CAQH CORE Overview

Operating Rules Streamline the Business of Healthcare

Mission

Drive the creation and adoption of healthcare operating rules that support standards, accelerate interoperability, and align administrative and clinical activities among providers, payers and consumers.

Vision

An industry-wide facilitator of a trusted, simple and sustainable healthcare data exchange that evolves and aligns with market needs.

Operating rules are crucial in a technology-driven world

Organizations have a critical need to electronically share large quantities of data quickly and accurately. Many industries, such as banking and telecommunications, embrace technical standards and common business practices to simplify sharing data among many parties.  Operating rules support standards, and then specify the business actions each party must adhere to in order to ensure a high volume of reliable transactions can occur smoothly in a given industry.

Effectively sharing data is especially important in healthcare

To meet this need, healthcare stakeholders have come together to develop, agree upon and then adopt operating rules for the industry.

Operating rules require collaboration 

Almost a decade ago, CAQH established the Committee on Operating Rules for Information Exchange, also known as CAQH CORE.  CAQH CORE is an industry-wide stakeholder collaboration committed to the development and adoption of national operating rules for administrative transactions.

CAQH CORE is governed by a multi-stakeholder executive-level board to address the interests of more than 140 participating organizations representing healthcare providers, health plans, government agencies and the organizations setting the standards for healthcare and data exchange. In fact, the health plans in CAQH CORE alone cover more than 75% of all Americans with commercial insurance, as well as those covered by Medicare and Medicaid.

Certification demonstrates action and adherence

Not only does CAQH CORE develop operating rules, it also offers a voluntary certification program so organizations can demonstrate they have adopted and are adhering to those rules. Organizations that create, use or transmit administrative healthcare data (such as health plans, healthcare providers and vendors) can earn CORE certification. To date, more than 150 CORE Certifications have been attained.

CAQH CORE certification verifies that an organization or product operates in agreement with the operating rules and the underlying standards, and is doing so with their trading partners as well.  The greatest value and return-on-investment from operating rules is realized when they are broadly adopted throughout the entire healthcare system by each critical player.  

 
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