September 2021
CAQH CORE is pleased to announce that it has welcomed two new members to its board: Kevin Mulcahy, Senior Director, Payer Relations, Special Billing & Provider Enrollment at Massachusetts General Physician Organization, part of Partners HealthCare, who will replace Dr. Susan Turney, CEO at Marshfield Clinic Health System in the MGMA-proposed seat. Achudhan (Achu) Sivakumar, Software Development Product Lead – Referrals and Authorizations at Epic, who will replace Sreevinas (Vasu) Pasumarthi, Software Development Group Lead - Registration, Eligibility, Referrals & Authorizations in… Read more »
August 2021
How has COVID-19 impacted administrative transactions?  In May 2021, CAQH Explorations released an issue brief examining the impact of COVID-19 on transaction volumes. The initial results indicated that most administrative transactions experienced a decline in volume during the early months of the pandemic (January – May 2020) compared to the same timeframe in 2019. The reductions in transaction volume can in large part be attributed to changes in pandemic resource allocation and state and local policy changes intended to contain the spread of COVID-19. For example, to ensure that patients… Read more »
July 2021
AultCare is the first healthcare organization to earn CORE Recertification for three sets of CAQH CORE Operating Rules, demonstrating its ongoing commitment to streamlining eligibility and benefits, claim status and payment and remittance transactions. To ensure organizations continue to conform with operating rules as technology evolves, mergers and acquisitions occur and other market dynamics take place, CORE Recertification is now required every three years. AultCare is an insurance company and third party administrator serving employer groups, individuals, families and Medicare… Read more »
June 2021
What is primary source verification of a healthcare provider? Why is it important? Primary source verification (PSV) is the process by which a health plan or hospital checks an individual provider’s reported credentials and qualifications. This crucial step not only protects the provider but also the hospital, health plan and—more importantly—the patient. Primary source verification of healthcare providers is required for confirming that an individual possesses a valid license, certification, or registration to practice medicine. Primary sources include medical school diplomas; specialty… Read more »
June 2021
In a recent study, CAQH found that inefficient COB processes cost the healthcare industry more than $800 million annually. The bulk of these costs are incurred because health plans often do not have access to high-quality data about other overlapping coverage before claims are paid. A successful COB program increases efficiency, prevents incorrect payments, and provides a better experience for providers and members, but it requires trustworthy data about coverage overlaps. Many vendors claim to have this data, but the quality varies. The success of a plan’s COB program hinges on having… Read more »
May 2021
There are a lot of reasons to start a payment integrity program: potential cost savings, operational efficiency, a taste for innovation. For Chad Roswick, senior director of Enterprise Shared Services at L.A. Care, a health plan serving the most vulnerable residents of Los Angeles County, the reason was financial stewardship. The health plan has a large Medi-Cal membership, and Chad wanted to make sure that they were properly administering state and federal funds and reducing expenses when possible. Regardless of your reason for looking into payment integrity, Chad’s journey provides a… Read more »
May 2021
What Is a Provider Directory? Simply put, a provider directory is a list of physicians in an area and within an insurance plan. People use that information when they need care to find a local doctor that takes their insurance and is also accepting new patients, so the information needs to be accurate. Health plans also create directories to help members decide which insurance product to sign up for during open enrollment periods, so members can ensure that their preferred doctors accept the plan they choose. The information in health plan provider directories is often inaccurate, with… Read more »
April 2021
What is provider credentialing or physician credentialing? Provider credentialing is a regulated process of assessing the qualifications of specific types of providers. This important safety check requires providers such as doctors, dentists, and other allied healthcare professionals to show they have the proper education, training and licenses to care for patients. Hospitals and health plans verify the information supplied by the provider before they are included as an in-network provider. The Centers for Medicare and Medicaid Services (CMS) and the Joint Commission on Accreditation of… Read more »
March 2021
The term “coordination of benefits” pops up everywhere these days. But hearing it and knowing what it is are two different things. Read on for a little primer, so you can get up to speed on this essential topic of healthcare administration.  What is coordination of benefits?  There are instances where a person will have more than one insurance plan. For example, a person could have healthcare coverage through their employer but also through their spouse and their spouse’s employer. Those health plans will have to work together to pay claims correctly. That process is called coordination of… Read more »

Platform offers easy access to work group information, resources and events.

February 2021
In February 2021, CAQH CORE launched a new CAQH CORE Participant Dashboard. This user-friendly platform will simplify how participants can engage with their current work groups and join new ones. It also includes a global calendar of all CAQH CORE events, and enables easy access to all work group documentation, rosters and meeting information. If you are a CAQH CORE participant and did not receive an email with information about how to register, please email core@caqh.org.   ​ A Preview of the CAQH CORE Participant Dashboard