Council for Affordable Quality Healthcare (CAQH) & Committee on Operating Rules for Information Exchange (CORE) for Providers who Submit Electronic Transactions

August 6, 2013

CAQH is a non-profit alliance of health plans and trade associations, working to simplify healthcare administration through industry collaboration on public-private initiatives. CORE is a federal initiative led by the CAQH that is included in Section 1104 of the Patient Protection and Affordable Care Act (ACA). The CAQH CORE initiative is mandated for payers who exchange electronic transactions with providers and billing agents.

Mandatory CAQH CORE operating rules will:

  • Enhance interoperability between providers and payers
  • Streamline eligibility, benefits, and claims data transactions
  • Reduce the amount of time and resources providers spend on administrative functions – time better spent with patients These rules dictate how Trading Partners can interact electronically in a standardized manner and achieve more consistent and predictable data, regardless of health plan.

At this time, the CAQH CORE operating rules apply only to the 270/271 (eligibility file) and a 276/277 (claim status file) transactions. They identify the requirements for real time transactions for these two file types. This means you can receive an immediate response when submitting them as opposed to waiting for a batch response. These rules are outlined in the updated 270 or 276 EDI 5010 Eligibility Benefit Inquiry Companion Guides found in the Companion Guides folder on the MIHMS Health PAS Online Portal.

If you are currently submitting and receiving 270/271 transactions, no action is needed. The EDI Helpdesk is in the process of calling all Trading Partners identified as using these transactions in order to provide additional information and training opportunities. If you are interested in using these real time transactions, please call the EDI Helpdesk at 866-690-5585, option 3.

MaineCare will continue to work closely towards a quality, timely delivery of the CAQH Core requirements and their target implementation dates.

For a summary about CAQH CORE, visit MaineCare’s Provider Advisory Group/Technical Advisory Group PAG/TAG) webpage. For more detailed information, go to the CAQH CORE website.

If you have questions, please contact the EDI Helpdesk at 866-690-5585, option 3.