CAQH CORE Operating Rules for Eligibility & Benefits

Type	Standard / Implementation Specification	Standards Process Maturity	Implementation Maturity	Federally required	Cost	Test Tool Availability
Operating Rules	CAQH CORE Eligibility & Benefits (270/271) Data Content Rule Version EB.1.0	Final	Production	No	Free	Yes
Operating Rules	CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule Version EB.1.0	Final	Production	Yes	Free	Yes^$
Operating Rules	CAQH CORE Eligibility & Benefits (270/271) Data Content Rule Version EB.2.0	Final	Production	No	Free	Yes^$
Operating Rules	CAQH CORE Eligibility & Benefits (270/271) Infrastructure Rule Version EB.2.0	Final	Production	No	Free	Yes^$
Operating Rules	CAQH CORE Eligibility & Benefits (270/271) Single Patient Attribution Data Content Rule vEB.1.0	Final	Production	No	Free	Yes^$

Limitations, Dependencies, and Preconditions for Consideration	Applicable Security Patterns for Consideration
Operating rules for HIPAA standard transactions were added 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 standard transactions. They may include certain requirements to help implement the transaction in a more uniform way between health plans and providers, and to ensure a more complete set of information in the response. In 2012 HHS adopted CORE Operating Rules for Eligibility and Benefits, which were incorporated by reference at §162.920. Prior versions of the adopted operating rules for Eligibility and Benefits are available on the CAQH CORE Mandated Operating Rules website and are incorporated by reference at § 162.920. In 2022, The CAQH CORE Operating Rules for Eligibility & Benefits were updated to align with current industry business requirements to better support complex benefit design, telehealth, and support for the implementation of value-based payment initiatives. These updates also support the identification of prior authorization requirements for services queried during eligibility verifications in real-time, at the point of care. Updated and new CORE Operating Rules for Eligibility & Benefits were recommended for Federal adoption by the National Committee of Vital Health and Statistics (NCVHS) to the Department of Health and Human Services (HHS) in June 2023. Testing, or certification with the operating rules is voluntary and available through CORE. CORE maintains free tools to support operating rule implementation. Additionally, CORE offers educational webinars on its website.	Feedback requested.

Limitations, Dependencies, and Preconditions for Consideration

Applicable Security Patterns for Consideration

Operating rules for HIPAA standard transactions were added 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 standard transactions. They may include certain requirements to help implement the transaction in a more uniform way between health plans and providers, and to ensure a more complete set of information in the response.
In 2012 HHS adopted CORE Operating Rules for Eligibility and Benefits, which were incorporated by reference at §162.920.
Prior versions of the adopted operating rules for Eligibility and Benefits are available on the CAQH CORE Mandated Operating Rules website and are incorporated by reference at § 162.920.
In 2022, The CAQH CORE Operating Rules for Eligibility & Benefits were updated to align with current industry business requirements to better support complex benefit design, telehealth, and support for the implementation of value-based payment initiatives.
These updates also support the identification of prior authorization requirements for services queried during eligibility verifications in real-time, at the point of care.
Updated and new CORE Operating Rules for Eligibility & Benefits were recommended for Federal adoption by the National Committee of Vital Health and Statistics (NCVHS) to the Department of Health and Human Services (HHS) in June 2023.
Testing, or certification with the operating rules is voluntary and available through CORE. CORE maintains free tools to support operating rule implementation. Additionally, CORE offers educational webinars on its website.

Feedback requested.

Comment

Submitted by mphillips@caqh.org on 2024-08-09

CAQH CORE 2025 ISA Updates

Recommended updates to the Operating Rules for Eligibility & Benefits are included on pages 12-13 of the attached document.

CORE Submission_2025 ISA Updates_Eligibility.pdf

Submitted by mphillips@caqh.org on 2023-10-06

Updates to Eligibility and Benefits Page

CORE recommends several substantive content and clarifying changes to the CAQH CORE Operating Rules for Eligibility and Benefits website. The changes are outlined on Page 9-10 of the letter found at this link: CORE Submission for the 2024 ISA Open Comment Period.

Submitted by mphillips@caqh.org on 2022-09-27

CAQH CORE Operating Rules for Eligibility and Benefits Updates

Updates to the CAQH CORE Operating Rules for Eligibility and Benefits are on pages 6-7 in the attached document. Proposed changes are highlighted in gray with proposed deletions being shown as strikethrough text. CAQH CORE recommends renaming the section to ‘Operating Rules for Eligibility and Benefits’ for consistency in naming conventions. Additionally, CAQH CORE recommends that this section be the first in the list of Operating Rules. Further, language has been included to denote differences between federally mandated CAQH CORE Operating Rules for Eligibility and Benefits and those that are available for voluntary adoption. Other non-substantive updates have been made.

CAQH CORE ISA Letter 2022_0.pdf

Submitted by doodles531 on 2020-12-13

updated weblink

updated weblink -previous one does not work

Submitted by jporras on 2020-11-01

CAQH CORE Comments to ONC ISA - Phase I

Aligning ISA with New Operating Rule Structure: In Spring 2020, CAQH CORE restructured its operating rules from phase-based rule sets to rule sets based on the business processes supported by the rules. No substantive changes were made to existing rule requirements. As a result of the restructuring, CAQH CORE recommends updates to the following sections of the ISA:

Operating Rules to Support Eligibility Transactions (Phase I) -- Eligibility & Benefits Operating Rules

ISA Comments from CAQH CORE 11.1.20 FINAL_1.pdf

Submitted by jporras on 2020-11-01

Aligning ISA with New…

Operating Rules to Support Eligibility Transactions (Phase I) -- Eligibility & Benefits Operating Rules

ISA Comments from CAQH CORE 11.1.20 FINAL.pdf

Submitted by CAQHCORE on 2018-10-01

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 Transactions (Phase I): “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 I 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 I CAQH CORE Operating Rules to 4 out of 5.

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

Submitted by pwilson@ncpdp.org on 2017-11-20

NCPDP - Comments

This should be under the main category of V-E: Operating Rules to Support Administrative Transactions.

Add a bullet for Operating Rules for the ASC X12N 270/271 Transactions in Electronic Prescribing

Type-Implementation Specification

Standard Implementation/Specification- NCPDP Operating Rules for the X12 270/271 Transactions in Electronic Prescribing v1.0

Standards Process Maturity – Final

Implementation Maturity- Production

Adoption Level – 5

Federally Required – No

Cost – $

Test Tool Availability -