The federal CMS has provided information on the operating rules for adopted HIPAA transactions, highlighting phase I and phase II operating rules for the eligibility and benefits inquiry.

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.

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 Jan. 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.

CAQH CORE offers resources to help practices 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. 

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