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Physicians and other health providers are now using this industry standard for provider data collection


Committee on Operating Rules for Information Exchange (CORE)

Why can’t verifying patient eligibility and benefits and other administrative
data in provider offices be as easy as making an ATM withdrawal?


CORE Mission and Vision
CAQH launched the Committee on Operating Rules for Information Exchange (CORE) after completing a year of research with health plans, providers and industry leaders. The research showed that improved electronic access to accurate, timely healthcare administrative information, including eligibility and benefits data, would significantly reduce the resources required by providers to verify patient coverage, submit cleaner claims and help eliminate unnecessary bad debt.

CORE’s vision is provider access to healthcare administrative information before or at the time of service using the electronic system of their choice for any patient or health plan.

CORE is more than 100 industry stakeholders (www.caqh.org/ben_participating.php) – health plans, providers, vendors, CMS and other government agencies, associations, regional entities, standard-setting organizations and other healthcare entities.

CORE participants maintain eligibility and benefits data for more than 130 million lives, or more than 75 percent of the commercially insured plus Medicare and state-based Medicaid beneficiaries.

Working in collaboration they are building consensus on a set of operating rules that will:

  1. Enhance interoperability between providers and payers
  2. Streamline eligibility and benefits data transactions
  3. Reduce the amount of time and resources providers spend on administrative functions – time better spent with patients.
Operating rules build on existing standards to make electronic transactions more predictable and consistent, regardless of the technology. Rights and responsibilities of all parties, security, transmission standards and formats, response time standards, liabilities, exception processing, error resolution and more must be clearly defined in order to facilitate successful interoperability. Beyond reducing cost and administrative hassles, operating rules foster trust among all participants.

All CORE rules will build on applicable HIPAA requirements and other related standards.

CORE is solely focused on creating operating rules and will not develop software solutions, a switch, a database or central repository of administrative information.

CORE: A Multi-phase Initiative
Phase I, completed in April 2006, developed operating rules that cover a limited number of key eligibility and benefits data elements and the processes required to exchange them. They will help providers:
  • Determine whether a health plan covers the patient
  • Determine patient benefit coverage
  • Confirm coverage of certain service treatments and the patient’s co-pay amount, coinsurance level and base deductible levels (as defined in the member contract) for each of those types
Phase I rules and policies developed to govern exchange of this data include:
  • System connectivity
  • Standard inquiry acknowledgements
  • Maximum response times (real-time and batch)
  • Minimum hours a system must be available
  • Standard 270/271 companion guide flow and format
  • Standard testing, certification and enforcement processes to ensure CORE compliance
Additional eligibility components and business transactions will be addressed by CORE in Phase II (2006-2007) and later phases (2007-and beyond).

CORE Phase I Certification/Endorsement
Use of the CORE rules/policies is voluntary and open to all organizations that create, send or transmit healthcare administrative data, including eligibility and benefits information.

To receive a CORE-certification Seal, organizations must sign a binding pledge to adopt, implement and comply with CORE Phase I rules. By signing the CORE Pledge, the organization commits to work with a CORE-authorized testing vendor to prove its IT system(s) are compliant with the CORE Phase I rules. Testing must be completed within 180 days of signing the CORE Pledge. CORE testing and certification is tailored for providers, health plans, vendors and clearinghouses.

Organizations that do not create, send or transmit data can demonstrate their support for CORE’s mission and the Phase I rules by signing the CORE Pledge and applying for a CORE Endorser Seal.

CAQH has authorized the Claredi certification testing solution from Ingenix (www.ingenix.com) and Edifecs, Inc. (www.edifecs.com) to certify that healthcare organizations’ IT systems are in compliance with CORE Phase I rules.

The SSI Group, Inc. (SSI) is the first healthcare organization to receive CORE certification seals, after successfully completing CORE Phase I certification testing. It was awarded a CORE Clearinghouse certification seal for its ClickON® E-Verify product and a CORE Vendor certification seal for its ClickON® Net Eligibility product.

More than 20 healthcare organizations have committed to CORE certification by no later than March 31. 2007. Over 20 additional organizations have endorsed the CORE Phase I rules. Visit CORE Certifications/Endorsers for more information.