CAQH Initiative to Speed Physician Access to Patient Insurance Coverage Data, Reduce Unnecessary Administrative Burden Leading Health Insurers, Providers, Vendors Commit to Follow CORE Rules by March 2007

WASHINGTON, DC - 9/14/06

More than 20 leading healthcare organizations, including Aetna, Inc.; AultCare; Blue Cross Blue Shield of North Carolina; Emdeon; Health Net, Inc.; Health Plan of Michigan; Humana Inc.; Mayo Clinic; McKesson Provider Technologies; Montefiore Medical Center; Siemens; and WellPoint, Inc. and its 14 Blue-licensed subsidiaries, have committed to making it significantly easier for physicians and other health professionals to verify patient insurance information – one of the biggest administrative challenges identified by providers, CAQH announced today.

By March 31, 2007, these organizations will electronically exchange eligibility and benefits information according to operating rules developed through the CAQH Committee on Operating Rules for Information Exchange (CORE).  Operating rules build on existing standards, such as HIPAA, to make electronic transactions more efficient, predictable and consistent, regardless of the technology.

“Today’s announcement is the first wave of an industry campaign to reduce unnecessary administrative burden related to verifying patient insurance coverage,” said Bob Greczyn, CAQH Board chairman and CEO and President of Blue Cross and Blue Shield of North Carolina.  “These stakeholders are taking a revolutionary step that will help define the future of electronic communication between health plans and providers.”

According to CAQH, a nonprofit alliance of the nation's leading health plans, networks and trade associations working to simplify healthcare administration, provider practice staff often spend hours researching and making follow-up calls to obtain insurance information.  The CORE operating rules will allow providers to get the information from any participating health plan in 20 seconds or less.

Nearly 70 million Americans are covered by the health plans committed to using the CORE Phase I rules by March 2007.         

“Health plan commitment to use these standard rules is welcome news for providers across the country,” said Spencer Foreman, M.D., president of Montefiore Medical Center.  “Eligibility verification is a cumbersome and time-consuming but critical process.  These rules should dramatically reduce the administrative burden required to chase this important data.”

The other leading healthcare organizations that also have committed to follow the CORE rules by the March 2007 date include the following vendors and clearinghouses: ACS State Healthcare; Availity, LLC; athenahealth, Inc.; GHN-Online; HTP, Inc.; MedAvant Healthcare Solutions; MedCom USA; MedData; NaviMedix Inc.; Passport Health Communications and Quovadx, Inc.

CAQH also announced that 20 organizations are endorsing the CORE Phase I rules. Those organizations are Accenture; the American Academy of Family Physicians; the American College of Physicians; the American Health Information Management Association; the California Regional Health Information Organization; Claredi, an Ingenix Division; Edifecs, Inc.; the eHealth Initiative; Foresight Corporation; the Greater New York Hospital Association; the Healthcare Financial Management Association; the Healthcare Information and Management Systems Society; the Medical Group Management Association; the Michigan Public Health Institute; Microsoft Corporation; MultiPlan, Inc.; Pillsbury Winthrop Shaw Pittman, LLP; the Smart Card Alliance; URAC and the Workgroup for Electronic Data Interchange.

"Well-developed and widely used information standards are central to realizing our national goals for better quality and efficiency,” said David J. Brailer, M.D., Ph.D., former National Coordinator for Health Information Technology at the U.S. Department of Health and Human Services. “The CORE standards can simplify health care administration and improve the experience of America's consumers at a critical time in their lives.”

CAQH launched CORE to promote health plan-provider interoperability and improve provider access to administrative information.  The voluntary industry-wide initiative has brought together more than 85 healthcare industry stakeholders – health plans, providers, vendors, CMS and other government agencies, associations, regional entities, standard-setting organizations and banking industry experts – to develop CORE’s first set of operating rules, finalized earlier this year, which are modeled on those used to make ATM banking an everyday occurrence.  A complete list of CORE participants is available at

The CORE operating rules will help providers 1) determine whether a health plan covers the patient, 2) determine patient benefit coverage and 3) confirm coverage of certain treatments, as well as the patient’s co-pay amount, coinsurance level and base deductible levels (as defined in the member contract). In addition, the rules establish policies governing the exchange of that data, including:

  • System connectivity
  • Standard inquiry acknowledgements
  • Maximum response times
  • Minimum hours a system must be available
  • Standard 270/271 companion guide flow and format

The CORE initiative will create operating rules to address additional eligibility components and business transactions in Phase II (2006-2007) and later phases (2007-and beyond).  CAQH plans to launch the CORE Phase II operating rules in late 2007.

About CAQH
CAQH is a catalyst for healthcare industry collaboration on initiatives that simplify and streamline healthcare administration. CAQH solutions help promote quality interactions between plans, providers and other stakeholders, reduce costs and frustrations associated with healthcare administration, facilitate administrative healthcare information exchange and encourage administrative and clinical data integration. Visit for more information.

Chris McNamara
(202) 778-3271

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