Updates to Recipient Eligibility Inquiry and Claim Status for CAQH CORE

The Council for Affordable Quality Healthcare (CAQH) is a nonprofit alliance of health plans and trade associations. The Committee on Operating Rules for information Exchange (CORE) is an initiative through CAQH to promote streamlining and ease of use for physicians and hospitals to access eligibility, benefits and claim information for their patients at the point of care. Implementation of the CAQH CORE operating rules is a mandate of the Affordable Care Act. (For more information about CAQH CORE, see link below.)

Several enhancements related to Recipient Eligibility Inquiry and Claim Status have been implemented in NCTracks. These system changes were implemented as part of the CAQH CORE (Phase I and Phase II) standards, and affect the secure NCTracks Provider Portal, HIPAA X12 transactions, and the Automated Voice Response System (AVRS).

The enhancements to recipient eligibility inquiry on the secure NCTracks Provider Portal include:

• Normalization of the recipient last name in search criteria - Providers may enter the beneficiary's last name in the search criteria with spaces, special characters, hyphens, etc.
• Service type selection capability in search criteria - Providers may enter up to 5 specific service types in search criteria in an inquiry. If no service types are specified, the system returns up to 54 covered service types.
• Copay information by service type in the search response - Co-pay information is returned with each service type in the response.

In addition, a new communication channel is now available to trading partners for submission and receipt of 270/271 and 276/277 HIPAA X12 transactions. The NCTracks Trading Partner Connectivity Guide has been updated with information regarding the new communication channel for 270/271 and 276/277 transactions. The updated version of the Connectivity Guide, as well as the updated companion guides for the 270/271 and 276/277 transactions, are now available on the Trading Partner Information page of the NCTracks Provider Portal. (See link below)

Also, the AVRS has been updated to provide more specific messages for certain error conditions, based on the information submitted in the inquiry. It may also result in multiple error messages being returned. Applicable error messages include:
- Patient Birth Date Does not Match that for the Patient in the Database
- Invalid/Missing Subscriber/Insured ID
- Subscriber/Insured Not Found

These CAQH CORE changes to the secure provider portal, HIPAA X12 transactions, Communication Channel, and AVRS are effective today.