CAQH CORE Phase IV Operating Rules

Click HERE to read the July 29, 2016 CAQH CORE Board letter to HHS in Reponse to the NCVHS Recommendation on Adoption of the Phase IV CAQH CORE Operating Rules.

The Phase IV CAQH CORE Operating Rules Package was approved in September 2015 for four healthcare business transactions: healthcare claims; prior authorization; employee premium payment; and enrollment and disenrollment in a health plan.

The Department of Health and Human Services (HHS) will determine if the new Phase IV CAQH CORE Operating Rules will be included in any regulatory mandates.

Process for Rule Approval

The Complete Set of Phase IV CAQH CORE Operating Rules was approved the CAQH CORE voting process in September 2015. The review and approval process includes voting by Subgroups and Work Groups that develop the draft rules and subsequent approval by those CAQH CORE participating organizations that create, transmit or use healthcare administrative data. The operating rules package is then forwarded to the CAQH CORE Board for final review and approval. For the Phase IV package, more than 90 percent of these participating organizations took part in the final vote, resulting in 88 percent approval; the board approval was unanimous.

All CAQH CORE Operating Rules have the capacity to address both transaction data content and infrastructure (e.g., connectivity, response time, system availability, etc.) requirements. The Phase IV CAQH CORE Operating Rules address infrastructure requirements, with data content to be added later if deemed appropriate by industry stakeholders. By focusing first on infrastructure requirements, CAQH CORE is building on the industry’s familiarity with previous operating rule requirements to further national infrastructure expectations to support existing standards.

Phase IV Implementation Resources

The Phase IV CAQH CORE Operating Rules Analysis & Planning Guide is now available. Click HERE to access all the CAQH CORE Operating Rule Implementation Tools.

Learn more about the benefits of the Phase IV CAQH CORE Operating Rules and how they may impact your stakeholder type HERE.

 

Phase IV CAQH CORE Operating Rules and Policies

 

Phase IV CAQH CORE Operating Rules

The Complete Set of Phase IV CAQH CORE Operating Rules is available HERE.

 

Phase IV CAQH CORE 450 Health Care Claim (837) Infrastructure Rule v4.0.0

Phase IV CAQH CORE 452 Health Care Services Review – Request for Review and Response (278) Infrastructure Rule v4.0.0

Phase IV CAQH CORE 454 Benefit Enrollment and Maintenance (834) Infrastructure Rule v4.0.0

Phase IV CAQH CORE 456 Premium Payment (820) Infrastructure Rule v4.0.0

Phase IV CAQH CORE 470 Connectivity Rule v4.0.0

Phase IV CAQH CORE-Required Processing Mode and Payload Type Tables v4.0.0

XML Schema Specification (normative)

Web Services Definition Language (WSDL) Specification (normative)

 

Phase IV CAQH CORE Voluntary Certification

For each Phase of CAQH CORE Operating Rules, a CAQH CORE Certification Test Suite is developed specifying how entities can demonstrate conformance with each respective phase through pursuit of CORE Certification. CORE Certification Testing on the Phase IV CAQH CORE Operating Rules is now open for public beta testing. Follow the link to access the Phase IV CORE Certification Test Site. Please contact CORE@caqh.org if your entity is interested in becoming an early adopter of this rule set.  If you want to become a CAQH CORE-authorized testing vendor, learn more HERE.

 

Phase IV CAQH CORE Policies

Phase IV CAQH CORE 400 Guiding Principles

Phase IV CAQH CORE 401 Pledge

Phase IV CAQH CORE 402 Certification Policy

Phase IV CAQH CORE 403 Health Plan IT System Exemption Policy

Phase IV CAQH CORE 404 Certification Testing Policy

Phase IV CAQH CORE 405 Enforcement Policy

 

ACA Mandated Operating Rules

The Patient Protection and Affordable Care Act (PPACA), also known as the Affordable Care Act (ACA), Section 1104 requires the Secretary of HHS to adopt and regularly update operating rules for each of the HIPAA-mandated healthcare administrative transactions. The remaining operating rules mandated in ACA Section 1104 address the following five HIPAA-mandated administrative transactions:

  • Health claims or equivalent encounter information
  • Health plan enrollment/disenrollment
  • Health plan premium payments
  • Referral certification and authorization
  • Health claims attachments

HHS will determine if the new Phase IV Operating Rules will be included in any regulatory mandates. Any such considerations will include an HHS public comment period.

NOTE: For more information on the ACA-mandated timelines see the CMS website HERE.

What is Not Included in the Phase IV CAQH CORE Operating Rules: Health Claims Attachments

Section 1104 of the ACA includes the health claims attachment transaction in the list of electronic healthcare transactions for which the HHS Secretary must adopt a standard under HIPAA. To date, HHS has not adopted a standard for health claims attachments or indicated what standard(s) it might consider for the transaction, and an effective date for these operating rules is not included in the ACA. As such, the immediate focus of the Phase IV CAQH CORE Operating Rules does not include health claims attachments.

Interim CAQH CORE Activities Related to Attachments

Since 2012, CAQH CORE has conducted extensive research to identify how regulatory requirements can help drive the adoption of electronic attachments. A market assessment was conducted in 2013 to identify business needs, data content and format requirements, technical infrastructure, and priorities for the exchange of attachments/additional information using administrative transactions. In 2014, CAQH CORE held listening sessions with over 300 participants to continue this dialogue, discuss trends, and obtain data from current industry activities and experience. The findings of this research indicate that the vast majority of entities are still using paper to provide clinical data on a claim or other administrative transactions, and, when attachments are electronic, the most common formats are PDF, JPG, TIF, and Word.

Based on these findings, CAQH CORE supports an incremental, flexible use of operating rules to move attachments from paper to electronic documents, as recommended by the National Committee on Vital and Health Statistics (NCVHS) in its June 21, 2013 letter to the Secretary. For example, CAQH CORE Operating Rules could adopt requirements around a limited set of industry-neutral electronic document formats to quickly (within two years) provide the industry with efficiencies and movement toward electronic formats; e.g., use of JPG and requiring a trace number or other tracing mechanism to link an attachment to its request. Additionally, based on CAQH CORE research, it is evident that industry-wide education will be key given the current level of knowledge of specific attachment-related standards such as HL7 C-CDA. CAQH CORE supports such industry education and coordinate with key stakeholders. After HHS adopts a standard for health claims attachments, there are a range of opportunities for CAQH CORE Operating Rules, such as:

  • Use of LOINC attachment type codes to identify specific document/information needed
  • Workflow/business rules for unsolicited attachments
  • Scenario-based adoption of structured documents
  • Potential ways to reduce the number of attachments

To research these needs, in 2015 CAQH CORE will conduct a pilot on Attachments options. To volunteer for the pilot, e-mail CAQH CORE at CORE@caqh.org.

 

Other CAQH CORE Operating Rules

ACA-Related

  • The Phase I, II and III CAQH CORE Operating Rules already are mandated by the ACA. Follow the links for more information on each Phase. Voluntary CORE Certification is available for all three Phases.

 

Voluntary

  • CAQH CORE also has developed other operating rules that currently are used on a voluntary basis.  If you are interested in learning more or obtaining a copy of these draft rules, email CORE@caqh.org.

Contacts

For more information about the operating rules process contact CAQH CORE at CORE@caqh.org.

 

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