40k Core Rules Download

[Lara Preece]

Operatingrules support a range of standards to make electronic data transactions more predictable and consistent, regardless of the technology. CAQH CORE is designated by the Secretary of the Department of Health and Human Services (HHS) as the National Operating Rule Authoring Entity for the administrative transactions covered by HIPAA.

Three sets of CAQH CORE Operating Rules are federally mandated under HIPAA. Click the Operating Rules Mandate tab below to access the federally mandated versions of the Eligibility & Benefits, Claim Status and Payment & Remittance Operating Rules. More information is available on the CMS website. CAQH CORE Operating Rule requirements are a floor, not a ceiling, with updated versions of the rules building on the existing requirements. Therefore all federally mandated operating rule requirements are included in the current versions of the CAQH CORE Operating Rules.

Addresses requirements associated with electronic funds transfers (EFT) and electronic remittance advice (ERA), and establishes consistent use of claim adjustment and denial codes. A set of these rules is federally mandated.

CAQH CORE Operating Rules set national responsibilities and requirements for timely and accurate use of electronic transactions within the healthcare revenue cycle. To keep up with evolving business needs and new technologies, all operating rules are subject to a cycle of maintenance based on applicability, need and lessons learned.

The CAQH CORE Operating Rule Maintenance Process addresses three types of updates: Substantive, Non-substantive, and Typographical, as well as routine, periodic maintenance.

Routine maintenance is included in the rule. Some CAQH CORE Operating Rules include specific maintenance processes that may result in modifications of the rule. Routine maintenance requirements are outlined in the applicable rules, including the CAQH CORE Payment & Remittance Operating Rules and the CAQH CORE Connectivity Rules.

Key to effectively managing and maintaining these various potential CAQH CORE Operating Rule updates is the careful and precise assignment of version identifiers to the rules and any of their companion documents. This version identification scheme is shown below.

CAQH CORE is committed to conducting substantive, non-substantive, typographical, and routine maintenance on existing rules and developing new rules as appropriate. All rule development and maintenance is conducted by CAQH CORE Participating Organizations and is performed in accordance with the CAQH CORE Operating Rules Development Process in alignment with the CAQH CORE mission and vision.

Section 1104 of the Patient Protection and Affordable Care Act (ACA) requires the Secretary of the Department of Health and Human Services (HHS) to adopt and regularly update standards, implementation specifications and operating rules for the electronic exchange and use of health information for the purposes of financial and administrative transactions under HIPAA. This section applies to HIPAA covered entities and business associates engaging in HIPAA standard transactions on behalf of covered entities.

CAQH CORE is designated by the Secretary of HHS as the Operating Rule Authoring Entity for the HIPAA-mandated administrative transactions. CAQH CORE Operating Rules addressing eligibility & benefits, claim status and payment & remittance are federally mandated.

In 2020, CAQH CORE updated its phase-based operating rule structure to align with current stakeholder operations. The CAQH CORE Operating Rules are now organized by the business processes they support which enhances flexibility to update requirements, enables more rapid and targeted rule development and eliminates the potential for an infinite number of future operating rule phases.

While the CAQH CORE Eligibility & Benefits, Claim Status and Payment & Remittance Operating Rule versions have been updated to meet current and emerging business needs, all of the requirements included in the HIPAA-mandated rule versions remain in the current versions.

If you have been tasked with implementing the CAQH CORE Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule, part of the Affordable Care Act (ACA)-mandated Payment & Remittance Operating Rules, you will find all the necessary tools and information here to comply with this operating rule.

The CAQH CORE Payment & Remittance Operating Rules, among other things, simplify the language used to communicate about claim payment and remittance information. The CAQH CORE Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule brings uniformity to the use of Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), and Claim Adjustment Group Codes (CAGCs) by identifying a limited set of CARC/RARC/CAGC combinations to be used in defined universal business scenarios. These codes are used in combination to convey details about a claim adjustment or denial in the X12 v5010 835.

Together, the business scenarios and code combinations make up the CORE-required Code Combinations for CORE-defined Business Scenarios (CORE Code Combinations), a companion document to the CAQH CORE Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule.

Version 3.8.2 of the CORE Code Combinations includes updates based on Compliance-based as part of the CAQH CORE Code Combinations Maintenance Process based on published CARC and RARC lists as of November 1, 2023.

The table below summarizes the Compliance-based Adjustments approved by the CAQH CORE Code Combinations Task Group for inclusion in the current version of the CORE Code Combinations by CORE-defined Business Scenario.

CAQH CORE facilitates a public 60-day period during which industry entities can submit potential Market-based Adjustments to code combinations in the existing CORE-defined business scenarios. Industry entities can submit three categories of potential code combination adjustments:

The CORE Code Combinations are updated at scheduled intervals to align with updates to the published CARC and RARC lists, which are maintained by CARC/RARC Code Committees external to CAQH CORE. The following table illustrates the timeline.

Exception: In some instances, the effective date for code modifications and deactivations approved by the code maintenance committees is more than six months after publication of the updated code list. To accommodate code modifications or deactivations that go into effect after the compliance date for the new version of the CORE-required Code Combinations for CORE-defined Business Scenarios (e.g. adjustments with effective dates greater than six months from the code list publication date), CAQH CORE has incorporated the following exceptions to the 90 day compliance timeframe:

NOTE: The 04/19/13 CMS Notice to the Industry states that because the Maintenance Process was adopted in the IFC, covered entities should understand that revised and updated versions of the CORE Code Combinations are part of the regulation (applies to both Compliance and Market-based Adjustments to current CORE-defined Business Scenarios); covered entities are responsible for complying with the latest version.

NOTE: ACA Section 1104 mandates that all HIPAA covered entities comply with the Payment & Remittance Operating Rules; however non-HIPAA covered entities play a crucial role in enabling their provider and health plan clients to realize the benefits of industry adoption and often act as Business Associates on behalf of a HIPAA covered entity.

The CAQH CORE Code Combinations Task Group conducts two types of reviews and adjustments of the CORE Code Combinations as part of its ongoing CAQH CORE Code Combinations Maintenance Process required by the CAQH CORE Payment & Remittance Uniform Use of CARCs and RARCs (835) Rule:

Compliance-based Reviews: Occur three times per year and consider only additions, deactivations, or modifications to the current published CARC and RARC lists by the code committees since the last update to the CORE Code Combinations

Adjustments to the existing CORE Code Combinations for existing CORE-defined Business Scenarios (additions, removals, etc.) based on real-world usage data and/or a strong business case

Two of the five CAQH CORE Payment & Remittance Operating Rules address the barriers to greater provider EFT and/or ERA enrollment. The EFT & ERA Enrollment Data Rules outline maximum sets of standard data elements to be collected by a health plan or its agent during provider enrollment in EFT and/or ERA. The rules also outline a flow and format for collection of the data elements, among other requirements.

The EFT & ERA Enrollment Data Rules also recognize the need for ongoing maintenance of the CORE-required Maximum EFT & ERA Enrollment Data Sets and establishes a policy and process to review the Enrollment Data Sets no less than annually. From 2014 - 2022, review of the Enrollment Data Sets was conducted annually, with limited in-scope submissions from the industry and no substantive adjustments to the data sets.

Old-School Essentials comes in Classic Fantasy and Advanced Fantasy flavours. Advanced Fantasy = Classic Fantasy + extra classes, optional rules, spells, monsters, and magic items. For those who prefer box sets of slim books for sharing around the table, Old-School Essentials is also available as a pair of box sets.

Netiquette, or network etiquette, is concerned with the "proper" way to communicate in an online environment. Consider the following "rules," adapted from Virginia Shea's The Core Rules of Netiquette, whenever you communicate in the virtual world.

When communicating electronically, whether through email, instant message, discussion post, text, or some other method, practice the Golden Rule: Do unto others as you would have others do unto you. Remember, your written words are read by real people, all deserving of respectful communication. Before you press "send" or "submit," ask yourself, "Would I be okay with this if someone else had written it?"

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