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CAQH CORE Presents Prior Authorization Operating Rules for Federal Adoption

Health insurers use prior authorization as a check on the safety, quality, necessity and cost of medical services. When done manually, this process can be confusing, labor-intensive and expensive for the provider and payer teams that manage it. This can create delays to patient care, and frustrations across the industry.

This month, CAQH CORE proposed three Prior Authorization & Connectivity Operating Rules to accelerate automation of the prior authorization process at a hearing with the National Committee on Vital and Health Statistics (NCVHS), an advisory committee to the Secretary of the Department of Health and Human Services.

The proposed rules standardize components of the prior authorization process by closing gaps in electronic data exchange to enable a more automated adjudication of a request. The rules also establish two-day maximum response times for health plans to respond to a provider regarding needed documentation and to provide a final determination once all documentation is received. Additionally, the CAQH CORE Connectivity Rule vC3.1.0 establishes a safe harbor connectivity method that drives industry alignment by converging on common transport, message envelope, security and authentication standards.

However, there is still work to be done. If you would like to voice your support for the proposed operating rules, please:

  • Post on your social media channels and tag @CAQH
  • Share content from the CAQH LinkedIn and Twitter pages
  • Contact

Click here to learn more about the operating rules and how to get engaged in future rule development.

Read more about the importance of streamlining prior authorizations in Modern Healthcare.