CAQH CORE Announces New National Healthcare Operating Rules

October 2015

Health plans, healthcare providers, and the clearinghouses and vendors that support them, now have national operating rules to improve how they can work together as trading partners. The voluntary operating rules will help streamline the electronic data exchange of four more healthcare business transactions: healthcare claims; prior authorization; employee premium payment; and enrollment and disenrollment in a health plan.

CAQH CORE recently announced that the Phase IV CAQH CORE Operating Rules package has been approved and the industry should begin coordinating voluntary implementation. Reaching this milestone is the result of enormous effort by the multi-stakeholder CAQH CORE collaboration, which includes a wide range of public and private entities.

The approval of the Phase IV package included voting by Subgroups and Work Groups that developed the draft rules with a wide range of input, as well as subsequent voting by those participating organizations that create, transmit or use healthcare administrative data. The operating rules package was then forwarded to the CAQH CORE Board for final review and approval. For the Phase IV package, there was more than 90 percent participation in the vote, and over 88 percent approval.

Based on industry input, the Phase IV Operating Rules focus on infrastructure requirements for data exchange, including:

  • Offering at least one common method of connectivity (i.e., a “safe harbor”) among entities transmitting data electronically.
  • A minimal amount of time that systems must be available to receive and send data.
  • An acknowledgement to ensure the transaction has been received, has not been lost between entities, and will be addressed.
  • Required response times for acknowledgement and processing for both real-time and large record “batch” submissions.
  • A common format that entities must use when providing information about their proprietary data exchange systems via “companion guides.”

These infrastructure operating rules support existing standards and will help bring more uniformity and consistency to data exchange. As one example, use of these operating rules means providers will immediately learn if the claim submission was successfully received by the plan and moved into their adjudication system. The provider is quickly made aware of obvious errors, so they can be corrected, reducing payment time.

The Phase IV Operating Rules represent the next wave of operating rules developed by CAQH CORE for the HIPAA transactions that currently have federally mandated standards. National operating rules were mandated by the Affordable Care Act (ACA) for all HIPAA transactions to ensure large amounts of data can be shared electronically among a wide range of parties across the healthcare system.

Operating rules for claims attachments, which were also included in the third set of ACA operating rules, will be formally developed once the Department of Health and Human Services (HHS) adopts a standard for this transaction. To help inform the market, CAQH CORE has already conducted significant research and will pilot options from a range of current approaches.

HHS will determine if the Phase IV Operating Rules will be included in any regulatory mandates; any considerations will include an HHS public comment period. The Phase I, II and III CAQH CORE Operating Rules became federally mandated for HIPAA-covered entities after HHS designated CAQH CORE as the authoring entity of those operating rules. 

CAQH CORE anticipates that – as with earlier phases of operating rules – a number of health plans, providers, clearinghouses, vendors and others will choose to adopt the rules prior to any HHS mandate. To facilitate this process, the Phase IV package includes a CORE Test Suite that outlines the testing requirements for entities to demonstrate their conformance with the rules.

To drive and track market adoption, CAQH CORE offers a voluntary certification program where organizations may earn a CORE Seal by successfully testing that they are adhering to the operating rules and their underlying standards. Earning a CORE Seal is akin to achieving an industry “gold standard.”

Based on the Test Suite, a CAQH CORE-authorized testing vendor will build the Phase IV testing site over the coming months. Voluntary CORE Certification will be available in summer 2016. CAQH CORE will also roll out a set of educational resources and tools to help organizations implement Phase IV.

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