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ACA Operating Rules for Eligibility and Claim Status transactions

CAQH CORE is a multi-stakeholder collaboration developing industry-wide operating rules, built on existing standards, to streamline administrative transactions. These operating rules address gaps in standards, help refine the infrastructure that supports EDI and recognizes interdependencies among transactions. The ACA Operating Rules include enhancements for two transactions: X12 270/271 Eligibility & Benefits Transactions and the X12 276/277 Claim Status Transactions.

The Eligibility & Benefits and Claim Status rules address two areas; data content and infrastructure.

  • Data content The rules for data content for eligibility transactions provide for more robust eligibility and patient identification verification with enhanced error reporting.
  • Infrastructure The rules for eligibility and claim status transactions address needs for more accessible information, such as consistent companion guides and system availability. Additionally, responses and response times are addressed in the standards. Connectivity using a secure machine to machine internet exchange as a transmission method is added as an option.

In order to submit the real time or batch Eligibility and Claim Status transactions using an internet connection, you must first register. As this alternative method is a machine to machine connection, please check with your software vendor to inquire if your program has this capability.