use for details. The X12 TR3 that details the full requirements for this transaction can be licensed at https://x12.org/licensing

CORE®, the CORE-certification/Endorser Seals and logo are registered trademarks of CAQH®, copyright 2021, Council for Affordable Quality Healthcare®.