National Plans Improve Provider Access to Consistent Electronic Eligibility,
Benefits and Claims Data for 50 Million Members
CAQH® announced today that Aetna and WellPoint, together serving over 50 million members, are the first national health plans to earn certification for electronically exchanging administrative data using the CAQH Committee on Operating Rules for Information Exchange® (CORE) Phase II rules.
Aetna and WellPoint are active participants in the ongoing development of the CORE rules, which represent an all-payer solution enabling improved electronic provider access to patient insurance information before or at the time of service. Achieving CORE Phase II certification means providers working with these plans can access a richer set of consistent and accurate electronic administrative data, such as eligibility, benefits, and patient financial information. The Phase II rules also enable improved access to claims status, which was not included in Phase I.
“The CORE Phase II rules are advancing the way the healthcare industry communicates,” said Ronald A. Williams, CEO of Aetna and CAQH board chairman. “We are investing in an infrastructure that is improving connectivity and operability among healthcare providers and payers, while helping to fulfill the priorities of the national health IT agenda. This ongoing advancement can increase efficiency and quality through more timely access to key healthcare data. We strongly encourage all industry stakeholders to become CORE-certified.”
The CORE rules complement the national solutions outlined by the American Recovery and Reinvestment Act (ARRA) and its Health Information Technology for Economic and Clinical Health (HITECH) Act. HITECH includes objectives to generate cost savings, promote adoption of a single set of national rules, and drive interoperability in healthcare. CORE shares these goals. The rules are helping foster the development of regional and state data exchanges by pairing robust content with infrastructure requirements that streamline electronic patient data flow through existing information technology systems.
Momentum for the initiative is growing, as evidenced by regional and state support of the CORE rules. Multi-stakeholder groups in Ohio, Texas, Colorado and Virginia have recommended the CORE rules for statewide implementation.
“By using the CORE rules, WellPoint is further promoting the use of electronic data exchange so members and physicians have access to the necessary information to make the best healthcare decisions,” said Angela Braly, president and CEO, WellPoint, Inc. “Through initiatives like this, which take advantage of lessons learned by other industries, the healthcare industry is working together to find innovative solutions to drive down costs and improve the quality of care for Americans.”
The CORE rules are developed by over 115 participating organizations, representing providers, vendors, health plans, CMS and other government agencies, associations, regional entities, standard-setting organizations and other healthcare entities. More than 20 leading health plans, large provider groups and technology vendors are committed to completing Phase II certification in the coming months. CORE participants are currently developing the Phase III rules, which build on Phase I and Phase II. The third set of rules focuses on improving the electronic exchange of additional administrative transactions, such as prior authorization and remittance advice. The CORE rules actively support critical privacy and security practices, including HIPAA.
“The CORE Phase II rules represent a significant milestone in using transparent, consensus-based, national operating rules to streamline electronic administrative transactions among providers, health plans and vendors,” said Doug Henley, MD, FAAFP, executive vice president and CEO of the American Academy of Family Physicians. “Health plans that complete CORE Phase II certification can exchange data more effectively, thereby improving efficiency and freeing up time for physicians to focus more on their patients.”
CORE Phase II certification by Aetna and WellPoint represents a turning point in this voluntary industry-driven effort to advance healthcare interoperability. A CAQH study by IBM Global Business Services issued earlier this year found that industry-wide implementation of the CORE Phase I rules alone could yield $3 billion in healthcare savings. Widespread adoption of the Phase II rules and subsequent phases of CORE will result in even greater savings for stakeholders across the industry.