CAQH CORE Releases Industry Guidance on Advanced Explanation of Benefits

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 and clinical activities among providers, payers and consumers. Today, more than 130 organizations participate in CAQH CORE representing more than 75 percent of insured Americans, including healthcare providers, health plans, vendors, government entities and standard setting organizations. Four phases of CAQH CORE Operating Rules and Certification Test Suites have been issued to date. For more information, visit www.caqhcore.org

CAQH CORE convenes stakeholders from across healthcare to develop recommendations for meeting No Surprises Act requirements

WASHINGTON, DC - 11/09/2021

WASHINGTON, DC—NOVEMBER 9, 2021—CAQH CORE released guidance today for how healthcare providers and plans can meet the Advanced Explanation of Benefits (EOB) requirements included in the No Surprises Act, signed into law in December 2020. To develop the guidelines, CAQH CORE convened an advisory group that included more than 60 participants from 30 diverse healthcare organizations, including providers, health plans, vendors, clearinghouses, associations, government entities and standards development organizations.

“The Advanced EOB provisions of the Act were intended to increase consumer awareness of the cost of care and limit surprise bills, but these goals can only be achieved efficiently if they are implemented in a coordinated way across the industry,” said April Todd, CAQH Senior Vice President for CORE and Explorations. “Developed with broad industry participation, this guidance is an important step toward making Advanced EOBs efficient, understandable and readily available to members.”

Section 111 of the No Surprises Act requires health plans to provide members an Advanced EOB for scheduled services at least three days in advance so they know which doctors are expected to provide treatment, their network status, and the projected cost. Section 112 requires providers and facilities to verify, three days in advance of a service and no later than one day after scheduling a service, the type of coverage the patient is enrolled in. Providers must then give the health plan a Good Faith Estimate of charges. Implementation of these new requirements necessitates workflow changes and standardized processes, without creating undue burden for patients, providers and health plans.

Launched in August 2021, the CAQH CORE Advanced EOB Advisory Group was formed to coalesce the industry around approaches that promote uniform Advanced EOB implementations and leverage existing and emerging industry standards. Thus far, the advisory group has focused on recommendations pertaining to messaging standards, connectivity protocols and related data content. These recommendations are a set of building blocks to enable communications related to price transparency, and are intended for use by healthcare industry stakeholders and regulatory agencies.

“CAQH CORE is committed to coordinating industry efforts so these requirements can be implemented uniformly and efficiently,” said Todd. “We will engage the industry in discussions to assess additional use cases, evaluate opportunities to develop operating rules to automate and streamline Advanced EOBs and consider pilot projects to drive the industry forward.”

On November 17, CAQH will host a webinar on the recommendations of the CAQH CORE Advanced Explanation of Benefits Advisory Group. To register for the webinar, click here. On an ongoing basis, CAQH CORE will educate industry participants about the progress of these efforts.