November 2019

For the third consecutive year, CAQH has earned certification for information security from the Health Information Trust (HITRUST) Alliance. By earning this status for CAQH ProView®COB Smart®EnrollHub®DirectAssure®VeriFide… Read more »

November 2019

In 2018, 57% of Americans received an invoice for services they thought were covered by insurance, also known as a “surprise bill.” Of that group, 20% reported that these charges were the result of visiting a doctor who was not part of their insurance network.

To find an in-network practitioner, including office location, hours and contact information, many consumers rely on their health plan’s provider directory. Although much of the information they contain is submitted to the plan by the providers themselves, directories have come under scrutiny from policymakers for high error… Read more »

Educational series aims to close knowledge gap for common healthcare transactions. 

November 2019

As part of their ongoing work to streamline the business of healthcare, CAQH CORE and X12 are collaborating on a new webinar series. These educational sessions aim to close knowledge gaps and support industry professionals navigating standard transactions and how they interact with the CAQH CORE Operating Rules.

The first webinar, Introduction to the 835 Transaction, Standard & Operating Rules, was held earlier this month and provided entry-level… Read more »

Responses due by Friday, November 1, at 5 p.m. PT

October 2019

CAQH CORE is seeking participants for its survey on the exchange of medical documentation, also known as “attachments.” Since no federally mandated standard for sharing electronic attachments exists, the goal of the survey is to better understand how they are currently exchanged. The findings will help inform the development of operating rules to support a more standardized workflow.

Respondents should have an intimate knowledge of their organization’s workflow, infrastructure and data needs as it pertains to the exchange of medical documentation in one or more of the following use… Read more »

In a recent Medium post, Rachel Goldstein, Senior Manager at CAQH CORE, takes a look at the history of prior authorization and how we can move forward.

October 2019

A standard electronic method for conducting at least a portion of the prior authorization process has been federally mandated since the early 2000s. However, nearly 20 years later, 88 percent of prior authorizations are still conducted either partially or entirely manually, using faxes and phone calls to request and provide clinical information. When managed this way, prior authorizations can take hours, days and even weeks — leaving patients in limbo.

For providers, juggling the individual requirements and processes of each health plan is a significant administrative burden. On… Read more »

With 13 percent of beneficiaries reporting that they have additional coverage, the coordination of benefits process for Medicaid plans can be complicated and costly.

October 2019

CAQH estimates that administrative inefficiencies associated with coordination of benefits cost the industry $800 million each year. At the Medicaid Health Plans of America (MHPA) Annual Conference, Morgan Tackett, Senior Product Manager of COB Smart, and Laura Carraway, Senior Vice President of Cost Optimization-Program Integrity Coordination of Benefits at Anthem, shared recommendations for how to make this process more efficient and accurate.  

The session, “Claims processing and coordination process benefits,” provided… Read more »

A coordinated approach to provider data management fosters data accuracy and adds efficiency to healthcare administration.

October 2019

Members expect their health plan to deliver reliable and accurate provider information so they can find the care they need. Yet maintaining up-to-date, high-quality provider directories is challenging. About half of all provider location listings have at least one inaccuracy, according to the Centers for Medicare and Medicaid Services (CMS).

Provider data standardization can help ensure accurate provider information is available to use for connecting patients with providers, provider licensing and paying for services. High-quality provider information also has the downstream… Read more »

Even as many dentists retire, a greater number of dental providers are continuing to enter the field.

October 2019

Today, more dentists are practicing each year and the U.S. dental industry is growing1. According to the Health Policy Institute (HPI), the number of practicing dentists is expected to increase between 2.6 and 4.5 percent between 2017 and 20372.

The increase in dentists is a positive change for consumers, who need a larger dental population to serve what the American Dental Association (ADA) has identified as a steady increase in demand for dental services. However, the rapid growth of this market also means an influx of dental provider data to manage.

Read more »
September 2019

CAQH CORE and Health Level Seven International (HL7) have come together to accelerate automation and improve interoperability between healthcare administrative and clinical systems.

Though this is the first time that these organizations have collaborated on solutions specific to technical and administrative burdens, their complementary individual work has helped improve the electronic exchange of data across the healthcare industry.

Together, the organizations will address some of the most… Read more »

September 2019

In response to a request for information (RFI) from HHS and CMS, CAQH CORE submitted comments on “Reducing Administrative Burden to Put Patients over Paperwork,” an initiative to focus the healthcare delivery system on patient-centered care, innovation and outcomes.

In the response, CAQH addressed:

  • Modification or streamlining of reporting requirements, documentation requirements or processes to monitor compliance to CMS rules and regulations.
  • Aligning Medicare, Medicaid and other payer coding, payment and documentation requirements and processes.
  • Read more »