Discussion of NCVHS Recommendations

CORE Goal

Per the December 2010 NCVHS hearings and timelines of PPACA Section 1104, CORE will aim to finalize a set of CORE-approved Phase I and II rule enhancements by the end of February 2011.

Background

The September 30th, 2010 NCVHS letter regarding Section 1104 of the Patient Protection and Affordable Care Act (ACA) included a recommendation of the Phase I and II CORE Operating Rules for eligibility/benefits and claim status for the non-retail pharmacy sector.

Given the NCVHS recommendation for CORE to review potential enhancements to the Phase I and II rules, CAQH staff collected suggestions from states (see page 6 ofCAQH’s 12/03/10 NCVHS testimony for more detail), providers and other key stakeholders on potential enhancements throughout October to early December, 2010. In November, additional feedback was sought from CORE participants and non-CORE participants via an open survey and “Tiger Team” calls. (View a brief summary of the survey results or a high-level summary of the discussions). The appropriate CORE Subgroups and Work Groups then met to discuss the potential enhancements to the Phase I and II CORE rules due to the NCVHS recommendation.

Per the CORE voting process, in late-November/early December, 2010, both the Rules Work Group and Technical Work Group held ballots on potential enhancements to the CORE rules. Summaries of these calls and ballot results are available on the CAQH Calendar which can be accessed by logging in on the left side of this webpage. The table below summarizes the status of the potential enhancements as agreed by the two Work Groups:

Potential Rules Approved by Work Groups
Status
Next Steps
1. Use of 277CA for acknowledging v5010 837 claims (Complete draft Phase III Rule) Approved by Rules Work Group 1. CORE Steering Committee Review
2. All-CORE vote
2. Uniform use of claims status category and claims status codes (Complete draft Phase III Rule)
3. Replace 997 functional acknowledgement with 999 interchange acknowledgement (Modifications to Phase I/II CORE Rules based on Phase III update)
4. Four enhancements to the Phase II CORE Connectivity Rule for NCVHS as proposed by the Connectivity & Security Subgroup including:
i. Updates to rule to support all HIPAA-mandated and non-HIPAA mandated X12 v5010 administrative transactions
ii. Enhancements to support the Draft Phase III CORE rules, e.g. 835 transaction
iii. Enhancements to address optional and required field inconsistencies in the Phase II CORE Connectivity Rule
iv. Enhancements to address Phase II CORE FAQ, errata and clarifying language
Approved by Technical Work Group
Other
5. Test scripts for items #1 and #2 above Approved by the Technical Work Group 1. CORE Steering Committee Review
2. All-CORE vote
6. Communicate industry interest in reviewing WEDI /ASC X12 Companion Guides and associated documents Approved by Rules Work Group None, with regard to enhancements.
An ad hoc Companion Guide Subgroup was convened to review the WEDI/ASC X12 Companion Guides and consider the feasibility of drafting an operating rule in such a compressed timeframe or updating current Companion Guide rule. The Subgroup recommendation to the Rules Work Group, which the Work Group agreed upon, was that it is not feasible to draft an operating rule for the WEDI/ASC X12 Companion Guides within the time frame allowed. This work will be considered in future rules.

 

Next Steps in the CORE Process

NCVHS expressed support for CORE to complete the CORE voting process, including an all-CORE vote. To that end, CORE will be holding CORE-participant calls through January 2011 with the goal of holding an all-CORE vote in February. Reminder emails will be distributed to the appropriate distribution lists as the call dates approach. For the call schedules, see the CAQH calendar or contact CAQH staff.

What Is Needed From You:

Your organization may have representatives that sit on different CORE Subgroups and Work Groups. Please contact Omoniyi Adekanmbi at oadekanmbi@caqh.org or 202-778-8489 if you wish to join a particular Subgroup or Work Group or if you are unsure who is the CORE Voting Representative from your organization for the all-CORE vote (each organization that creates, transmits or uses the transaction data or is a member in good standing of CAQH has one vote).

Reminder: If no enhancements are made to the CORE Phase I and II rules, NCVHS will determine how the Phase I and II rules may be used to meet the Section 1104 deadlines.

References:

  1. The CORE Operating Rules can be accessed on the CAQH CORE web site and are free of charge:
  2. CORE survey - Issued to consider potential enhancements to the CORE Phase I and II operating rules related to eligibility and claim status: PDF format. (Reference only; survey is closed.)
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