New CAQH CORE Operating Rules Improve How Plans and Providers Exchange Information Related to Eligibility and Supplemental Documentation

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. CAQH CORE Participating Organizations represent more than 75 percent of insured Americans, including plans, providers, vendors, government entities, and standard setting organizations. CAQH CORE Operating Rules and Certification Test Suites addressing eight healthcare business transactions have been issued to date. For more information, visit caqhcore.org

Industry approved guidelines support better administrative operations and information at the point of care

WASHINGTON, DC - 04/20/2022

CAQH CORE, a multi-stakeholder organization representing a broad spectrum of health plans, providers, vendors and government entities, today released new operating rules to improve day-to-day healthcare operations and how plans and providers exchange information related to benefits coverage and supplemental documentation. More than 88 percent of participating organizations approved adoption of these rules.

“The operating rules released today represent another step in improving the way plans and providers exchange information millions of times every day,” said Tim Kaja, MBA, Senior Vice President, Optum Care and CAQH CORE Board Chair. “These rules will improve operations -- in administrative offices and at the point of care -- and will enhance the experience for all stakeholders.”

New rules for supplemental documentation attachments

The new CAQH CORE Prior Authorization and Health Care Claim Attachments Operating Rules enable providers to send to health plans documentation to support a claim or prior authorization in a uniform, electronic format using industry standards. The exchange of attachments has been a longstanding industry challenge and these rules will lead to quicker coverage and payment decisions.

Updated rules for eligibility and benefits verification

The updated CAQH CORE Eligibility and Benefits Operating Rules enhance the exchange of information related to telemedicine, prior authorization, remaining coverage benefits, procedure-level information and tiered benefits when a provider confirms patient eligibility. This will enable providers to have better information regarding patient coverage prior to or at the time of service and will result in more timely patient care and accurate pricing and billing.

Updated rules for infrastructure

The updated CAQH CORE Infrastructure Rules call for greater health plan system availability and less frequent periods of downtime. These rules will support care delivery, the patient experience and revenue cycle processing as providers will have more reliable access to data at the time of service.

“CAQH CORE participating organizations are taking on the most pressing and timely administrative issues in healthcare related to prior authorization, telemedicine and delivering better information to providers at the point of care,” said Linda Reed, RN, MBA, CHCIO, FCHIME; Senior Vice President and Chief Information Officer, St. Joseph’s Health and CAQH CORE Board Vice Chair. “Healthcare stakeholders came together to develop, debate and adopt these important rules, and we expect the benefits to be significant and industry-wide.”

CORE Certification for these new and updated rules will be available in early 2023. However, organizations that are interested in piloting the new standards can contact CORE@caqh.org.

To learn more about these rules, attend the webinar on April 27 from 12:30-1:30pm ET. Register now.