New CAQH CORE Operating Rules Improve Connectivity and Accelerate Transition to Value-Based Payments

About CAQH CORE

Industry-led, CAQH CORE was formed to drive the creation and adoption of healthcare operating rules that support standards, accelerate interoperability and align administrative and clinical activities among providers, payers and consumers. Today, more than 130 organizations participate in CAQH CORE representing more than 75 percent of insured Americans, including healthcare providers, health plans, vendors, government entities and standard setting organizations. Four phases of CAQH CORE Operating Rules and Certification Test Suites have been issued to date. For more information, visit www.caqhcore.org

Guidelines establish consistent industry expectations for sharing of patient attribution information and exchanging data

WASHINGTON, DC - 01/14/2021

CAQH CORE, a multi-stakeholder organization representing a broad spectrum of health plans, providers, vendors and government entities, today released new operating rules for patient attribution data exchange and an update to existing connectivity rules.

“For more than a decade, CAQH CORE has helped health care organizations exchange data and operate more efficiently,” said Tim Kaja, COO of UnitedHealthcare Networks and CAQH CORE Board Chair. “The operating rules announced today address changes in technology and payment models that are shaping the future of healthcare.”

CAQH CORE Value-based Payments Attribution Rules Package

Attribution refers to how a patient is assigned to a provider who is then responsible for the quality and cost of his or her care. This process is an essential part of value-based healthcare, in which providers are compensated based on the health outcomes of those patients attributed to them. However, providers often find out too late, and through inconsistent mechanisms, which patients those are. The new rules package establishes uniform expectations for the necessary data to support the electronic exchange of attribution data between health plans and providers, and the frequency by which it is shared for individual patients or for a roster of patients.

CAQH CORE Connectivity Rule vC4.0.0

First introduced in 2008, the CAQH CORE Connectivity Rule establishes a national standard for how healthcare entities exchange data—a fundamental part of healthcare interoperability. The latest version has been updated to support protocols including REpresentational State Transfer (REST) and application programming interfaces (APIs). The version C4.0.0 update aligns with CMS and ONC Interoperability Rules, and moves the industry closer to a single, uniform approach for administrative and clinical data exchange.

“The business of healthcare is changing rapidly, from the technology organizations use to exchange data to the way care is billed and paid,” said Linda Reed, Vice President and CIO of St. Joseph’s Health and CAQH CORE Board Vice Chair. “CAQH CORE continues to expand and update its rules to accommodate these changes and enable administrative transactions to be more automated, efficient and electronic.”

CAQH CORE Operating Rules support a range of standards to make electronic data transactions more predictable and consistent. The organization has been designated by the Secretary of the Department of Health and Human Services (HHS) as the author for federally mandated operating rules under the Health Insurance Portability and Accountability Act (HIPAA). These new Operating Rules will be ready for industry implementation later this year.

For more information, visit caqhcore.org.