Operating Rules to Support Eligibility and Claim Status Transactions (Phase II)

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Type Standard / Implementation Specification Standards Process Maturity Implementation Maturity Adoption Level Federally required Cost Test Tool Availability
Operating Rules
Rating 4
Limitations, Dependencies, and Preconditions for Consideration Applicable Value Set(s) and Starter Set(s)
  • Operating rules were adopted as a requirement of the Patient Protection and Affordable Care Act of 2010, under section 1104, Administrative Simplification.
  • Operating rules are intended to support and enhance the use of the standard transactions.  They include additional requirements to help implement the transaction in a more uniform way across health plans, and ensure a more complete set of information in the response. For example, rather than just “yes or no” for eligibility information, the operating rule requires health plans to return patient eligibility and financial responsibility for a list of service types such as emergency care, inpatient hospitalization, and dental and vision services.
  • Operating rules include other business rules to support the eligibility transaction as it moves between the provider and the health plan, such as the format of the health plan’s companion guide (see CORE Rule 152), as well as response time for real time and batch transactions (see CORE Rules 155 and 156).
  • Operating rules are developed through workgroups which are consensus driven, based on the members who participate.  Greater participation from more diverse members will result in more robust content and utility to enable to the rules to support the transactions and serve the users effectively. This is where the convergence of administrative and clinical systems will take place with respect to patient benefit information in the electronic health record.
  • Phase II eligibility and claim status operating rules include:
    • (1) Phase II CORE 250: Claim Status Rule, version 2.1.0 March 2011 (Incorporated by reference in § 162.920).
    • (2) Phase II CORE 258: Eligibility and Benefits 270/271 Normalizing Patient Last Name Rule, version 2.1.0, March 2011. (Incorporated by reference in § 162.920).
    • (3) Phase II CORE 259: Eligibility and Benefits 270/271 AAA Error Code Reporting Rule, version 2.1.0. (Incorporated by reference in § 162.920).
    • (4) Phase II CORE 260: Eligibility & Benefits Data Content (270/271) Rule, version 2.1.0, March 2011. (Incorporated by reference in § 162.920).
    • (5) Phase II CORE 270: Connectivity Rule, version 2.2.0, March 2011. (Incorporated by reference in § 162.920).(b)
  • Testing, or certification with the operating rules is voluntary and available through a vendor contracted to the authoring entity. The checklist is available on the website. Testing between covered entities is always encouraged. Certification for operating rules is voluntary and not currently required by federal regulation.
  • CAQH CORE maintains a host of free implementation tools to support operating rule adoption on its website. Additionally, CAQH CORE offers regular educational webinars which are archived on its website to drive greater industry awareness of the value of operating rules in collaboration with leading healthcare organizations


CAQH CORE Comments on 2018 Interoperability Standards Advisory

  • “Operating Rules” should be included as one of the structures under “Type,” which presently only includes “Standard” or “Implementation Specification.” Although there are other utilities referenced in the ISA (e.g. Integrating the Healthcare Enterprise (IHE)’s Integration Profiles) that also technically do not meet the definition of either a standard or implementation specification, operating rules are distinct in this regard. The Centers for Medicare and Medicaid Services (CMS) notes, in its definition of operating rules, that they are “the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications” (emphasis added).
  • Operating Rules to Support Eligibility and Claim Status Transactions (Phase II): “Adoption Level” for these operating rules is currently listed as 3 out of 5. CAQH CORE updated its market share data in 2018 and determined that 65 percent of the commercial and publicly insured population in the United States are covered by Phase II CORE-certified health plans. Given the Phase I CAQH CORE Operating Rules are federally mandated and CORE Certification is voluntary, it is reasonable to conclude that more health plans have implemented the rules than have pursued CORE Certification. Therefore, CAQH CORE suggests increasing the industry adoption level of the Phase II CAQH CORE Operating Rules to 4 out of 5.

(Above content is an except of the full CAQH CORE Comment Letter).