The CAQH® CORE® Operating Rules described on this page have been finalized and approved by CAQH® CORE® and its participating members for voluntary adoption and certification. They are not mandated by federal law.
For more information on CAQH® CORE® voluntary certification, see https://www.caqh.org/core/core-certification-process.
Change Healthcare has obtained CAQH® CORE® voluntary certification for the Eligibility & Benefit, Claim Status, and Payment & Remittance Operating Rules. See Change Healthcare Accreditations & Certifications for additional information.
The table below shows all voluntary operating rules.
|Operating Rules||X12 TR3||Rules Define|
|Health Care Claims||X12/005010X222A2 (837P)|
|Infrastructure, connectivity, response time, companion guide, acknowledgments.|
|Prior Authorization & Referrals||X12/005010X217 (278)||Data content, proprietary web portal standardization, final determination timeframe, infrastructure, connectivity, response time, companion guide, acknowledgments.|
|Benefit Enrollment||X12/005010X220A1 (834)||Infrastructure, connectivity, response time, companion guide, acknowledgments.|
|Premium Payment||X12/005010X218 (820)||Infrastructure, connectivity, response time, companion guide, acknowledgments.|
|Patient Attribution (Value-Based Payment)||X12/005010X279A1 (270/271)|
|Single Patient Attribution requirements for the Health Care Eligibility Benefits Inquiry and Response (270/271)|
Attributed Patient Roster requirements for Member Reporting (834): data content, infrastructure, connectivity, response time, companion guide, acknowledgments.
|Connectivity Rule v4.4.0||n/a||An update to prior connectivity rules. Not yet rolled to earlier operating rule sets; see www.caqh.core for additional information.|
No federal regulation has been issued adopting the operating rules described on this page; however, the National Committee on Vital and Health Statistics (NCVHS) conducted hearings on prospective adoption in 2016 and again in 2020. After these hearings, the NCVHS recommended against federal mandate of these rules, but encouraged the industry to pursue voluntary adoption.
NCVHS letters of recommendation are available here:
- Recommendations for the Proposed Phase IV Operating Rules; July 6, 2017
- Recommendations for Proposed Operating Rules for Prior Authorization and Connectivity for HIPAA Transactions; November 23, 2020
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®.
- Benefit Enrollment
- Claim Status
- Claims / Encounters
- Eligibility / Benefits
- ERA / EFT
- Payroll Deducted and Other Group Premium Payment
- Referral / Priority Authorization