CORE Phase II Rules

The CORE Phase II rules have been approved by the CORE membership and have recently been endorsed by the CAQH Board. (Click this link for the voting process timeline).

The Phase II rules build on the CORE Phase I rules, with additional rules for patient identifiers, patient accumulators, claims status and connectivity. The Phase II rules also require patient financial responsibility for an increased number of service codes. CAQH expects to announce Phase II certification testing beginning at the end of Q3 2008 and into 2009.

Phase II – Scope and Approved Rules

View the complete CORE Phase II Policies and Rules.

Policies (Follows the same approach as Phase I with appropriate adjustments)
Approved

• Pledge
  Goal: Demonstrates public support for CORE and commitment to become Phase II certified.
• Phase II Test Suite for Certification and Testing (conducted by independent entities)
  Goal: For each stakeholder type that can receive CORE certification (health plan, vendor, clearinghouse and large provider), Test Suite provides objective, standardized method to conduct non-exhaustive testing for each Phase II rule.

Rules (new rules for Phase II)
Approved

Related to 270/271 Eligibility:

1. Data Content Rule*
Goal: Provides reporting of patient liability information (remaining deductible amount, plus static co-pay and co-insurance information) in response to a generic or explicit eligibility inquiry; along with 39 additional service type codes beyond the nine service type codes provided in Phase I.

2. Infrastructure-related Rules

Connectivity Rule*
Goal: Provides a comprehensive “Safe Harbor” connectivity rule to facilitate connectivity standardization and interoperability across healthcare information exchange, including message envelope standards and metadata requirements.

Patient Identification Rules
Goal: Provides enhanced patient matching and better information on why a match did not occur in an eligibility request.


• Normalizing Patient Last Name


• Use of AAA Error Codes for Reporting Errors in Subscriber/Patient IDs & Names

Related to 276/277 Claims Status*:

CORE Phase II Claim Status Rule
Goal: Promotes increased availability and usage of the claims status transaction through application of Phase I infrastructure rules to the 276/277 claims status transactions, including rules for real-time and batch response times, system availability, connectivity, and acknowledgements.

To join the more than 100 industry stakeholders collaborating on the development of CORE Phase II rules, click here to download a CORE Participant Application Form. For more information, please contact CAQH at (202) 861-1492.

* Enhancing/expanding upon Phase I rules