The Ohio Advisory Committee on Eligibility and Real Time Claim Adjudication recommends adoption of the CAQH Committee on Operating Rules for Information Exchange (CORE) rules in its January 2009 Report on Eligibility and Real Time Claim Adjudication (pursuant to HB125, section 7). The CORE rules are to be used for payer and provider exchanges of patient eligibility information.

Formed by the Superintendent of the Ohio Department of Insurance, the committee was tasked with studying and recommending standards for electronic communication between providers and payers regarding patient eligibility and real-time claim adjudication.

The committee met monthly from July through December 2008 and includes 26 members representing various constituencies, including physicians, hospitals, healthcare administrators, preferred provider networks, healthcare technology vendors, and other healthcare stakeholders. During selected meetings, information on CORE was presented to the committee by Anthem (WellPoint), Availity, CAQH, Humana, and other leading industry stakeholders.

“The Advisory Committee agreed that CAQH’s CORE initiative represented the most advanced national effort to standardize electronic administrative transactions in general. The Advisory Committee further agreed that promoting the adoption of CORE standards was ultimately to the advantage of all segments of the healthcare industry,” the report states.

The committee report included the following recommendations:

  • “The Advisory Committee should continue in operation to promote stakeholder adoption of best practices, to promote the adoption of CORE rules, and to address the technical and other questions likely to arise during the implementation of CORE.”
  • “Stakeholders should not be required to include any data elements beyond those required by CORE for electronic eligibility and benefits verification.”
  • “When deciding to purchase a new practice management system, providers should select a CORE-certified practice management system.”

The committee explains in its report, “following the requirements of CORE will allow Ohio to develop in accordance with and be consistent with national efforts.” Some organizations, including the Ohio State Medical Association, are already promoting the use of CORE-certified practice management systems.

Several CORE-certified organizations and CORE participants operate in Ohio. CORE Phase I-certified health plans serving Ohio are Aetna, Inc.; Anthem (WellPoint); AultCare; and Humana Inc. Many CORE Phase I-certified vendors also are serving Ohio, such as Availity, LLC; athenahealth; and RelayHealth. CORE participants operating in Ohio include CareMedic Systems, Inc.; CIGNA; NextGen; TRICARE; and UnitedHealth Group.

The final report was submitted to the General Assembly and its recommendations will be considered in the 2009 legislative session.

Please see the full committee report for more information.

About CORE
CAQH, a nonprofit alliance of health plans and trade associations, launched the Committee on Operating Rules for Information Exchange (CORE) with the vision of giving providers access to eligibility and benefits information before or at the time of service using the electronic system of their choice. CORE has brought together more than 100 industry stakeholders to collaborate on a set of uniform business rules to achieve that goal. Built upon national standards such as HIPAA, each phase of CORE expands the pool of available data and advances system interoperability.

Please contact CAQH at (202) 861-6380 for additional information about CORE.

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