CORETM Phase I Rules and Policies …

                           CORETM Phase I Rules and Policies
                                 Glossary of Terms


INTRODUCTION: This glossary of terms has been developed for CORE's Phase I Rules and
Policies related to the healthcare eligibility benefit inquiry and response. Each term is defined
below alphabetically and in bold.
·   Where the definition of the term is from a source outside of CORE, the source is noted in
    italics under the bolded term.
·   A few terms are defined in the CORE Phase I Rules and therefore reference the rule itself.
·   Unless otherwise defined here, definitions for any terms or data elements referenced in the
    Rules are taken from the Health Care Eligibility Benefit Inquiry and Response Health
    Insurance Portability and Accountability Act (HIPAA) Implementation Guide (IG) ASC
    X12N 270/271 (00401X092).


Batch (Batch Mode, Batch Processing Mode)
Batch mode is when the initial (first) communications session is established and maintained open
and active only for the time required to transfer the batch X12 Interchange, which may contain
one or more Functional Groups containing one or more 270 Transaction Sets, and receive the
acknowledgement that the file was successfully received. The next (second) communications
session is established at a later time and maintained open and active only for the time required to
retrieve the batch X12 Interchange containing one or more Functional Groups containing one or
more 271 Transaction Sets and acknowledge that the file was successfully received.
Alternatively, at the discretion of the trading partners, the communications session may be
maintained open and active for a period of time to be mutually defined between the trading
partners following the successful transfer of any file of data.
"Fast batch" or any batch that is converted to real time by the receiver is required to meet the
CORE requirements for batch.

Benefit Begin Date (DTP01 271 code 348)
The date on which coverage for a specific benefit begins. See CORE 154: Eligibility and
Benefits 270/271 Data Content Rule version 1.0.0.

Business Day
A business day consists of the 24 hours commencing with 12:00 am (Midnight or 0000 hours) of
each designated day through 11:59 pm (2359 hours) of that same designated day. See CORE
155: Eligibility and Benefits Batch Response Time Rule version 1.0.0.

Calendar Week
From 12:01 am Sunday to 12:00 am the following Sunday. See CORE 157: Eligibility and
Benefits System Availability Rule version 1.0.0.

Certification
Source: Overview of Conformance Testing document developed by NIST Information Technology
Laboratory Software Diagnostics & Conformance Testing Division (January 25, 1999).
Acknowledgement that a validation was completed and the criteria established for issuing
certificates (brands) was met. In the context of CORE, it is official acknowledgment that
conformance testing (validation) was completed and the criteria for issuing the CORE-
Certification Seal was met.

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                                      Glossary of Terms

Chiropractic (X12 Data Element 1365 Service Type Code 33)
Professional services which may include office visits, manipulations, lab, x-rays, and supplies.
CORE 154: Eligibility and Benefits 270/271 Data Content Rule version 1.0.0.1

Clearinghouse
Source: Code of Federal Regulations. Title 45: Public Welfare. Subtitle A: Department of
Health and Human Services Part 160: General Administrative Requirements. 160.103:
Definitions. http://www.access.gpo.gov/nara/cfr/waisidx_02/45cfr160_02.html
A public or private entity, including a billing service, repricing company, community health
management information system or community health information system, and "value-added"
networks and switches, that processes or facilitates the processing of health information received
from another entity or provides other services that facilitate the exchange, delivery or transfer of
electronic health information between organizations. Used interchangeably with the terms
"SWITCH" and "INTERMEDIARY" in the context of CORE rules.

Conformance
Source: Overview of Conformance Testing document developed by NIST Information Technology
Laboratory Software Diagnostics & Conformance Testing Division (January 25, 1999).
The fulfillment of a product, process or service of specified requirements. In the context of
CORE, it is the demonstration that the software/system meets the specified requirements set forth
in a CORE rule.

Conformance Clause
Source: Overview of Conformance Testing document developed by NIST Information Technology
Laboratory Software Diagnostics & Conformance Testing Division (January 25, 1999).
A section of a specification that defines at a high level, the requirements, criteria, or conditions
to be satisfied in order to claim conformance. In the context of CORE, it is the language in a
CORE rule that defines at a high level the requirements criteria or conditions that must be
satisfied in order to claim conformance.

Conformance Criteria
Source: Overview of Conformance Testing document developed by NIST Information Technology
Laboratory Software Diagnostics & Conformance Testing Division (January 25, 1999).
Requirements indicating the behavior, action, capability that constitutes implementation of the
function. In the context of CORE, it is the requirements set forth in a CORE rule indicating the
behavior, action or capability that constitutes actual implementation of the function.

Conformance Testing (Validation)
Source: Overview of Conformance Testing document developed by NIST Information Technology
Laboratory Software Diagnostics & Conformance Testing Division (January 25, 1999).
A way to determine directly or indirectly that relevant requirements are fulfilled. In the context
of CORE, the term "Certification Testing" is used to mean the same as Conformance Testing.



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    CORE extended definition to X12 Standard Definition for Data Element 1365 Code 33

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                                   Glossary of Terms

Dental Care (X12 Data Element 1365 Service Type Code 35)
Benefits for services, supplies or appliances for care of teeth. See CORE 154: Eligibility and
Benefits 270/271 Data Content Rule version 1.0.0.2

Eligibility (X12 Data Element 374 Service Type Code 307)
The date on which health plan coverage begins for this patient. See CORE 154: Eligibility and
Benefits 270/271 Data Content Rule version 1.0.0.3

Emergency Services (X12 Data Element 1365 Service Type Code 86)
Medical services and supplies provided by physicians, Hospitals, and other healthcare
professionals for the treatment of a sudden and unexpected medical condition or injury which
requires immediate medical attention. CORE 154: Eligibility and Benefits 270/271 Data Content
Rule version 1.0.0.4

Hospital Inpatient (X12 Data Element 1365 Service Type Code 48)
Hospital services and supplies for a patient who has been admitted to a hospital for the purpose
of receiving medical care or other health services. CORE 154: Eligibility and Benefits 270/271
Data Content Rule version 1.0.0.5

Hospital Outpatient (X12 Data Element 1365 Service Type Code 50)
Hospital services and supplies for a patient who has not been admitted to a hospital for the
purpose of receiving medical care or other health services. CORE 154: Eligibility and Benefits
270/271 Data Content Rule version 1.0.0.6

IETF
Source: The Internet Engineering Task Force. http://www.ietf.org
The Internet Engineering Task Force (IETF) is charged with developing and promoting Internet
standards, in particular, those of the TCP/IP protocol suite. The IETF has grown into a large
open international community of network designers, operators, vendors, and researchers
concerned with the evolution of the Internet architecture and the smooth operation of the
Internet. Formally an activity under the umbrella of the Internet Society. The IETF is overseen
by the Internet Architecture Board.

Intermediary
Source: Health Insurance Portability and Accountability Act 4010 IG
A public or private entity, including a billing service, repricing company, community health
management information system or community health information system, and "value-added"
networks and switches, that processes or facilitates the processing of health information received
from another entity or provides other services that facilitate the exchange, delivery or transfer of
electronic health information between organizations. Used interchangeably with the terms
"SWITCH" and "CLEARINGHOUSE" in the context of CORE rules.

2
  CORE extended definition to X12 Standard Definition for Data Element 1365 Code 35
3
  CORE extended definition to X12 Standard Definition for Data Element 1365 Code 35
4
  CORE extended definition to X12 Standard Definition for Data Element 1365 Code 86
5
  CORE extended definition to X12 Standard Definition for Data Element 1365 Code 48
6
  CORE extended definition to X12 Standard Definition for Data Element 1365 Code 50

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                                      Glossary of Terms

May
Source: The Internet Engineering Task Force. Request for Comments. 2119.
http://www.ietf.org/rfc/rfc2119.txt. March 1997.
This word, or the adjective "OPTIONAL," mean that an item is truly optional. One vendor may
choose to include the item because a particular marketplace requires it or because the vendor
feels that it enhances the product while another vendor may omit the same item. An
implementation which does not include a particular option MUST be prepared to interoperate
with another implementation which does include the option, though perhaps with reduced
functionality. In the same vein an implementation which does include a particular option MUST
be prepared to interoperate with another implementation which does not include the option
(except, of course, for the feature the option provides.)

Medical Care (X12 Data Element 1365 Service Type Code 1)
Medical care services to diagnose and/or treat medical condition, illness or injury. Medical
services and supplies provided by physicians and other health care professionals. CORE 154:
Eligibility and Benefits 270/271 Data Content Rule version 1.0.0.7

Must
Source: The Internet Engineering Task Force. Request for Comments. 2119.
http://www.ietf.org/rfc/rfc2119.txt. March 1997.
This word, or the terms "REQUIRED" or "SHALL", mean that the definition is an absolute
requirement of the specification.

Must Not
Source: The Internet Engineering Task Force. Request for Comments. 2119.
http://www.ietf.org/rfc/rfc2119.txt. March 1997.
This word, or the terms "NOT REQUIRED" or "SHALL NOT", mean that the definition is a
specific prohibition of the specification.

Not Recommended
Source: The Internet Engineering Task Force. Request for Comments. 2119.
http://www.ietf.org/rfc/rfc2119.txt. March 1997.
This phrase or the phrase "SHOULD NOT" mean that there may exist valid reasons in particular
circumstances when the particular behavior is not acceptable or useful, but the full implications
should be understood and the case carefully weighed before implementing any behavior
described with this label.

Not Required
Source: The Internet Engineering Task Force. Request for Comments. 2119.
http://www.ietf.org/rfc/rfc2119.txt. March 1997.
This word, or the terms "MUST NOT" or "SHALL NOT", mean that the definition is a specific
prohibition of the specification.



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    CORE extended definition to X12 Standard Definition for Data Element 1365 Code 1

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                                CORETM Phase I Rules and Policies
                                      Glossary of Terms

Optional
Source: The Internet Engineering Task Force. Request for Comments. 2119.
http://www.ietf.org/rfc/rfc2119.txt. March 1997.
This word, or the adjective "MAY", means that an item is not required. One vendor may choose
to include the item because a particular marketplace requires it or because the vendor feels that it
enhances the product while another vendor may omit the same item. An implementation which
does not include a particular option MUST be prepared to interoperate with another
implementation which does include the option, though perhaps with reduced functionality. In the
same vein an implementation which does include a particular option MUST be prepared to
interoperate with another implementation which does not include the option (except, of course,
for the feature the option provides.)

Pharmacy (X12 Data Element 1365 Service Type Code 88)
Drugs and supplies dispensed by a licensed Pharmacist, which may include mail order or internet
dispensary. CORE 154: Eligibility and Benefits 270/271 Data Content Rule version 1.0.0.8

Professional (Physician) Visit- Office (X12 Data Element 1365 Service Type Code 98)
Professional services of a Physician or other Health Care Professional during an office visit.
CORE 154: Eligibility and Benefits 270/271 Data Content Rule version 1.0.0.9

Real Time (Real Time Mode, Real Time Processing Mode)
Real Time mode is when an immediate response to an inquiry is required and a single
communications session is established and maintained open and active until the required X12
acknowledgement is received by the entity initiating the communications session.
Communication is complete when the session is closed. A Real Time inquiry is limited to one
270 eligibility request transaction set inquiring about one individual, one Functional Group
containing only one 270 transaction set, and one Interchange containing only one Functional
Group.

Recommended
Source: The Internet Engineering Task Force. Request for Comments. 2119.
http://www.ietf.org/rfc/rfc2119.txt. March 1997.
This phrase, or the phrase "SHOULD" mean that there may exist valid reasons in particular
circumstances when the particular behavior is acceptable or even useful, but the full implications
should be understood and the case carefully weighed before implementing any behavior
described with this label.

Rejection
An acknowledgment that communicates that an electronic transaction has not been successfully
received. See CORE 150 and 151: Eligibility and Benefits System Acknowledgements versions
1.0.0.




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    CORE extended definition to X12 Standard Definition for Data Element 1365 Code 88
9
    CORE extended definition to X12 Standard Definition for Data Element 1365 Code 98

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                           CORETM Phase I Rules and Policies
                                 Glossary of Terms

Required
Source: The Internet Engineering Task Force. Request for Comments. 2119.
http://www.ietf.org/rfc/rfc2119.txt. March 1997.
This word, or the terms "MAY" or "SHALL", mean that the definition is an absolute requirement
of the specification.

Shall
Source: The Internet Engineering Task Force. Request for Comments. 2119.
http://www.ietf.org/rfc/rfc2119.txt. March 1997.
This word, or the terms "MUST" or "REQUIRED", mean that the definition is an absolute
requirement of the specification.

Shall Not
Source: The Internet Engineering Task Force. Request for Comments. 2119.
http://www.ietf.org/rfc/rfc2119.txt. March 1997.
This word, or the terms "MUST NOT" or "NOT REQUIRED", mean that the definition is a
specific prohibition of the specification.

Should
Source: The Internet Engineering Task Force. Request for Comments. 2119.
http://www.ietf.org/rfc/rfc2119.txt. March 1997.
This phrase, or the phrase "RECOMMENDED" mean that there may exist valid reasons in
particular circumstances when the particular behavior is acceptable or even useful, but the full
implications should be understood and the case carefully weighed before implementing any
behavior described with this label.

Should Not
Source: The Internet Engineering Task Force. Request for Comments. 2119.
http://www.ietf.org/rfc/rfc2119.txt. March 1997.
This phrase, or the phrase "NOT RECOMMENDED" mean that there may exist valid reasons in
particular circumstances when the particular behavior is acceptable or even useful, but the full
implications should be understood and the case carefully weighed before implementing any
behavior described with this label.

Switch
Source: Health Insurance Portability and Accountability Act 4010 IG
A public or private entity, including a billing service, repricing company, community health
management information system or community health information system, and "value-added"
networks and switches, that processes or facilitates the processing of health information received
from another entity or provides other services that facilitate the exchange, delivery or transfer of
electronic health information between organizations. Used interchangeably with the terms
"SWITCH" and "INTERMEDIARY" in the context of CORE rules.

System Availability
The amount of time various components of a computer system are up and available for
processing as required. In the context of CORE, it includes all necessary components of a system

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                                CORETM Phase I Rules and Policies
                                      Glossary of Terms
required to process a 270 inquiry and return the required response(s). See CORE 157:
Eligibility and Benefits System Availability Rule version 1.0.0.

Validation (Conformance Testing)
Source: Overview of Conformance Testing document developed by NIST Information Technology
Laboratory Software Diagnostics & Conformance Testing Division (January 25, 1999).
The process, policy and procedures necessary to perform conformance testing in accordance with
a prescribed procedure and official test suite. In the context of CORE, this process uses the
Master CORE Certification Test Suite and incorporates the CORE Certification and Enforcement
Policies and CORE Pledge.

Vision (X12 Data Element 1365 Service Type Code AL-Optometry)
Routine vision services furnished by an optometrist. May include coverage for eyeglasses,
contact lenses, routine eye exams, and/or vision testing for the prescribing or fitting of eyeglasses
or contact lenses. CORE 154: Eligibility and Benefits 270/271 Data Content Rule version
1.0.0.10




10
     CORE extended definition to X12 Standard Definition for Data Element 1365 Code AL

© CAQH 2006                                                                                    7 of 7