Horizon Healthcare Services, Inc. Among Growing Number of Healthcare Organizations to Achieve Voluntary CAQH CORE Operating Rules Certifications

First Regional Health Information Organization and First-Ever Phase III CORE Certifications Awarded as Certification Queue Builds

WASHINGTON, DC - 10/9/13

The CAQH® Committee on Operating Rules for Information Exchange (CORE®) today announced that Horizon Healthcare Services, Inc., New Jersey’s oldest and largest health insurer, has earned voluntary CORE Certification for its Phase I and Phase II CAQH CORE Operating Rules implementation. Nearly 70 organizations and products have voluntarily achieved one or more phases of CORE Certification.

The Phase I and Phase II CAQH CORE Operating Rules support electronic eligibility and claim status inquiries, streamlining and bringing uniformity to these essential administrative transactions between healthcare providers and health plans. In addition, the rules simplify interoperability for all trading partners.

“Providers and patients want and need to know the patient cost of a particular medical procedure or visit in real time,” says Mark Barnard, senior vice president, service division, Horizon Healthcare Services, Inc. “Since implementing and becoming certified on the CAQH CORE rules, we are able to bring more clarity to financial aspects of health encounters. Our members and providers are now able to have more informed conversations about billing, and we are working toward a more efficient process that reduces administrative costs for everyone in the payment cycle.”

The CORE Certification achievement applies to Horizon’s network of more than 33,000 doctors and health care professionals, 74 hospitals, and its 3.7 million members.

“As a longtime participant in the CAQH CORE rule-writing process, Horizon is a leader in the movement to take wasteful cost and needless frustration out of the healthcare system,” says CAQH CORE Board Chair George Conklin, CIO, CHRISTUS Health. “These certifications bring substantial benefits to the hospitals, healthcare systems, physician offices, and other providers caring for Horizon members. They verify that Horizon has successfully implemented the rules to give providers electronic access to real-time, robust eligibility and claim status information.”

The value of CORE Certification accelerates as more participants in the data exchange use the rules, and additional announcements by CAQH CORE indicate growing end-to-end implementation. HEALTHeNET, the administrative side of the Western New York health information exchange (HIE), HEALTHeLINK, is the first HIE to achieve Phase I and Phase II CORE Certification for its clearinghouse service. In addition, Cigna, a global health service company, has earned Phase II CORE Certification, and RelayHealth has achieved Phase II CORE Certification for its RelayClearance™ Plus vendor product.

Another milestone for the CORE Certification program, InstaMed has become the first organization to earn Phase III CORE Certification, achieving the clearinghouse distinction for the InstaMed Network. In addition, Humana has become the first health plan to achieve Phase III CORE Certification. The Phase III CAQH CORE Operating Rules make it easier for providers to enroll in and benefit from Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA).

Health plans that have achieved one or more phases of CORE Certification currently cover more than 120 million individuals.

A number of healthcare organizations have recently committed to achieving CORE Certification, or additional phases of CORE Certification, in the near future. Committed health plans include MVP Health Care (Phase I and II), Aultcare (Phase III), and Blue Cross and Blue Shield of Nebraska (Phase III). Committed clearinghouses include ClaimRemedi for its ClaimRemedi Clearinghouse (Phase I), and vendor commitments include Pay-Plus® Solutions, Inc. for its Pay-Plus® Direct product (Phase III) and RelayHealth for its RelayPayer Connectivity Services (Phase III).

Organizations that do not create, transmit, or use the administrative transactions addressed by the CAQH CORE Operating Rules can demonstrate support for CAQH CORE by becoming a CORE Endorser. SunCoast RHIO, a clinically focused Regional Health Information Organization, and emids Technologies are the latest organizations to endorse CAQH CORE.

Together, the Phase I, II, and III CAQH CORE Operating Rules, most of which have been adopted under federal law implementing the Patient Protection and Affordable Care Act (ACA), are estimated to save as much as $15 billion over 10 years. Certification accelerates the return on investment by promoting broader use of the operating rules, which drives value for all trading partners in the data exchange. In addition, organizations continue to see value in the CAQH CORE voluntary certification process because it imposes accountability and ensures alignment with all CAQH CORE-authored operating rules, including those mandated by law and those not adopted as part of ACA, as well as with the underlying standards.

Entities that create, transmit, or use the administrative transactions in accordance with the CAQH CORE Operating Rules may become CORE-certified. The voluntary CORE Certification process begins with testing implementation by an independent CAQH CORE-authorized testing vendor, such as Edifecs. Once successful implementation is demonstrated, CAQH certifies and awards voluntary CORE Certification Seals.

CAQH CORE regularly offers webinars and provides resources and tools to help organizations implement the CAQH CORE Operating Rules. Visit /benefits.php for more information.

The CAQH Committee on Operating Rules for Information Exchange (CORE) is a multi-stakeholder industry collaboration developing operating rules that streamline administrative transactions. Over the past eight years, CAQH CORE participation has grown to more than 140 organizations. CAQH CORE has a proven track record of delivering a strong return on investment that is driven by widespread adoption and voluntary certification of operating rules. CAQH CORE was designated by the Department of Health and Human Services to author three sets of federally mandated operating rules under ACA. To learn more about CAQH CORE, visit www.caqh.org/benefits.php.

About CAQH
CAQH serves as a catalyst for industry collaboration on initiatives that simplify healthcare administration for health plans and providers, resulting in a better care experience for patients and caregivers. 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.

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