CAQH CORE Board Urges Adoption of Phase IV Operating Rules for Industry

May 2016

In a recent letter to the National Committee on Vital and Health Statistics (NCVHS), the multi-stakeholder CAQH CORE Board urged the recommendation of the Phase IV CAQH CORE Operating Rules to the Secretary of the Department of Health and Human Services (HHS). The letter is signed by CAQH CORE Board representatives from CHRISTUS Health, Aetna, Marshfield Clinic Health System, Montefiore, New Mexico Cancer Center, Anthem, AultCare, Blue Cross Blue Shield North Carolina, United Health Group, Allscripts, and Athenahealth. 

As the HHS-designated operating rules authoring entity and per the Affordable Care Act (ACA) mandate, CAQH CORE submitted to NCVHS the Phase IV Operating Rules in October 2015, shortly following their completion. CAQH CORE sees Phase IV as the first step in an iterative process to drive adoption of four related HIPAA standards – for which adoption has been a challenge.

Phase IV addresses infrastructure requirements for claims, prior authorization, enrollment/disenrollment, and premium payment transactions. More than 90 percent of CORE participating organizations that create, transmit, or use the transactions took part in the final vote for the Phase IV package, with 88 percent voting in favor. The CAQH CORE Board approval was unanimous.

The letter from the CAQH CORE Board responds to five key concerns that were raised at the NCVHS hearing on February 16, 2016:

(1) The letter explains that the Phase IV Operating Rules are only the initial step to streamline the related transactions. The Board elaborates that this first step is critical to facilitating a path forward because it establishes basic data exchange expectations that can be built upon in the future.

(2) The letter also clarifies the meaning of “safe harbor” in the operating rules, offering a reference to the precise definition and noting its value based on the flexibility it allows.

(3) In response to those who suggested waiting for more data content or new versions of standards, the Board emphasizes that the Phase IV Rules can be applied to any standard or version since they are payload agnostic.

(4) The Board highlights that Acknowledgements are a necessary inclusion and should be supported by the mandate since they are a crucial component of the overall infrastructure operating rules establish.

(5) The final key point in the letter is that Phase IV can be enforced as demonstrated by the voluntary CORE Certification Program.  Overall support of industry enforcement efforts is a critical part of encouraging industry progress.

As part of the Phase IV package, a Phase IV Test Suite was approved by the CORE participants. An independent CORE-authorized testing vendor has begun building a testing site using this Test Suite requirement. The site will enable entities to test their implementation of the Phase IV CAQH CORE Operating Rules, which is one of the requirements of the CORE Certification application. The formal launch of the testing site is scheduled for mid-2016 following beta testing. Entities that successfully demonstrate conformance with the Phase IV rules and their underlying standards will be able to achieve voluntary CORE Certification, which is widely recognized as the industry “gold standard” for interoperable administrative data exchange.

Many HIPAA-covered entities are already planning their implementation of Phase IV. As industry progress is being made, CAQH CORE remains committed to supporting education and technical assistance for implementation of its operating rules and to their continued maintenance. 

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