On October 5, we completed the third and final phase of the CAQH^® CORE¹ recertification enhancements to the 270/271 eligibility and benefits inquiry and response transaction set. Providers can now receive procedure code-specific information through this transaction set. This phase 3 enhancement applies to medical, dental, and behavioral health providers.

How this helps your office

Building on the enhancements launched in phase 1 (April) and phase 2 (June), this enhancement can help your office get even more targeted eligibility and benefit details in the 271 response ‒ so you can confirm coverage and patient cost-share with fewer follow-ups. These updates also support CAQH^® CORE¹ compliance requirements.²

Enhancement details

When you include Current Procedural Terminology (CPT^®), Healthcare Common Procedure Coding System (HCPCS), and American Dental Association^® Current Dental Terminology (ADA CDT) codes on your 270 request, you’ll receive more targeted benefit details in the 271 response for the services you’re planning to bill.

Submission tips

• For best performance, limit each request to 10 or fewer procedure codes.
• To help return the most accurate benefit details, include a diagnosis code and place of service code, when applicable:
  • Submit the diagnosis code in the HI segment
  • Submit the place of service code in the III segment

Note that when this information is not provided, Cigna Healthcare^® will use the most commonly billed diagnosis and place of service associated with the requested procedure code.

What this means for your EDI vendor

• This enhancement has been tested and aligns with CAQH CORE requirements.
• An updated 270/271 companion guideis available and has been shared with electronic data interchange (EDI) vendors.
• Your vendor may contact you regarding implementation or testing.
• No action is needed from your office unless your EDI vendor instructs you to update your system or complete testing.

Questions?

If you have questions about how this change may affect your 270/271 eligibility and benefit inquiries, please contact your EDI vendor first. They can confirm whether any system updates or testing is needed and provide guidance that aligns with your workflow.

1    Council for Affordable Quality Healthcare^® Committee on Operating Rules for Information Exchange.

2    Cigna Healthcare is a CAQH CORE-certified entity, demonstrating compliance with the administrative simplification provisions of the Affordable Care Act.