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CORE Operating Rules Recommended to HHS for Federal Adoption

Background

In May of 2022, the CORE Board sent a letter to the National Committee on Vital and Health Statistics (NCVHS), a federal advisory committee to the Secretary of Health and Human Services (HHS), proposing new and updated operating rules for federal adoption. These rules modernize requirements related to the exchange of data for telehealth, prior authorization, complex benefit design and value-based payments.

After an open comment period and industry hearing, in a June 2023 letter to HHS, NCVHS recommended that the new and updated operating rules be mandated. If HHS supports the NCVHS recommendation, an Interim Final Rule (IFR) will be issued with public comment period. Once HHS finalizes the rule, industry stakeholders would have 25 months to implement the newly mandated operating rules.

The table below outlines the CORE Operating Rules recommended by NCVHS to HHS. The rules promote interoperability and ease the burden of workarounds and manual processes.

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Overview of Recommended CORE Operating Rules  

Data Content
  1. UPDATED CORE Eligibility and Benefits (270/271) Data Content Rule vEB.2.0
  • Expands required service type codes and requires use of procedure codes.
  • Indicates requirements for prior authorization.
  • Enhances required details about benefit structure and patient financial responsibility.
  • Facilitates telehealth coverage through required inclusion of CMS Place of Service Codes.
  1. NEW CORE Eligibility and Benefits (270/271) Single Patient Attribution Data Content Rule vEB.1.0
  • Standardizes communication of a patient’s attribution status to a provider under a value-based contract.
  

Infrastructure
  1. UPDATED CORE Eligibility and Benefits (270/271) Infrastructure Rule vEB.2.0
  2. UPDATED CORE Claim Status (276/277) Infrastructure Rule vCS2.0
  3. UPDATED CORE Payment and Remittance (835) Infrastructure Rule vPR2.0
  • Increases weekly system availability requirements to 90%.
  • Aligns connectivity requirements with most current version of CORE Connectivity.
  • Supports a version-agnostic Master Companion Guide Template.
  

Connectivity
  1. UPDATED CORE Connectivity Rule vC4.0.0
  • Modernizes certification and authentication requirements, referencing X.509 and OAuth 2.0.
  • Expands payload support to easily facilitate exchange of X12 v6020.
  • Adds support for REST, strengthening application to HL7 FHIR-based APIs.
  

Recommended Operating Rules

The rules recommended by NCVHS to HHS for federal mandate align with industry efforts to reduce administrative burden, streamline healthcare transactions, increase security and address modern business practices. The rules are summarized below.

Updated Version of CORE Connectivity

The CORE Connectivity Rule vC4.0.0 is a single, uniform that supports administrative and clinical data exchange. The rule updates and aligns CORE connectivity & security requirements to support REST and other API technology, building upon prior versions of CORE Connectivity.

Existing vs New Requirements
Existing HIPAA-mandated Connectivity Rules Updated NCVHS Recommended Connectivity Rule

Key Requirements:

  • Use of public internet connection and HTTP transport standards to establish an industry Safe Harbor
  • Employs Username and Password with optional use of digital certificate for authentication
  • Use of both SOAP and MIME messaging standards
  • Defined metadata to relieve burden of implementation and reduce variances across industry
  • Supports batch and real time interactions meeting industry needs
  • Specifies error handling processes and messaging requirements
  • Requires development and implementation of a capacity plan

Updates:

  • Continues Safe Harbor Connectivity requirements to support SOAP messaging standards
  • Incorporation of HTTPS and more stringent security standards – TLS 1.2 or higher
  • Requirement to use digital certificate for authentication – X.509
  • Implementation of stronger authorization standards – OAuth 2.0
  • Add support for the exchange of Attachments transactions – including X12 275, HL7 C-CDA, FHIR, etc.

Addition of REST standards in vC4.0.0:

  • Support for standard-agnostic REST style web resources 
  • Messaging in human-readable JAVA format
  • Support for API integration and versioning standards for CORE Connectivity

The CORE Connectivity Rule vC4.0.0 is a Safe Harbor and updates conformance requirements for implementing organizations:

  • Health plans or Clearinghouses must support all connectivity methods, SOAP and REST.
  • Providers or Vendors must support at least one connectivity method, SOAP or REST.
  • Trading partners may also use a mutually agreeable connection to facilitate the exchange of information; however, if a trading partner requests SOAP or REST exchange, that method must be accommodated.
Benefits to Industry
  • Aligns the CAQH CORE Connectivity Rule vC4.0.0 with CMS and ONC interoperability rules, including the use of REST and other API technology.
  • Establishes a Safe Harbor that aligns with existing and emerging approaches for exchanging data by continuing to support SOAP and adding support for data exchanged using REST.
  • Supports the intersection of administrative and clinical data exchange by adding support for the attachments transaction and publishing a single updated rule to include all transactions that are addressed in CAQH CORE Operating Rules, including those in development.
  • Updates the national floor guiding connectivity communication in the industry.
Updated CORE Infrastructure Rules

Updates to the CORE Infrastructure Rules for eligibility, claim status, and remittance advice provide enhanced security, greater system availability, flexibility to accommodate multiple payloads and conformance with the most current CORE Connectivity Rules.

Existing vs New Requirements

Existing HIPAA-mandated Infrastructure Rules

 

 

Updated NCVHS Recommended Infrastructure Rules

86% per calendar week

Weekly System Availability

 ➧

90% per calendar week*

N/A: Current Mandated CAQH CORE Infrastructure Rules do not include a quarterly system availability requirement

Quarterly System Availability

 ➧

Health plans and their agents may use 24 additional hours of system downtime per calendar quarter to accommodate larger system updates and maintenance*

Phase I & II Connectivity Rules/p>

(vC.1.1.0 & vC.2.2.0)

Connectivity

 ➧

Most current CAQH CORE Connectivity Rule (vC.4.0.0)

Companion guides must follow format and flow of CORE Master Companion Guide

Companion Guide

 ➧

Updates include support for the non-X12 transactions to accommodate multiple standards

*Applies to the CORE Eligibility and Claims Staus Infrastructure Rules.


Benefits to Industry
  • Aligns with today’s technology given the 24/7 nature of healthcare. Updates to system availability requirements increase up-time by 364 hours annually.
  • Supports overall greater system availability while allowing for longer, less frequent periods of downtime in recognition that today’s systems are more integrated than in the past.
  • Providers will have improved access to needed data to better serve the patient at the time of service - improving the revenue cycle, immediacy of care, and the patient experience.
  • Aligns requirements to use the CORE Connectivity Rule v4.0.0 to encourage use of both existing and emerging technology.
Updated and New Eligibility & Benefits Operating Rules

The updated CORE Eligibility & Benefits Data Content Rule enhances the exchange of  information related to telemedicine, prior authorization, remaining coverage benefits, tiered benefits, and procedure-level information between health plans and providers.

In addition to the existing data content rule update, an additional, new, Single Patient Attribution Data Content Rule was recommended to standardize communication of a patient’s attribution status to a value-based contract.

Existing vs. New Requirements

Existing HIPAA-mandated Eligibility & Benefits Data Content Rule

Updated and New NCVHS Recommended Eligibility & Benefits Data Content Rules

Key Requirements:

  • Respond in real-time response (20 seconds or less) or next day for a batch response time
  • Support detailed responses for 52 Service Type Codes (STCs)
  • Return patient financial responsibility for co-pay, co-insurance and deductible
  • Return benefit information at least 12 months into the past, up to the end of the current month
  • Use standard characters, cases, prefixes and suffixes for last names
  • Follow defined reporting of errors using AAA error codes

 

 

 

Updates:

  • Return detailed eligibility and benefit information for tiered benefit coverage.
  • Support 126 additional STCs
  • Return maximum and remaining benefits for 10 STCs
  • Indicate if included STCs or procedure codes require prior authorization or certification
  • Use CMS place of service codes when service is available through telehealth
  • Return eligibility and benefit information at the procedure code level for PT, OT, surgery, and imaging

 

New:

  • Single Patient Attribution Data Content Rule requires returning patient attribution status and effective dates of attribution
Benefits to Industry
  • Reflects complex benefit designs by expanding and including individual service type and procedure codes, respectively, and requiring health plans to return benefit design and prior authorization necessity.
  • Addition of telehealth place of service codes at eligibility verification reduces the need for manual follow-up
  • Updates align with regulatory priorities by providing detailed patient financial information and returning detailed prior authorization requirements at the point-of-care.
  • Supports value-based care models by disentangling complicated, proprietary patient attribution methodologies, returning status at the point-of-care.
  • Updates to the CAQH CORE Eligibility and Benefit Operating Rules ensure pressing industry needs are met and offer significant cost and time savings opportunities.
  • According to the 2022 CAQH Index, industry has an opportunity to save $11.78 per eligibility and benefit verification transaction when switching from manual to fully electronic transactions; these requirements will enable more transactions to be conducted electronically.  
  • Confronts emerging industry needs by addressing telemedicine, prior authorization, and providing more granular data about enrollee benefits and involvement with value-based payment models.

Resources and Issue Briefs

NCVHS Recommendations Roundup Webinar

To hear an explanation of the NCVHS process and rule recommendations from CORE leadership, listen to CORE’s recent NCVHS Recommendation Roundup Webinar.

The operating rules recommended for federal adoption are the result of an industry led, consensus-based process that included health plans, providers, government entities, vendors, clearinghouses, associations, and others. Each requirement represents a step toward automation and the elimination of costly manual workarounds. If you have any questions, please reach out to CORE@caqh.org.