Operating Rules for the Claim Status Transaction

Today’s Operating Rules Week message highlights the claims status transaction and its operating rules.

About Claim Status Transactions

A claim status transaction is communication between a provider and a health or dental plan about the status of a health care claim.

A claim status transaction is used for:

An inquiry from a provider to a health or dental plan about the status of a health care claim. This is the request transaction known as the X12 005010 276.
A response from the health or dental plan to a provider about the status of a claim. This is the response transaction, known as the X12 005010 277.

Operating Rules

HHS adopted operating rules for the eligibility for a health plan and health care claim status transactions in a December 2011 Interim Final Rule (IFC) titled Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transaction (CMS-0032-IFC). These operating rules are known as Phase I and II operating rules. Covered entities were required to use these adopted operating rules by January 1, 2013.

In the December 2011 IFC, HHS did not adopt the operating rule requirements pertaining to the use of the acknowledgement transaction. Although not an adopted standard, the acknowledgement plays an important role in the exchange of transactions between covered entities, and we encourage industry to use this transaction, as well as the related operating rules.

Here are some examples of Phase II operating rules for use of the claim status transactions:

Phase II 250 Rule provides requirements for claim status transactions, including requirements for:
- Connectivity (transaction participant must follow the Connectivity rule)
- Real-time acknowledgement
- Batch acknowledgement
- Response time
- System availability
- The template and structure for a health plan companion guide

Phase II Rule 258 provides guidance on normalizing a patient’s last name. This rule explains how health plans are to identify and parse a patient’s last name to ensure a best case for identification and matching. Instructions are provided for the codes and segments to be used in the transaction, and responses that are to be sent when names do not match, or information is not valid, so that providers’ systems can be programmed consistently with all health plans.

Visit the CAQH CORE website for the full rule set for Phase I rules (Rules 150-157) and Phase II rules, which includes the guiding principles and specifications for each individual rule.