CAQH CORE Town Hall Highlights Progress of Operating Rules and Opportunities Ahead

November 2016

From greater implementation of the CAQH CORE operating rules to research on the operational needs of the industry to support value-based payments, CAQH CORE continues to identify and implement opportunities that drive the industry toward true interoperability and electronic data exchange. These topics, among others, were highlighted in a recent Town Hall webinar in which CAQH CORE provided progress updates and discussed initiatives underway to enhance the exchange of electronic data in healthcare business transactions.

Gwendolyn Lohse, Deputy Director of CAQH, noted that the CAQH CORE Participating Organizations and industry at large have developed, supported and begun implementing national operating rules for seven major transactions that support the entire payment system for healthcare delivery in the nation. Equally important, the operating rule requirements have established a data exchange infrastructure to facilitate efficient HIPAA claims-related transactions, which can easily support the underlying standards as they are updated.

The webinar also described the benefits that organizations gain from becoming voluntarily CORE-certified. As the number of CORE certifications awarded approaches 300, organizations are increasingly looking to this “gold-standard” certification program as a way to conform to the rules while also strategically planning how to integrate the rules into their broader e-health vision.
 

The Value of Phase IV Rules and Certification

The Phase IV rules, the most recently finalized phase of CAQH CORE rules, aim to eliminate the “black hole” experience that occurs for providers with certain communications with health plans.  They establish national expectations to respond in batch or real-time to both confirm the receipt of claims by health plans (or the vendors and clearinghouses with whom they work) and immediately communicate important claims-related information. By adopting the rules voluntarily, entities can get ahead of the marketplace and establish their positions as industry leaders.

The rules provide a set of infrastructure requirements that cover the following transactions: claims, prior authorization, enrollment and disenrollment and premium payments. The Phase IV infrastructure rules are consistent with the first three phases and include infrastructure requirements for response times, connectivity, standardized companion guides, system availability, acknowledgements and targeted expectations for the exchange of data.

While the operating rules for Phases I-III are mandated under the Affordable Care Act, regulatory action by the Department of Health and Human Services regarding the Phase IV rules is pending.

Approximately 55 percent of respondents to a poll at the Town Hall webinar on August 24th indicated that they have begun internal education, awareness, and systems planning and design to begin implementation of the Phase IV CAQH CORE Operating Rules in 2016. Entities can begin getting CORE-certified in the Phase IV operating rules later this year.

There are a number of resources available on the CAQH website to support the Phase IV testing process and to help entities communicate the value of Phase I-IV certification to stakeholders.

Exploring New Operating Rules

New efforts by CAQH CORE include acting on the CORE Board commitment to develop a path to go beyond the Phase IV rules on prior authorization, while the industry is implementing the Phase IV foundation on which additional rules can be built. For example, only 10 percent of prior authorization transactions are conducted electronically, according to the most recent CAQH Index report. Research on this issue is launching this month to inform the development of additional, voluntary prior authorization rules that would build on the Phase IV rules.

Addressing Industry Shifts to Value-Based Care

As the healthcare system increasingly moves away from a fee-for-service model, CAQH CORE is exploring how to address operational activities that would support electronic data exchange for evolving value-based payment models. This includes a series of interviews with individuals experienced in value-based care delivery to help identify areas for coordinated industry action by CAQH CORE or others. The standardization of terminology used in value-based payment and identification of common data sets are two examples of areas that are being explored. Results of the research will be shared with the industry.

“In anticipation, we need to figure out—as an industry—the health IT needs required to support these models,” said Lohse. She noted that it is important to ask how to ease the process of transformation now, instead of aligning the industry after various implementations occur.

To learn more about the topics discussed during the webinar, the recording and slide deck are available for download.

Visit www.caqhcore.org for more information.

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