CAQH CORE Releases Operating Rules to Promote Automation for Prior Authorization


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. CAQH CORE Participating Organizations represent more than 75 percent of insured Americans, including health plans, healthcare providers, vendors, government entities, and standard setting organizations. Five phases of CAQH CORE Operating Rules and Certification Test Suites have been issued to date. For more information, visit

Guidelines established by industry will reduce inefficient information exchange between plans and providers, reduce costs, and help remove barriers to care

WASHINGTON, DC - 05/15/2019

CAQH CORE today released Phase V Operating Rules approved by the CAQH CORE Board to strengthen the accuracy and consistency of the prior authorization process and move the industry toward full automation. The rules are the result of a collaborative multi-stakeholder effort and were approved by nearly 90 percent of voting CAQH CORE Participating Organizations, demonstrating strong industry support.

“Not only do the operating rules announced today represent a foundational step forward in improving the prior authorization process,” said Tim Kaja, COO of UnitedHealth Networks and CAQH CORE Board Vice Chair. “They also signal broad industry commitment to adopting tangible solutions to reduce administrative burdens.”

Prior authorizations serve as a check on potentially unnecessary, inappropriate, and unsafe medical treatments. For this reason, plans often require them for surgeries, diagnostic tests, procedures, and other categories of service. However, today 88 percent of prior authorizations are conducted either partially or entirely manually through an inefficient process -- often by phone or fax -- whereby the plan requests, and the practitioner provides, supporting clinical information. This process can take hours, days, and sometimes weeks before the request is ultimately approved or denied.

For providers, prior authorizations can present a significant administrative burden. Providers juggle multiple health plan requirements and processes to submit a request, identify additional information that is needed, and receive a final response.

The Phase V Rules enhance and standardize the data shared between plans and providers, eliminating unnecessary back-and-forth, accelerating adjudication timeframes, and freeing staff resources spent on manual follow-up. In particular, the rules standardize data related to the exchange of clinical information and offer providers a more consistent, efficient, and predictable process across all the plans with which they participate.

The potential benefits of the Phase V Rules to move the industry towards greater automation are significant. For example, according to the 2018 CAQH Index, full adoption of the standard electronic prior authorization transaction by industry can result in a savings of over 70 percent per transaction.  However, more work is needed and planned in the future to continue to reduce the administrative burdens associated with prior authorization.

“These rules are an important step in addressing the challenges regarding prior authorization, however more work needs to be done to reduce delays in patient care,” said Susan Turney, MD, MS, FACMPE, FACP, President and CEO, Marshfield Clinic Health System and CAQH CORE Board Chair. “CAQH CORE is also working to reduce the timeframe for a prior authorization decision, help providers determine whether a prior authorization is needed, and improve the way attachments and medical documentation are exchanged.”

“Bringing the industry together to overcome administrative challenges like prior authorization are at the heart of what CAQH CORE does,” said April Todd, Senior Vice President, CAQH CORE and Explorations. “We have ambitious plans to further improve business processes using existing and emerging standards and encourage all industry stakeholders to engage in our multi-stakeholder efforts to accelerate automation in the healthcare system.”

To learn more about the Phase V Operating Rules, how to start implementing the rules, and how to engage in future prior authorization efforts please join the CAQH CORE webinar on May 29, 2019.