CAQH CORE Releases Phase V Operating Rules

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 relates to the exchange of information regarding procedures, laboratory testing, medical services, devices and medications within the medical benefit, including cancer drugs and other complicated conditions.

The potential benefits of automating prior authorizations are significant. According to the CAQH Index, full automation of the prior authorization process can result in medical industry savings of $7.28 per transaction.

Read the press release on the Phase V Operating Rules to Improve Prior Authorization.

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