Ten Additional Healthcare Organizations Achieve Voluntary CAQH CORE Operating Rules Certifications

Voluntary Certifications Ensure Operating Rules Compliance and Enhance Value across Providers, Vendors, and Health Plans

WASHINGTON, DC - 4/18/13

CAQH® announced today that ten additional organizations, including leading health plans representing approximately 30 million covered lives, and prominent clearinghouses and vendors, have earned voluntary CAQH CORE Phase I or Phase II Operating Rules certification after completing a rigorous testing process. This brings to more than 60 the number of healthcare organizations and products that have achieved CORE certification.

A broad multi-stakeholder collaboration of more than 130 participants developed the CAQH CORE operating rules, as well as voluntary testing and certification requirements, to streamline administrative data exchanges.

“Accessible and objective testing and certification opportunities, such as CORE certification, are critical to verifying compliance with operating rule mandates,” says Steve Erkenbrack, president and chief executive officer of Rocky Mountain Health Plans. “This certification also assures that our business partners can rely on streamlined exchanges with us.”

The latest healthcare organizations to successfully complete the voluntary CORE certification process are:

  • Blue Cross and Blue Shield of Nebraska - Phase I and II
  • HealthFusion for its HealthFusion® Real-Time product - Phase II
  • Humana Inc. - Phase II
  • Loxogon, Inc. for its Loxogon AlloyTM product - Phase I
  • NextGen Healthcare for its NextGen Practice Management product - Phase I and II
  • Office Ally for its Office Ally Clearinghouse product - Phase II
  • OptumInsight for its Optum Netwerkes 2.2.0 product - Phase II
  • RelayHealth for its RelayExchange product - Phase II
  • Rocky Mountain Health Plans - Phase I and II
  • Smart Data Solutions for its Smart Data Stream product - Phase I and II

In addition, CAQH announced a queue of healthcare organizations committed to achieving voluntary CORE certification in the near future, including a health plan and three clearinghouses and vendor companies. The health plan is Centene Corporation (Phase I and II). The clearinghouses and vendors include GE Healthcare Centricity EDI Services (Phase I and II), HEALTHeNET Administrative Data Exchange service for Western New York (Phase I), and IVANS EligibilityOneTM (Phase I).

The CAQH CORE Phase I and Phase II Eligibility and Claim Status Operating Rules are the first in a series to be adopted under federal law implementing the Patient Protection and Affordable Care Act (ACA), making the rules mandatory for HIPAA-covered entities. The U.S. Department of Health and Human Services (HHS) estimates the eligibility and claim status rules to save providers, health plans and government $12 billion over the coming 10 years.

CORE certification remains voluntary, yet organizations continue to see its value. Voluntary certification supports accountability and promotes broader use of the operating rules, driving value and return on investment for all trading partners in the data exchange. The process also verifies compliance and ensures alignment with all CAQH CORE-authored operating rules mandated by law.

Some states are formally recognizing CORE certification. For example, Colorado has identified voluntary CORE certification as acceptable evidence of compliance with a state law requiring health plans to conduct transactions using the CAQH CORE Operating Rules.

The industry-developed operating rules streamline and standardize how health plans, physician offices, and others communicate certain information about individual benefits and claims, and also expand the data available. They make it possible to know whether key services are covered, how much patients should pay at the time of service, and allow providers to check the status of a claim electronically, all in real-time.

CAQH certifies and awards voluntary CORE Certification Seals to entities that create, transmit or use the administrative transactions in accordance with the CAQH CORE Operating Rules. Organizations begin the voluntary CORE certification process by testing operating rules implementation online through Edifecs, an independent CORE-authorized testing vendor.

About CAQH CORE
The CAQH Committee on Operating Rules for Information Exchange (CORE) is a multi-stakeholder industry collaboration developing operating rules that streamline administrative transactions. Over the past eight years, CAQH CORE participation has grown to more than 130 organizations. CAQH CORE has a proven track record of delivering return on investment that is driven by widespread adoption and voluntary certification of operating rules. HHS designated CAQH CORE to author three sets of federally mandated operating rules under the ACA. To learn more, visit www.caqh.org/benefits.php.

About CAQH
CAQH serves as a catalyst for industry collaboration on initiatives that simplify healthcare administration for health plans and providers, resulting in a better care experience for patients and caregivers. Visit www.caqh.org for more information.

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