CORE Phase II Rules Approved

CAQH is pleased to announce that for the first-time providers will be able to receive consistent electronic information about patient deductible balances from potentially any health plan before or at the point of care. This achievement is the result of voluntary business rules developed during the second phase of activities conducted by the CAQH Committee on Operating Rules for Information Exchange (CORE), a collaborative, multi-phase healthcare industry initiative. The CORE Phase II rules build on the Phase I rules, introduced in 2006.

The following rules were created during CORE Phase II:

• Data Content (270/271) Rule
  This Phase II rule defines the specific business information requirements that health plans must return and vendors, clearinghouses and providers must use if they are CORE-certified. The rule requires health plans to provide patient remaining deductible amounts and other patient liability for 39 additional service type codes beyond the nine service type codes provided in Phase I. The purpose of this rule is to more fully automate electronic eligibility and benefits inquiry processes.
• Claim Status (276/277) Rule
  This Phase II rule allows providers to electronically check the status of a claim and/or confirm payer organization receipt of the claim. The rule requires that health plans respond to an inquiry in real time (within 20 seconds) and requires providers and vendors to make appropriate use of the standard acknowledgements as well as the CORE connectivity requirement.
• Patient Identifier Rules: (Normalizing Patient Last Name) & (AAA Error Codes)
  These Phase II rules make it easier to uniquely identify individuals. The rules offer enhanced patient matching for all stakeholder types and further details on the error codes that outline why a match did not occur during an eligibility request.
• Connectivity Rule
  This Phase II rule provides two detailed message envelope specifications necessary for electronic connectivity and two authentication methods. As with all CORE rules, the connectivity rule is a base, not a ceiling. It is expected that entities will add specifications beyond the CORE rules. This safe harbor rule facilitates interoperability across healthcare information exchange, thus working to reduce the costly process of having many variations of the same standard. The rule targets all stakeholder types.
• Test Suite
  The Phase II Test Suite outlines each rule in a set of stakeholder-specific test scripts to allow organizations to test and certify system compliance with all the Phase II rules.

After Labor Day, CAQH will issue a press release to announce organizations that have committed to complete CORE Phase II certification or endorse the Phase II rules. Entities pursuing CORE Phase II certification must be Phase I certified, as Phase II builds upon the Phase I rules. Certification for both Phases can be achieved simultaneously. [NOTE: There is an exception to this requirement for vendors that do not offer Eligibility or do not offer Claims Status. Vendors in this position may become certified for just the Phase I or Phase II Eligibility or Phase II Claims Status requirements]. CORE expects to announce the first Phase II certifications in late 2008 or early 2009.

For more information about CORE Phase II certification, please contact Steve Zlotkus, Marketing and Business Development Analyst, at szlotkus@caqh.org or 202-778-3226.

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CAQH Administrative Simplification Conference 2008

CAQH is hosting a complimentary conference Sept. 24 – 25, 2008 in Washington, DC for healthcare professionals and their business partners involved in improving business practices through the Universal Credentialing Datasource and CORE initiatives. The CAQH Administrative Simplification Conference 2008 will kickoff with an evening reception on Sept. 24 and continue with a full day's program on Sept. 25. Building on the success of the Universal Credentialing Datasource (UCD) Best Practices Conferences, the 2008 Conference will feature sessions in two tracks. The UCD track will discuss credentialing solutions and broader business applications for provider data. The CORE track will explore how the CORE rules are transforming electronic administrative data exchange and gather recommendations for the Phase III scope of work through a town hall session. View the full agenda.

Session*	Track 1: UCD Topics	Track 2: CORE Topics
1	Universal Credentialing Datasource Positioned for the Future (ACS)	The National Drive Toward Interoperability: How the CAQH CORE Rules Make a Difference
2	Defining Quality: an Update from the UCD Data Quality Task Force	Measuring CORE ROI: an IBM Study Update
3	New Directions for the Universal Credentialing Datasource (Disaster preparedness)	Achieving an All-Payer Solution: Regional and National Implementations of the CORE Phase II Rules
4	Unlocking the Value: Using UCD Data Throughout The Enterprise	CORE Phase II Connectivity Rule: Leading the Way in Healthcare Administrative Communications
5	The Last Frontier: Capturing Delegate and Large Practice Data	CORE Certification Testing: Tips and Tools
6	Continuation of Session 5	The Future of CORE: Phase III and Beyond

*Agenda subject to change.

Please visit the conference registration page to register today.

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CORE Phase III Rules Update

Work on CORE Phase III is underway, with the committee now outlining potential areas of focus. Phase III will build on the rules created in Phase I and Phase II. Ideas contributed by CORE participants, federal and state initiatives and industry standards and HIT goals set by other healthcare organizations are shaping the potential scope of work. Topics under early consideration include detailed rules for authentication processes, content for claims status, eligibility network determination, prior authorization and remittance advice. The new 5010 regulations will be a critical part of the Phase III rule writing process.

The final scope of rules development will be determined by matching potential areas of focus against agreed-upon criteria, including what can be implemented in 2009/2010, the affordability of feasible solutions, pervasiveness of the identified challenges and resource requirements, among others.

Participation in CORE is open to all industry organizations interested in streamlining electronic healthcare administrative data transactions. For more information, please contact Steve Zlotkus, Marketing and Business Development Analyst, at szlotkus@caqh.org or 202-778-3226.

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IBM CORE ROI Study

Working with CAQH staff and a group of CORE volunteers, IBM is conducting a study to measure the impact of CORE Phase I rules. Sponsored by CAQH, the study is analyzing a variety of stakeholder metrics to define the return on investment that CORE-certified entities are experiencing by completing CORE certification and exchanging data in compliance with the Phase I rules. Participants in the study include health plans (Aetna, BlueCross BlueShield of North Carolina, and WellPoint), vendors and providers. The study results are expected to be issued during the fourth quarter of 2008.

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CORE In The News

Summit Medical Group, Leading Healthcare Product Vendors, AAPPO Join In CORE Initiative

Summit Medical Group (SMG) is the latest large provider group to complete CORE certification. SMG sought certification after learning about the benefits its trading partner, Blue Cross Blue Shield of Tennessee, was experiencing as a CORE-certified entity. Through SMG, more than 200 physicians in 50 office locations and 10 hospitals serve patients in the East Tennessee region.

CAQH announced early this summer that four other organizations had joined in CAQH CORE’s national initiative to streamline patient administrative data exchange. Learn more about these organizations here.

CORE Announces BOSE Wave Music System Winner

Tammy Blair, claims manager of Group Health Cooperative of Puget Sound, was the winner of a CAQH CORE drawing for a Bose Wave Music System at the AHIP Institute 2008. The contest was part of a marketing campaign to introduce www.coreconnect.org; a Website designed to connect organizations interested in making CORE a part of their eHealth strategy with CORE-certified organizations.

CAQH Welcomes New CORE Staff

Please join CAQH in welcoming Bob Bowman, CORE Manager, and Jonathan Grau, CORE Business Development Manager. You can reach Bob at rbowman@caqh.org and Jonathan at jgrau@caqh.org.

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State Updates

Reducing the cost of healthcare is a top priority for many states. As a result, an increasing number of states are closely examining how the CORE rules can fit into their eHealth strategies:

Colorado - CAQH presented CORE to a multi-stakeholder committee, the Colorado Health IT Advisory Committee, in March and June to educate them about CORE's approach to electronic transactions.

Ohio - Recent legislation called for the formation of an advisory committee to present recommendations on issues related to electronic information exchange, including eligibility. CORE was noted in draft legislation and CAQH was invited to present at the advisory committee's July meeting.

Texas - At the request of the Texas Department of Insurance (TDI), CAQH has presented information about CORE twice, most recently in March, to the Committee On Electronic Data Exchange (CEDE), a multi-stakeholder committee created by state legislation. CAQH will discuss CORE Phase II with the committee in September.

Virginia - The Secretary of Technology is reviewing how technology can reduce the state’s healthcare costs. CAQH presented CORE to a statewide committee in April.

If you are aware of activities in your state where CORE may fit as part of an eHealth strategy, please contact Steve Zlotkus, Marketing and Business Development Analyst, at szlotkus@caqh.org or 202-778-3226.

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UCD Surpasses 600,000 Providers

Another milestone has been achieved by the Universal Credentialing Datasource. More than 600,000 providers are now using the UCD service to simplify data collection and the credentialing process.

The UCD service streamlines the initial application and re-credentialing processes, reduces provider administrative burdens and costs, and offers health plans and participating organizations real-time access to reliable provider information for claims processing, quality assurance and member services, such as directories and referrals.

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UCD Profile - Kansas

The CAQH Standard Provider Application is now the mandated or designated provider credentialing form in Indiana, Kansas, Kentucky, Louisiana, Maryland, New Jersey, Ohio, Rhode Island, Tennessee, Vermont and the District of Columbia. Additional states are looking into making a similar move in 2008 or 2009. To date, state adoption of the CAQH form has mostly been the result of a push by the department of insurance or legislative action. A Blue Cross and Blue Shield credentialing manager got the ball rolling in Kansas.

In 2004, Kansas Governor, Kathleen Sebelius took steps to reduce health care costs and improve provider credentialing by launching the Healthy Kansas initiative. Shortly thereafter, Sandy Praeger, the Kansas Commissioner of Insurance, formed a credentialing advisory committee (CAC) to discuss how the state credentialing form could be brought up to date and meet the current credentialing standards. After learning about both, Linda Pracht, a credentialing manager at Blue Cross and Blue Shield of Kansas (BCBKS), recognized the efforts aligned closely with the CAQH mission and its Universal Credentialing Datasource (UCD) service. As credentialing manager, she had relied on UCD to meet the provider credentialing data needs at BCBKS. Pracht was certain the state could benefit equally from the initiative.

“I wanted to promote the CAQH form because it has become an established source for credentialing information nationwide, already used by a large number of healthcare providers and insurers. Having a single form reduces errors, saves time processing an application, and is easier for the provider. It makes good business sense to use one application,” explains Pracht. "This is something we've needed for many years."

As a first step, she contacted Commissioner Praeger to discuss UCD as a possible solution. At a resulting meeting with members of the Kansas Insurance Department (KID) Health Policy and Finance subcommittee, Pracht offered her insights about the advantages of the CAQH form and the administrative savings it made possible in her organization and across the country. Impressed, Praeger asked Pracht to chair the CAC. Pracht welcomed the opportunity to suggest the CAQH application as a solution to committee members - representatives from the Kansas Medical Society, Kansas State Board of Healing Arts, Kansas Foundation of Medical Care, The Kansas Hospital Association, hospital staff and health plans.

CAC members ultimately agreed with Pracht that the CAQH form was the solution for streamlining provider credentialing data collection in the state and the committee recommended adoption of the form. The State of Kansas officially designated the CAQH application as the Kansas Standardized Credentialing Application on June 1, 2007.

“Educating others that the UCD form eliminates the need to complete multiple forms and that it can be completed online with no cost to the provider were important points in stimulating adoption,” says Pracht. "Getting the attention and support from our insurance commissioner and governor, through education and perseverance, also didn't hurt.”

For more information about Pracht's story or for tips on promoting the CAQH form in your state, please contact Sorin Davis, Director of Marketing and Business Development, at sdavis@caqh.org.

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Data Quality Task Force Update

The Universal Credentialing Datasource Data Quality Task Force was formed several months ago to assess the integrity, timeliness and accuracy of the self-reported provider data obtained through the UCD. The group is working to identify alternative uses of the UCD data and recommend future directions for the initiative.

The task force, including representatives from Aetna, CIGNA, Coventry, BCBS of Michigan, Health Alliance Plan, HIP, Humana, Independence BCBS, MagnaCare, United Healthcare (Chair) and WellPoint, held its first meeting on April 17th. With three meetings now completed, the group is currently in the process of compiling results from a data mapping exercise. The exercise was conducted to identify enterprise departments that use provider data and to define those provider data elements being used.

The next step is for the task force is to develop a validation study, which is expected to produce a final findings report by year’s end.

For more information, contact Christy Stroup, Credentialing Sales Manager, at cstroup@caqh.org or (202) 778-3208.

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UCD In The News

Unique CAQH-Hospital Association Agreement

CAQH and the Vermont Association of Hospitals and Health Systems (VAHHS) recently announced a first-in-the-nation agreement that offers member hospitals a lower price to participate in the Universal Credentialing Datasource® (UCD) service. CAQH believes the agreement can serve as a model for hospital associations across the country. Read the full press release here.

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State Updates

States are increasingly recognizing the benefits of using the industry standard for collecting provider data.

Missouri– In the June 16, 2008 edition of the Missouri Register, the State of Missouri published its intent to adopt the CAQH UCD application as the sole credentialing form in the state. State adoption is expected in early 2009.

New Jersey - The New Jersey Health Plan Association and local provider stakeholders have agreed to support changing current state legislation to make the CAQH UCD application the sole form in the state. CAQH is working with the New Jersey Department of Banking and Insurance on making these changes.

Ohio - The Ohio Department of Insurance recently ruled that all providers must use the CAQH Standard Provider Application to submit required information. Ohio providers must begin using the form no later than Sept. 25, 2008.

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Catalyst is a quarterly CAQH ePublication focused on strategies and best-practices for simplifying healthcare administration.