As the current and immediate past Chairs of the CAQH CORE Board, we are excited to discuss the operating rule package currently under consideration for federal mandate. Below we will review the path to federal mandate, the proposed rules, and what to expect next.
CAQH CORE is designated by the Secretary of the Department of Health and Human Services (HHS) as the Operating Rule Authoring Entity for the HIPAA-mandated administrative transactions. When the CORE Board approves new and updated operating rules as the final step in the formal CAQH CORE Voting Process, we discuss whether to submit them to the National Committee on Vital and Health Statistics (NCVHS) to be considered for recommendation to HHS to be federally mandated. Once decided, the CAQH CORE Board submits a letter to NCVHS describing the proposed rule set and its benefit to the industry.
On May 23rd, 2022, multiple new and updated rules were proposed in a letter to NCVHS, who will be soliciting public input via comments and a public hearing on January 18th and 19th, 2023 prior to making their recommendation to HHS. If recommended for federal adoption, the rules will undergo a federal rulemaking process. Though the process is lengthy, it will ultimately lead to widespread operating rule adoption and increased uniformity across the healthcare system. The proposed ruleset is summarized below:
- Updated: CAQH CORE Connectivity Rule vC4.0.0
- Updated: Federally Mandated CAQH CORE Infrastructure Rules
- Updated: CAQH CORE Operating Rules for Eligibility and Benefits
- New: CAQH CORE Operating Rules for Attachments
Operating rules are created and updated to ease the automation of healthcare transactions, aligning with the CAQH CORE vision to facilitate simple and trusted healthcare data exchange. At UnitedHealthcare and St. Joseph’s Health, we embrace the goals of operating rules and their role in achieving an efficient health system. Through adoption of the above-indicated operating rule package, important and evolving market needs will be met. These include necessary workflows for the electronic exchange of attachments, much called-upon modernization of federally mandated operating rules, and increased alignment between standards and technologies.
It is worth highlighting several of the substantive updates that will help achieve these goals. Together these address necessary updates that improve security, increase up-time, and produce cost-savings through the transition of manual to electronic transactions; adoption of fully electronic attachments workflows alone could result in $286 million of industry cost-savings annually!
- Connectivity: Updates key security requirements and optimizes support for APIs, ensuring that emerging standards can be exchanged in a uniform manner.
- Infrastructure: Increases weekly system availability from 86% to 90%, accommodating an additional 364 hours of up-time per year.
- Eligibility and Benefits: Reflects emerging industry needs related to telemedicine and value-based payments, as well as support for pre-authorization activities.
- Attachments: Establishes standard-agnostic workflows for the electronic exchange of attachments for health care claims and prior authorization workflows.
Our organizations are excited to work with CAQH CORE as they seek a uniform, automated, and less administratively burdensome healthcare system. To demonstrate our commitment, several board organizations are participating in pilot studies of the new Attachments Operating Rules that will return real-world data about their effectiveness and potential ROI. We, along with the rest of the CAQH CORE Board, fully support federal adoption of the proposed rules and encourage your organizations to do the same. Please stay tuned as we collaborate with the CAQH CORE Participating Organizations to advance these important efforts and impact our industry.
Timothy Kaja, President, Networks & Network Support, Optum Health; Immediate Past Chair, CAQH CORE Board
Linda Reed, Senior Vice President and Chief Information Officer, St. Joseph’s Health; Chair, CAQH CORE Board