Interest in Administrative Simplification Grows Under Healthcare Reform Efforts
CAQH® announced today that an additional 10 leading healthcare organizations have recently joined or increased their participation in its Committee on Operating Rules for Information Exchange® (CORE) initiative, a national collaboration that is advancing electronic connectivity and administrative data exchange.
CAQH launched CORE to create an industry solution that can support all payers and enables provider access to patient insurance information before or at the time of service using the electronic system of their choice. Through CORE, the organization has brought together more than 100 industry stakeholders to develop a multi-phase set of uniform business rules to achieve that goal. CORE has finalized and promulgated two phases of rules to date.
Wake Forest University Health Sciences completed a testing process to certify that its systems meet CORE Phase I rules requirements. The large provider group joins more than 35 organizations that are Phase I-certified, including health plans that cover nearly 70 million or one-third of U.S. commercially insured lives.
CAQH announced earlier this year that Humana Inc. had achieved CORE Phase I rules certification and Harvard Pilgrim Health Care had become Phase I and Phase II-certified.
Four other large provider groups, Physician HealthCare Network, PC; Spectrum Laboratory Network; the University of Nebraska Medical Center Physicians; and Valley Health, as well as technology vendor QS/1 Data Systems, have joined the initiative as committee participants.
Foresight Corporation and the Smart Card Alliance, both Phase I rules endorsers, reaffirmed their commitment to CORE by endorsing the Phase II rules. The Center for Health Transformation and the Virginia Health Exchange Network are now endorsing the Phase I and Phase II rules.
“CORE is increasingly being recognized as a complement to federal efforts focused on making healthcare more efficient,” said Robin Thomashauer, CAQH executive director. “These organizations will be instrumental in helping further advance CORE as a prime example of what can be accomplished through private and public sector collaboration.”
Built on HIPAA and other standards, the CORE rules address data critical to the healthcare revenue cycle, such as patient eligibility and benefits, patient financial liability for various service types, patient deductibles/co-pays and patient accumulators. The rules also cover specific requirements for exchanging that data, including system connectivity, system availability, patient identification, claims status, maximum response times (batch and real-time), and the consistent use of standard acknowledgements.
A number of CORE rules are being considered for use in national interoperability standards. For example, the entire set of CORE Phase I rules, plus three Phase II rules specific to eligibility, are incorporated into the Healthcare Information Technology Standards Panel (HITSP) Patient Generic Health Plan Eligibility Verification Transaction. The CORE Phase II connectivity rule is built into the HITSP Administrative Transport to Health Plan Transaction.
CORE participants have begun the Phase III rule-writing process. Phase III focuses on improving the electronic exchange of additional administrative transactions, such as prior authorization and remittance advice. Visit www.coreconnect.org for more information about the CORE initiative.