March 2020
CAQH CORE has voted to set two-day time limits on how quickly health plans must request additional supporting information from providers and make final determinations on prior authorization requests. “Prior authorizations serve as a check on the safety and appropriateness of medical treatments, but when they take too long, they can delay patient care,” said Dr. Susan Turney, CEO of Marshfield Clinic Health System and CAQH CORE Board Chair. “With today’s announcement, the industry has reached a compromise to ensure they are done efficiently.” With this operating rule, CAQH CORE… Read more »
January 2020
CAQH has released the seventh annual report measuring the progress made by the healthcare industry in reducing the costs and burden associated with administrative transactions through automation. The 2019 CAQH Index found that, of the $350 billion dollars widely cited as the cost of administrative complexity in the US healthcare system, $40.6 billion is spent on eight administrative transactions. Of that, the industry can save $13.3 billion, or 33 percent of existing annual spend, by transitioning to fully electronic processes. While the industry has already avoided $102 billion annually by… Read more »
January 2020
Over the years, healthcare industry stakeholders have implemented a multitude of methods connecting applications, systems and networks to exchange administrative and clinical healthcare data. This has resulted in a fragmented ecosystem that is impeding interoperability and administrative simplification. “Connectivity Conundrum: How a Fragmented System is Impeding Interoperability and How Operating Rules Can Improve It,” a recent white paper from CAQH CORE, is an in-depth study of the challenges and opportunities associated with connectivity and includes: A definition of connectivity and its… Read more »
January 2020
Last year, CAQH implemented several enhancements to CAQH ProView, many of which were inspired by feedback we have received by users. Here are a few highlights: The platform now automatically validates important imformation, such as hospital names, SSN and  NPI 1 to improve data accuracy. Providers can update practice locations in fewer steps and with USPS standardization. Contextual in-app technology now autocorrects entries.  Help desk chat support was expanded and a 24/7 virtual assistant was implemented that users rate with 98 percent satisfaction. To build on this progress, CAQH is… Read more »
January 2020
Two of the nation’s largest healthcare organizations have earned Phase III CAQH CORE certification in recognition of their commitment to streamlining the electronic funds transfer (EFT) and electronic remittance advice (ERA) processes. Learn more about CAQH CORE Phase III rules.
November 2019
A recent CAQH survey uncovered the administrative burden on providers associated with maintaining provider directories. The survey of 1,240 physician practices, conducted in September 2019, determined that directory maintenance costs practices nationwide $2.76 billion annually. Updating directory information costs each practice $998.84 on average every month and requires the equivalent of one staff day per week. The burden associated with directory maintenance is due, in part, to the fact that the average physician practice updates information for 20 health plan contracts, according to the… Read more »
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, CAQH has demonstrated that its solutions meet key healthcare regulations and requirements for protecting and securing sensitive private healthcare information. This achievement places CAQH in an elite group of organizations worldwide. The HITRUST CSF includes federal and state regulations, standards and frameworks and incorporates a risk-based approach to help organizations address challenges through a comprehensive and flexible… 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 rates.… 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 information surrounding electronic remittance advice transactions. The full recording is now available, and a follow up is planned for next… 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 average,… Read more »