Operating Rules for Eligibility and Claims Status

Operating rules for eligibility and claims status went into effect on January 1, 2013. They make it easier for providers to determine:

  • Whether a patient is eligible for coverage (transaction 270/271)
  • The status of a health care claim submitted to a health insurer (transaction 276/277)

View the Phase I Operating Rules and Phase II Operating Rules for eligibility and health care claim status on the CAQH CORE website. 

Eligibility Operating Rule Requirements

Eligibility operating rules require health plans to:

  • Respond in real time to providers’ eligibility questions with a patient’s financial information, including:
  • Deductibles, co-pays, coinsurance, in/out of network variances
  • Coverage information for specific service types
  • Provide secure access to eligibility information over the Internet

Claims Status Operating Rule Requirements

Health plans must furnish real-time online access to claims status information, meaning that providers can better estimate cash flow while spending less time on phone calls.

 

For More Information

Page Last Modified:
11/02/2016 10:58 AM