Multi-stakeholder Collaboration

CAQH CORE Operating Rules are helping streamline administrative transactions for health plans, healthcare providers and vendors.

More than 140 participating organizations representing healthcare providers, health plans, government agencies and the organizations setting the standards for healthcare and data exchange are part of the CAQH CORE multi-stakeholder collaboration. The health plans participating in CAQH CORE alone cover more than 75% of all Americans with commercial insurance, as well as those covered by Medicare and Medicaid.

The greatest value and

return on investment

from the operating rules

is realized when there

is broad adoption

throughout the entire

healthcare system by

each critical player.

Patient Protection and Affordable Care Act (ACA)

The ACA has taken operating rules to a new level. It mandated healthcare operating rules for HIPAA claims-related electronic transactions, and CAQH CORE was named by the Secretary of Health and Human Services (HHS) as the authoring entity of these operating rules.

As of January 2013, all HIPAA-covered entities must adhere to the federally mandated Phase I and II CAQH CORE Operating Rules, which relate to patient eligibility and claim status.

The CAQH CORE Phase III Operating Rules for EFT & ERA have been mandated by HHS and since January 2014 any provider is able to request the streamlined electronic transactions that can result due to these operating rules and their affiliated standards.

CAQH CORE is the author of the final set of ACA-mandated operating rules for remaining HIPAA transactions, which include healthcare claims, enrollment and disenrollment in a health plan, premium payments, prior authorization and claims attachments. HHS will determine if the Phase IV CAQH CORE Operating Rules will be included in any regulatory mandates.

CORE Certification

A health plan and its IT vendors cannot simply claim they are compliant with operating rules and their underlying standards — they now must prove it. To fulfill this requirement under the ACA, HHS has proposed Federal recognition of CAQH CORE’s robust testing and certification program. HHS has outlined a key role for CAQH CORE as the administrator for certifying that health plans are implementing the ACA mandates for the first set of operating rules and underlying standards. Learn more.

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