Health plan professionals gather to discuss provider data and other pressing topics 

June 2019
The 2019 CAQH ProView Symposium was held last month in Washington, DC. The event, titled “Achieving Provider Data Excellence,” was attended by representatives from nearly 50 health plans across the nation. Over the course of two days, attendees participated in sessions that explored some of the most pressing issues in healthcare, including approaches for improving provider data, health plan directories and primary source verification for credentialing. The Symposium offered a setting for attendees to network with their peers and learn how others in the industry are addressing provider data… Read more »

New rules aim to improve prior authorization process

May 2019
Today, 88 percent of prior authorizations are conducted either partially or entirely manually. CAQH CORE has released the Phase V Operating Rules to strengthen the accuracy and trustworthiness of the prior authorization process and move the industry toward full automation. These new rules build upon the Phase IV Rules and enhance and standardize the data shared between plans and providers, eliminating the unnecessary back-and-forth, accelerating adjudication timeframes and freeing staff resources that are today spent on manual follow-up. In particular, the data that the Phase V Rules address… Read more »

CAQH CORE releases new white paper

May 2019
The healthcare industry has made significant progress in adopting electronic transactions for common business practices. However, the lack of a standard for attachments has contributed to cumbersome processes for exchanging patient-specific medical information and supplemental documentation. A new CAQH CORE white paper, which summarizes insights from more than 250 healthcare organizations, identifies five opportunity areas to move the industry toward the electronic exchange of attachments: Workflows Data Variability Exchange Mechanisms Connectivity, Security and Infrastructure Utilities… Read more »

Integrated portal creates seamless transition between two CAQH Solutions

May 2019
CAQH continues to make progress in improving provider directory data. Most recently, CAQH launched a new portal that streamlines access to provider directory data by integrating DirectAssure and CAQH ProView. Touching more than 1.5 million health plan-provider relationships, DirectAssure is supporting directory accuracy for a large portion of Americans. Participating organizations will now have enhanced capabilities to simplify provider look-up, roster management, as well as basic and on-demand reporting. This year, CAQH plans to add additional enhancements to the new DirectAssure portal… Read more »

Integrated portal creates seamless transition between two CAQH Solutions

May 2019
Late last year, CAQH launched CAQH ProView for Groups to simplify the way data is shared between delegated provider groups and health plans. This first-of-its-kind functionality replaces the highly manual processes widely used today with an intuitive, efficient module within CAQH ProView. With CAQH ProView for Groups, delegated groups no longer need to maintain a separate file for each contracted plan. Instead, they can submit one standardized file through a centralized portal, which automatically checks for errors. Participating plans then receive higher quality provider data that can be… Read more »
March 2019
Artificial Intelligence developed by CAQH is now making it possible to increase the accuracy of healthcare provider directories, without contacting the provider. This new technology is helping plans overcome a longstanding challenge -- Incomplete, inaccurate and outdated provider data has been a pervasive problem for the healthcare system for years. However, the stakes increased when the Centers for Medicare and Medicaid Services (CMS) began conducting annual reviews of Medicare Advantage online provider directories in 2016. Since then, failure to maintain accurate provider directory… Read more »
March 2019
In a recent milestone for the healthcare system, industry-leading providers, Medicaid programs, health plans, clearinghouses, and product vendors have achieved more than 350 CORE Certifications. Each certification demonstrates a healthcare organization’s commitment to ensuring business transactions flow seamlessly. To date, CORE-certified organizations include health plans that cover 78 percent of commercial lives, 75 percent of Medicare Advantage lives and 44 percent of Medicaid lives in the United States. CORE Certification is available for four phases of operating rules that encompass… Read more »

Reducing Administrative Costs in Healthcare

March 2019
CAQH recently submitted a letter to the Senate Committee on Health, Education, Labor and Pensions (“HELP Committee”) with recommendations to reduce administrative costs in healthcare. In response to a request to stakeholders from HELP Committee Chair Lamar Alexander, CAQH recommended that Congress: (i) establish a goal to reduce unnecessary costs and administrative burdens across the health care system; (ii) rationalize state and federal regulatory requirements regarding provider data; (iii) accelerate adoption of administrative standards and operating rules; and (iv) urge HHS to immediately… Read more »
March 2019
Of the many business transactions measured in the 2018 CAQH Index, claims status inquiries offer the healthcare system the greatest per-transaction opportunity for cost savings. Despite fewer claim status inquiries occurring overall compared to the prior year, a significant savings opportunity remains because the transaction is highly inefficient when not conducted electronically. According to the most recent Index, the medical industry could still save an estimated $2.6 billion annually by completing the transition to electronic claim status inquiries. For claim status inquiries, the Index… Read more »

MD-Staff Generating CAQH ProView for Groups-compatible Rosters

February 2019
The traditional model of sharing data between delegated healthcare provider groups and health plans is complex for all parties. Plans frequently receive delegated group information in varying formats and at different times. Delegated groups must maintain unique rosters and change reports for each plan, and typically do not know when plans process their data. Applied Statistics & Management Inc. (ASM), through its credentialing system MD-Staff, is working with CAQH to simplify the way groups share provider information with health plans. MD-Staff now automatically generates rosters that… Read more »