Operating Rules for the Eligibility and Benefits Transaction

This week’s focus is Operating Rules for adopted HIPAA transactions. Today’s message highlights Phase I and Phase II operating rules for the eligibility and benefits inquiry.

About the Eligibility and Benefits for a Health Plan Transaction

An eligibility and benefits transaction covers inquiries and responses about a patient’s eligibility for insurance benefits, including information like co-pays and deductibles. The eligibility and benefits transaction has two parts:

The request transaction, known as the X12 0050 270 transaction for inquiries about eligibility and benefits, which can be sent from a health care provider to a health plan, or from one health plan to another.
The response transaction, known as the X12 0050 271 transaction for the health plan, responds to inquiries about eligibility and benefits.

Operating Rules for Eligibility and Benefits Transactions

The Phase I and Phase II operating rules for the eligibility for a health plan and health care claim status transactions were adopted in December 2011 through interim final rulemaking (CMS-0032-IFC) and became required for use on January 1, 2013. All HIPAA-covered entities must comply with these operating rules.

There are two exceptions to the compliance requirements for the Phase I and II operating rules adopted in the Final Rule for Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transaction. The CORE requirements for use of Acknowledgements were not adopted in the HHS rule. Also, the CORE operating rules exclude retail pharmacy transactions. Although HHS did not adopt the requirement for use of acknowledgments, HHS encourages the industry’s voluntary compliance with these operating rules, and indicated this on page 40469 in the final rule.

Here are some examples of what is included in the Phase I operating rule set:

Companion Guides: Phase I Rule 152 requires health plans to use the CORE template for structure and format for their published companion guides. By using a standard template, the structure of each health plan companion guide will be consistent with other health plan companion guides. This makes it easier for providers to find information quickly when they look for information across plan documents.
Service types to be included in transactions: Phase I Rule 154 lists the specific inquiry for service type either not supported by the health plan or for one of the CORE required service types, and the mandated response components, such as dates of eligibility with the health plan, patient financial responsibility and name of the plan.
Real time: Phase II Rule 260 requires health and dental plans to respond in real time to providers’ inquiries with a patient’s financial information including:
- Deductibles, co-pays, coinsurance, and in/out of network variances
- Coverage information for specific service types
- Secure access to eligibility information over the Internet

This rule also requires medical and dental plans to furnish data to help enable unique identification of individual patients.

CAQH CORE offers resources to help you understand how these rules affect eligibility and benefits transactions, including FAQs and companion guide templates. Visit the CAQH CORE operating rules website for more information, including guiding principles and specifications for each individual rule in Phase I and II.