In its September 2009 Final Report and Recommendations to Develop a Standardized Electronic Identification System for Health Insurance, a Colorado Work Group has recommended that the Commissioner of Insurance require the uniform use of the CAQH® Committee on Operating Rules for Information Exchange® (CORE) rules. The CORE rules are proposed for use by payers, providers, and vendors to improve interoperability and streamline the exchange of administrative healthcare information.

As mandated by Colorado state legislation (SB135), the Commissioner of Insurance was responsible for appointing this multi-stakeholder, sixteen-member Work Group, representing payers, providers, state personnel and consumer representatives. The mission of the Work Group was to “enhance consumer experience through building consensus among the essential Colorado healthcare industry stakeholders by making recommendations that demonstrate administrative interoperability between payers and providers.”

The Work Group recognized early that any state requirement regarding electronic exchange of healthcare information should complement national efforts. The Work Group meetings included numerous educational presentations that offered extensive details about standardized data exchange and national initiatives. It was through this information gathering process that the Work Group learned how the CAQH CORE initiative can be implemented on a state and local level.

“The most effective way for Colorado to support rapid deployment of electronic communications between payers and providers, reduce overall costs and achieve the long-term vision for an interoperable healthcare delivery system is to support the implementation of national standards and uniform operating rules,” the report states.

The report includes the following recommendations regarding CORE:

  • Colorado should require the uniform use of CORE rules for data content and infrastructure in administrative data exchanges between health plans and providers.
  • Health plans should be required to submit a Pledge for CORE-Phase I certification by July 1, 2012 and complete Phase I certification by June 30, 2013.
  • Health plans should be required to complete CORE-Phase II certification within one year of completing Phase I certification. Each additional Phase certification should be completed within one year of becoming certified for the prior Phase or within one year of the Phase becoming available for certification.
  • All providers, vendors, and health plans electronically exchanging administrative data should operate in accordance with the CORE rules.
  • Most providers and vendors should be required to have CORE-certified systems or contract with a CORE-certified vendor.* 
    *Refer to full report for exceptions

The report also makes recommendations regarding the use of the WEDI standardized electronic identification card Implementation Guide.

CORE is being recognized and/or adopted at both the state and Federal level for operating rules that support a national, single set of uniform rules to simplify administrative transactions.

Many CORE participating organizations operate in Colorado covering approximately 40 percent of the commercially-insured lives in the state, including CIGNA, UnitedHealth Group, Gateway EDI, LLC, and NextGen Healthcare Information Systems, Inc. CORE-certified organizations operating in Colorado cover more than one-quarter of the commercially-insured lives in the state and include Aetna, Inc., Humana, Inc. and WellPoint (Anthem Colorado).

Colorado is the third state to have a multi-stakeholder group recommend the adoption of the CORE rules to the Insurance Commissioner or state legislature. Texas and Ohio also released recommendations in the past year proposing the implementation of the CORE rules. Moreover, several other states are considering how CORE can serve as a catalyst for regional initiatives that are focused on simplifying healthcare administration. Since the CORE rules complement and enhance national requirements for healthcare administration, they can play an important role in state efforts. This is especially relevant given the evolving role of health information exchanges (HIEs).

As a next step in the process, the Colorado Commissioner of Insurance will review the report recommendations and consider regulations regarding the Work Group findings.

View the full Work Group report.

About CORE
CAQH, a nonprofit alliance of health plans and trade associations, launched the Committee on Operating Rules for Information Exchange (CORE) with the vision of giving providers access to eligibility and benefits information before or at the time of service using the electronic system of their choice. CORE has brought together more than 100 industry stakeholders to collaborate on a set of uniform business rules to achieve that goal. Built upon national standards such as HIPAA, each phase of CORE expands the pool of available data and advances system interoperability.

Please contact CAQH at (202) 861-6380 for additional information about CORE.

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