CAQH CORE Approves Two-Day Rule to Accelerate Prior Authorization Process

About CAQH CORE
Industry-led CAQH CORE was formed to drive the creation and adoption of healthcare operating rules that support standards, accelerate interoperability and align administrative activities among providers, payers and consumers. Today, more than 130 organizations participate in CAQH CORE, including healthcare providers, health plans representing 75 percent of insured Americans, vendors, government entities and standard setting organizations. Four phases of CAQH CORE Operating Rules have been issued to date, and CORE Certification is currently available for Phases I, II and III Operating Rules. For more information, visit www.caqhcore.org

Over 80 percent of industry stakeholders agree to time limits on requests for supporting information and final determinations on prior authorizations 

WASHINGTON, DC - 02/04/2020

CAQH CORE, a multi-stakeholder organization representing a broad spectrum of health plans, providers, vendors, and government entities, has voted to set two-day time limits on how quickly health plans must request additional supporting information from providers and make final determinations on prior authorization requests.

“Prior authorizations serve as a check on the safety and appropriateness of medical treatments, but when they take too long, they can delay patient care,” said Dr. Susan Turney, CEO of Marshfield Clinic Health System and CAQH CORE Board Chair. “With today’s announcement, the industry has reached a compromise to ensure they are done efficiently.”

With this operating rule, CAQH CORE participating organizations agreed to update requirements in the CAQH CORE 278 Prior Authorization Infrastructure Rule. The new requirements set national expectations for prior authorization turnaround times using the HIPAA-mandated standard to move the industry toward greater automation.

In particular, the updated operating rule establishes maximum timeframes at key stages in the prior authorization process for both batch and real-time transactions:

  • Two-Day Additional Information Request: A health plan, payer or its agent has two business days to review a prior authorization request from a provider and respond with additional documentation needed to complete the request.
  • Two-Day Final Determination: Once all requested information has been received from a provider, the health plan, payer or its agent has two business days to send a response containing a final determination.
  • Optional Close Out: A health plan, payer or its agent may choose to close out a prior authorization request if the additional information needed to make a final determination is not received from the provider within 15 business days of communicating what additional information is needed.

Under this operating rule, the timeframe requirements must be met 90 percent of the time in a calendar month. This updated rule, coupled with the release of the CAQH CORE 278 Prior Authorization Data Content Rule in May 2019, enhance the information sent in the HIPAA-mandated standard electronic transaction and allow for faster responses. CORE Certification is now available for entities to demonstrate conformance with the CAQH CORE Prior Authorization Operating Rules and show commitment to greater prior authorization automation.

“These industry-led efforts will benefit all stakeholders, and patients in particular,” said Tim Kaja, COO of UnitedHealthcare Networks and CAQH CORE Vice Chair. “In 2020, CAQH CORE Participants will continue working to improve the prior authorization process with a focus on how operating rules can streamline the exchange of medical documentation and support the use of new technologies with existing standards.”