The CORE 360 rule refers to the code combinations for claim adjustment reason codes and remittance advice remark codes, according to the report.
These codes are to be used to notify providers regarding the payment of a claim, including why the total charges originally submitted on a claim were not paid in full or why a claim payment was denied. The denial or adjustment of a claim is identified by the health plan or a pharmacy benefits manager agent using combinations of four claim denial/adjustment code sets that, when used in combination, should supply the provider with necessary detail regarding the payment of the claim.
The CORE 350 healthcare claim payment/advice infrastructure rule focused on improving the conduct and exchange of electronic claim advice data. The CORE 360 rule builds upon the CORE 350 rule by establishing data content rule requirements for conducting the electronic remittance advice and the electronic funds transfer transaction.
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