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Operating Rules for Eligibility and Claims Status

Guidance for operating rules for eligibility and claims status.

Final

Issued by: Centers for Medicare & Medicaid Services (CMS)

Issue Date: August 02, 2020

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 Eligibility & Benefits Operating Rules and Claims Status 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

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DISCLAIMER: The contents of this database lack the force and effect of law, except as authorized by law (including Medicare Advantage Rate Announcements and Advance Notices) or as specifically incorporated into a contract. The Department may not cite, use, or rely on any guidance that is not posted on the guidance repository, except to establish historical facts.