CORE Phase III Rules

The Complete Set of Phase III CAQH CORE EFT & ERA Operating Rules, developed by CORE Participants with industry input, was approved in the final CORE vote in June 2012 as the final step in the CORE voting process. On August 10,2012, HHS issued an Interim Final Rule with Comment (IFC) adopting the complete Phase III CAQH CORE EFT & ERA Operating Rules, including the CORE v5010 Master Companion Guide Template, to fulfill the ACA Section 1104 Federal mandate for national EFT & ERA Operating Rules. Covered entities must be in compliance with the EFT & ERA Operating Rule Set by January 1, 2014. In April 2013, CMS issued a notice adopting CMS-0028-IFC as a Final Rule. Industry implementation efforts should be well underway for the January 1, 2014 effective date for implementation of the Federally mandated CAQH CORE EFT & ERA Operating Rules. This notice also urged stakeholders to get involed in the CAQH CORE Code Combinations Maintenance Process.

NOTE: The IFC does not adopt the Batch Acknowledgement Requirements in Section 4.2 of CAQH CORE Rule 350, as the Secretary has not yet adopted HIPAA-standards for acknowledgements. Additionally, CORE Certification is and remains voluntary.

Phase III CAQH CORE Policies (300-305)

CAQH CORE 300: Guiding Principles

CAQH CORE 301: Pledge

CAQH CORE 302: Certification Policy

CAQH CORE 303: Exemption Policy

CAQH CORE 304: Testing Policy

CAQH CORE 305: Enforcement Policy

Phase III CAQH CORE EFT & ERA Operating Rules

• CAQH CORE 350: Health Care Claim Payment/Advice (835) Infrastructure Rule
  • CORE v5010 Master Companion Guide Template
• CAQH CORE 360: Uniform Use of CARCs and RARCs (835) Rule
  • CORE-required Code Combinations for CORE-defined Business Scenarios for CAQH CORE Rule 360 v3.0.1 January 2013
  • This document aligns with the current published CARC and RARC lists and supersedes v3.0.0. The list was approved by the CAQH CORE Code Combination Task Group in January 2013. Per CMS OESS, this document is immediately recognized under HIPAA given that CAQH CORE Rule 360 requires that adjustments made by the code list authors be addressed by CORE. It has been placed in Excel for ease of use. For a marked up version showing the adjustments between v3.0.0 and v3.0.1 please email CORE@caqh.org.
  • To learn more about the CAQH CORE Code Combinations Maintenance Process click HERE. To learn more about the CAQH CORE Code Combinations Emergency Update Process click HERE. To review the evaluation criteria that were used by the CORE Participants to develop the CORE-required Code Combinations and are also used by the CAQH CORE Code Combinations Task Group to evaluate potential adjustments to the CORE-required Code Combinations, click HERE. A webpage with detailed information specific to CAQH CORE Rule 360 and CAQH CORE Code Combinations Maintenance Process is being developed by CAQH CORE staff and will be available as a resource in Q2 of 2013.

• CAQH CORE 370: EFT & ERA Reassociation (CCD+/835) Rule
• CAQH CORE 380: EFT Enrollment Data Rule
• CAQH CORE 382: ERA Enrollment Data Rule

Per the CORE Rules Development Process, for each CAQH CORE Rule Set a Voluntary CORE Certification Test Suite is developed specifying how entities can achieve voluntary CORE Certification with the rule set. The Phase III CORE EFT & ERA Operating Rules Voluntary Certification Test Suite was also approved in the final CORE vote in June 2012. Voluntary CORE Certification will be available for the CAQH CORE EFT & ERA Operating Rules by early 2013. Please contact CORE@caqh.org if your entity is interested in becoming an early adopter for this rule set.

Other CAQH CORE Rules

ACA-Related

• The Phase I and Phase II CAQH CORE Eligibility and Claim Status Operating Rules are already mandated by the ACA with an implementation deadline of January 1, 2013 - see here for details.
• CAQH CORE is in the process of drafting additional rules to respond to the third and final set of operating rules required by the ACA. If you are interested in learning more or participating, email CORE@caqh.org.

Voluntary

• CAQH CORE has also developed other operating rules that are currently voluntary. If you are interested in learning more or obtaining a copy of these draft rules, email CORE@caqh.org.