AETNA Requries CAQH CORE Rules Certification for Vendors
Insurance leader urges healthcare industry to follow suit
Aetna is the first national healthcare organization to require all of its administrative data-exchange vendors to be certified in compliance with rules created by the Committee on Operating Rules for Information Exchange (CORE), CAQH announced today.
“CORE represents the future of electronic administrative data exchange,” said Ronald A. Williams, CAQH chairman of the Board and chairman and chief executive officer of Aetna. “We are proud to be the first to take this important step and call on organizations throughout the industry to improve healthcare by requiring CORE certification for their vendors.
According to Aetna, CORE rules generate a robust eligibility transaction that reduces costs and administrative hassles for providers and health plans, and improves healthcare delivery for patients.
CAQH, a nonprofit alliance of health plans and trade associations working to streamline healthcare administration, launched CORE to create an all-payer solution that gives providers access to insurance information before or at the time of service using the electronic system of their choice for any patient or health plan.
The organization has brought together more than 100 industry stakeholders to collaborate on a set of uniform business rules to achieve that goal. Built upon national standards, such as HIPAA, the CORE rules make electronic administrative data communications seamless, streamlined and predictable, regardless of the technology – in many cases eliminating the need for time-consuming phone calls and paperwork.
CORE participants collectively cover more than 130 million lives or more than 75 percent of the commercially insured plus Medicare and state-based Medicaid beneficiaries.
Findings from a 2006 CAQH study showed that providers may reduce labor costs associated with verifying insurance coverage as much as 50 percent by moving from labor-intensive verification methods (web, fax and phone) to automated HIPAA transactions. Health plans also can achieve significant labor savings, as the study showed that average labor costs per phone call are $1.38 vs. $0.00 for an automated transaction.
Currently, more than 25 leading national healthcare organizations, including Aetna, are CORE-certified and can exchange select eligibility and benefits information with providers in compliance with the CORE Phase I rules. Those organizations cover approximately 65 million or one-third of commercially insured lives in the U.S. Over 20 other healthcare associations, accrediting bodies, networks and businesses have endorsed the rules.
CORE’s second set of rules builds on the Phase I rules, with additional rules for patient identifiers, patient accumulators, claims status and connectivity. The Phase II rules also require reporting of patient financial responsibility for an increased number of service codes. CAQH expects to announce Phase II certifications beginning at the end of Q3 2008 and into 2009. CORE Phase III will focus on improving the electronic delivery of additional administrative transactions, such as prior authorization.