Harvard Pilgrim Health Care Using CORE Rules to Improve Provider Access to Consistent Electronic Eligibility, Benefits, and Claims Data

Health Plan Rules Certification Adds to CAQH Initiative Momentum


CAQH announced today that Harvard Pilgrim Health Care, Inc. (Harvard Pilgrim), a health plan serving one million members throughout New England, completed the testing process certifying its systems can exchange administrative data according to its Committee on Operating Rules for Information Exchange® (CORE) Phase I and Phase II rules.

By implementing both phases of CORE rules, 28,000 Harvard Pilgrim providers now have access to a significantly expanded set of consistent patient administrative information in response to electronic inquiries – data critical to initiating and completing the healthcare payment cycle.

“Implementing CORE allows us to further Harvard Pilgrim’s commitment to administrative simplification and better meet the administrative data needs of our network providers. This while advancing industry interoperability through the connectivity rules developed by the initiative,” said John Kelly, Director for eBusiness Architecture. “Harvard Pilgrim believes that CORE is an essential tool for improving electronic data exchange. In particular, the connectivity rules will open the door to broad-based, B2B integration of the Provider-Payer process community. We encourage other health plans to become certified to use the rules.”

The first organization to become CORE Phase II-certified, Harvard Pilgrim completed testing for both sets of rules during a single integrated process – also a first for the initiative. The health plan joins Aetna, Aultcare, Blue Cross and Blue Shield of North Carolina, BlueCross BlueShield of Tennessee, Health Net, WellPoint and nearly 30 other organizations that are CORE Phase I-certified. CORE-certified health plans cover more than 70 million or one-third of U.S. commercially insured lives.

CAQH launched CORE to create an all-payer solution that enables provider access to patient coverage information before or at the time of service using the electronic system of their choice. The organization has brought together more than 100 industry stakeholders to collaborate on a multi-phase set of uniform business rules to achieve that goal. To date, CORE has created and promulgated two phases of rules.

The CORE Phase I and II rules cover the exchange of data on patient eligibility and benefits, patient financial liability for service types, patient deductibles/co-pays, patient accumulators, claims status, and patient identification information. The rules, which complement Federal health IT efforts, also provide specific requirements for electronic connectivity. Both the data content and connectivity rules have been recognized by the government-funded Healthcare Information Technology Standards Panel (HITSP) for use in national interoperability standards.

Moreover, in anticipation of the industry responding to a federal regulatory move from HIPAA Version 4010 to Version 5010, the CORE Phase I and Phase II rules incorporate many of the features found in the X12 5010 TR3s to address the common information needs for patient eligibility.

More than 30 organizations are committed to Phase II certification by the end of 2009 or the first quarter of 2010.

CORE participants have begun the process to develop Phase III rules, which focus on improving the electronic exchange of additional administrative transactions, such as prior authorization and remittance advice.

About CAQH
CAQH, a nonprofit alliance of health plans and trade associations, serves as 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 www.caqh.org for more information.

About Harvard Pilgrim Health Care
Harvard Pilgrim is a not-for-profit health plan that provides a variety of health benefit options and funding arrangements to more than one million members in Massachusetts, Maine and New Hampshire. According to a joint ranking by U.S.News & World Report and the National Committee for Quality Assurance (NCQA), Harvard Pilgrim is a top commercial health plan in America, for the fourth consecutive year. Health Plans, Inc., a Harvard Pilgrim subsidiary offers employers health, dental and short-term disability benefits through self-insured plans in Maine, Massachusetts and New Hampshire. For more information, please visit www.harvardpilgrim.org.

Chris McNamara
(202) 778-3271

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