CORE Phase II Achievements 

Organizations are implementing a second set of business rules from the Committee on Operating Rules for Information Exchange^® (CORE) to advance administrative interoperability. CORE Phase II certification by a number of organizations is bringing enhanced benefits to providers and patients nationwide.

Vendors, clearinghouses, and health plans have fulfilled their commitments to achieve Phase II certification in recent weeks. Included in this group are national health plans, Aetna and WellPoint. Together, these two health plans serve more than 50 million members. Harvard Pilgrim Health Care, a regional health plan and NaviNet, a clearinghouse, were the first to become certified for the second set of CORE rules.

By earning the CORE Phase II Seal, these organizations are promoting the importance of a single set of operating rules in the healthcare industry. Approximately 40 organizations are now certified for CORE Phase I and/or CORE Phase II rules.

CORE enables stakeholders to capture and exchange consistent and accurate claims, eligibility and benefits data by pairing robust content rules with infrastructure requirements that streamline real-time data flow through existing systems. The CORE Phase II rules are helping providers access a significantly expanded set of electronic administrative data to support their commercial, Medicaid and Medicare Advantage patients.

CORE Phase II certification by these organizations represents an important milestone in this voluntary industry-driven effort to advance healthcare interoperability. A CAQH^® study by IBM Global Business Services found that industry-wide implementation of the CORE Phase I rules alone could yield $3 billion in healthcare savings. Widespread adoption of the Phase II rules and subsequent phases of CORE will result in even higher savings for stakeholders across the industry.

Read the full press release on Aetna and WellPoint. Click here for a current roster of CORE certified organizations.

Questions about the CORE rules and CORE Phase II certification should be directed to Jonathan Grau at jgrau@caqh.org or (202) 861-1487.

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Phase III Rules Coming Soon 

Organizations exchanging administrative data can look forward to adopting a new phase of operating rules to streamline transactions with trading partners. CORE Phase III rules are nearing completion and are expected to be finalized by the end of Q1, 2010.

The rules will undergo a multi-step voting process. This ensures that the rules have a thorough technical and strategic review by representatives of participating organizations before they reach the market and are widely adopted.

The third set of CORE rules builds on the first and second phases, adding new rules for payment/remittance advice, as well as authorizations, pre-certifications and referrals. The Phase III rules that have completed Subgroup and Work Group straw polling necessary to begin official voting include those for referral request infrastructure, remittance advice infrastructure, real-time claim history availability, claims acknowledgements, ID cards, and extending eligibility data. Still in development are rules for category/status/entity ID code usage, as well as the rule extensions for connectivity.

To learn more about the Phase III rules or to become involved in the rule-writing process, contact Steven Zlotkus at szlotkus@caqh.org or (202) 778-3226.

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Certifications on the CAQH Website 

Organizations interested in identifying trading partners that are certified for operating in accordance with the rules from the Committee on Operating Rules for Information Exchange^® (CORE), can easily access this information online. CAQH^® has revised its Website to reflect pending and current organizational certifications on a single Webpage: http://www.caqh.org/CORE_organizations.php.

At a glance, visitors can determine which health plans, providers, vendors and clearinghouses are certified for Phase I and/or Phase II. Additionally, organizational commitments to subsequent phases, including intended implementation dates, are also listed on the Webpage. Updates are made regularly.

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Secure Authentication Pilot 

On February 16^th, CAQH^® announced that it is joining with VeriSign, Inc. to conduct a pilot program demonstrating the secure authentication that is essential to the national agenda for health IT interoperability.

The six-month pilot will build upon the set of operating rules created by the CAQH Committee on Operating Rules for Information Exchange (CORE^®). The CORE Phase II rules include the requirement to use digital certificates to access patient data. CORE will use the VeriSign^® Public Key Infrastructure (PKI) to create a prototype community that identifies best practices and tests data encryption operating rules to safely transmit patient administrative information between providers, payers and healthcare vendors.

Read the press release here.

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CORE Podcast 

Gwendolyn Lohse is the Managing Director of the Committee on Operating Rules for Information Exchange^® (CORE) at CAQH^®.

In a 38-minute interview, Lohse discusses CORE and how it helps reduce the burden of healthcare administration by making it easier for providers and payers to exchange data. She shares the details of an independent study that shows how CORE saves providers and payers time and money. Lohse also discusses how CORE makes it easier for providers to meet the HITECH Meaningful Use draft criteria recently released by the Centers for Medicare and Medicaid Services (CMS), and supports the move to HIPAA v5010, including rules that require the use of the non-mandated aspects of 5010 eligibility such as year-to-date financials and in/out of network variances.

Listen to the podcast by clicking here. Or visit http://www.chaddsfordplanning.com/podcasts.html and select "Episode #3 01-14-10".

NOTE: A media player download may be necessary to listen to the podcast.

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UPD STATS AT A GLANCE UPD is the industry standard for self-reported provider data collection. On average, 8,000 providers join the service each month. Totals as of February 11, 2010: Providers Using UPD to Reduce Administrative Costs: 793,915 Annual Administrative Savings: $92 million (3.1 million hours) Paper Applications Eliminated Since Service Inception: 2.36 million Environmental Impact: Estimated 82.7 million pieces of paper or 9,900 trees NEW UPD PARTICIPANTS (Sept. 2009 - Feb. 2010) American Care, Inc. Children's Mercy Health Network Corinthian Medical IPA Detroit Medical Centers Guardian Healthcare, Inc Kaiser Foundation Health Plan     of Ohio KnightMD Logistics Health Magnolia Heath Plan (Centene) Medical Care at Home National Vision New York State Department     of Health (Medicaid) Psychcare SCAN Simply Healthcare State of CT Judicial Branch The Peoples Community Wellness     Center The Superior Plan (Centene) University Hospitals     (Cleveland, OH)

UPD Now Supports Almost 800,000 Providers 

In 2009 the Universal Provider Datasource^® (UPD) successfully grew its customer base by over 10 percent, starting the year with approximately 690,000 providers, and ending the year with nearly 100,000 additional providers submitting their data through the service. The result is simplified data collection, less paperwork, a streamlined credentialing process, and a robust source of provider data. UPD provider data is increasingly being leveraged enterprise-wide for credentialing, claims processing, quality assurance, emergency response, member services and more.

"UPD has been an indispensable tool for Women and Infants. Simplifying the data collection process for physicians is allowing us to focus on our fundamental business of enhancing patient care," said Jackie LaTorre, payer application specialist for Women and Infants Physician Hospital Organization in Rhode Island.

If you are interested in learning more about UPD, contact Christine Stroup at cstroup@caqh.org.

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New Mexico Designates UPD Form 

New Mexico recently became the thirteenth state to designate the Universal Provider Datasource^® (UPD) application as a state standard. The UPD form is one of two applications that are being accepted for credentialing and re-credentialing purposes throughout the state. Effective September 1, 2009, the Insurance Division of the New Mexico Public Regulation Commission began requiring health insurers to complete the credentialing process using either the Hospital Services Corporation (HSC) or UPD form.

New Mexico joins twelve other states, Indiana, Kansas, Kentucky, Louisiana, Maryland, Missouri, New Jersey, Ohio, Rhode Island, Tennessee, Vermont and the District of Columbia, in adopting the UPD form as their mandated or approved provider credentialing form. These state designations are enabling a high adoption rate for the UPD service among providers. Based on the most current Federation of State Medical Boards (FSMB) data (2008) for licensed and practicing physicians (MDs) and osteopaths (DOs), the four states with the highest percentage of UPD adoption are also states that have required or approved the UPD form for state-wide use: Rhode Island (99%), Kentucky (89%), Tennessee (89%), and Vermont (88%).

To find out more about state opportunities with UPD, contact Christine Stroup at cstroup@caqh.org.

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SanctionsTrack Offers New, Improved Functionality 

CAQH^® recently released enhancements to SanctionsTrack, an add-on feature of the Universal Provider Datasource^® (UPD). SanctionsTrack helps eliminate the redundant processes used by healthcare organizations to collect disciplinary action information on healthcare providers. In addition to NCQA approved on-going sanctions monitoring of all providers, these enhancements offer new functionality that allows system users to search by individual provider names to determine if there are any disciplinary actions.

Requested by subscribers, this new lookup feature will streamline the sanctions monitoring process for participating organizations and allow for immediate verification of new providers applying for network admission. SanctionsTrack quickly identifies all providers in the U.S. with sanctions and/or disciplinary actions through daily updates drawn from all state licensing boards, the Office of Inspector General, Office of Personnel Management and Medicare/Medicaid sources -- more than 400 in all.

Organizations interested in learning more about SanctionsTrack are encouraged to request a sample extract. Upon request, UPD can run a report that summarizes sanctions against organizational rosters and produce images of the board orders.

Find more information about SanctionsTrack at http://www.caqh.org/ucd_health_sanctions-track.php; or contact Charlene Harrison at charrison@caqh.org.

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Game-Changing Approach to Primary Source Verification 

The PSV component of credentialing procedures today is a redundant process required to individually verify the training and experience of the providers admitted to health plan networks or granted hospital privileges. In an era when healthcare expenditures are rapidly approaching 18 percent of GDP and quality and efficiency are at the forefront of healthcare reform efforts, this is a process that can benefit from an industry-wide approach to potentially improve the timeliness and accuracy of the data.

At the request of key stakeholders, CAQH^® launched a review of the current industry approach to PSV. The objective was to determine the feasibility of centralizing the verification of information each time a provider applies for health plan participation or hospital privileges, and the subsequent confirmations associated with periodic re-credentialing.

In early 2009, a work group of healthcare organizations and credentialing subject matter experts was established to analyze the current process, identify areas for improvement, review potential solutions, and recommend an enhanced process. The group produced a white paper highlighting the current PSV process and recommending the adoption of a continuous verification approach. Continuous verification would include performing an initial verification, followed by continuous monitoring to identify any reportable events (e.g. professional liability settlement) and routine updates to date-sensitive information (e.g. license renewal) driven by the due dates of those data elements. This approach, if implemented by the industry, could lower costs by eliminating redundancy and improve quality through more timely and consistent information.

As the next step in the feasibility study, CAQH is designing a prototype to evaluate the potential for industry-wide cost savings and to define the anticipated benefits. An update on the project will be included in the next issue of Catalyst.

To learn more or receive a copy of the white paper, please contact Sorin Davis at sdavis@caqh.org.

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Account Management Promotion 

CAQH^® is pleased to announce the promotion of Josh McDonald to Account Manager, Universal Provider Datasource^® (UPD). Josh joined CAQH in May 2008 and will be responsible for assisting participating organizations with account setup, training and utilization. He can be reached at jmcdonald@caqh.org.

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UPD Receives Excalibur Award 

The Army National Guard (ARNG) Centralized Credentialing Initiative, comprised of the ARNG, CAQH^®, Anthem Credentialing Solutions, Inc. (ASCI), part of the WellPoint family of companies, and Tenon Consulting Solutions, has received the Excalibur Award from the Army Surgeon General. This acknowledgment honors a multidisciplinary team that has improved the readiness and mobility of providers, while assuring their clinical competency for the highest level of care from the U.S. Army Medical Department to its fighting forces.

ARNG chose the CAQH Universal Provider Datasource^® (UPD) as its standard data collection application, minimizing the paperwork burden for 1,500 providers while simplifying the process of meeting overall credentialing requirements. Read the full press release here.

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