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HHS Recommends CAQH CORE Operating Rules for federal adoption

What comes next?

Since its formation, the Committee on Operating Rules for Information Exchange (CORE) has developed eight sets of operating rules to streamline transactions and remove cost and complexity from the healthcare ecosystem. Four of these rule sets — which address eligibility and benefits; claim status; payment and remittance; and connectivity requirements — have been federally mandated. 

Earlier this year, the National Committee on Vital and Health Statistics (NCVHS), a federal advisory body to HHS, recommended another set of CORE Operating Rules for federal adoption. Here’s what you need to know:

How do CORE Operating Rules increase collaboration in healthcare? 

Each operating rule was developed through an industry led, consensus-based process that included health plans, providers, government entities, vendors, clearinghouses, associations and others–ensuring that they provide value to the stakeholders who rely on them.

Further, by increasing standardization across the industry, the rules make it easier for entities to work together, exchange information and, ultimately, provide a better experience for patients. 

What comes next in the process for federal adoption?

If HHS supports the NCVHS recommendation, an Interim Final Rule (IFR) will be issued with public comment period. Once HHS finalizes the rule, industry stakeholders would have 25 months to implement the newly mandated operating rules.

What CORE Operating Rules were recommended for federal mandate? 

UPDATED CORE Eligibility and Benefits (270/271) Data Content Rule

  • Expands required service type codes and requires use of procedure codes. 
  • Indicates requirements for prior authorization. 
  • Enhances required details about benefit structure and patient financial responsibility. 
  • Facilitates telehealth coverage through required inclusion of CMS Place of Service Codes. 

NEW CORE Eligibility and Benefits (270/271) Single Patient Attribution Data Content Rule

  • Standardizes communication of a patient’s attribution status to a provider under a value-based contract. 

Updated CORE Eligibility and Benefits (270/271)5 , Claim Status (276/277)6, and Payment and Remittance (835) Infrastructure Rules 

  • Increases weekly system availability requirements to 90%. 
  • Aligns connectivity requirements with most current version of CORE Connectivity. 
  • Supports a version-agnostic Master Companion Guide Template. 

UPDATED CORE Connectivity Rule vC4.0.0 

  • Modernizes certification and authentication requirements, referencing X.509 and OAuth 2.0.
  • Expands payload support to easily facilitate exchange of X12 v6020. 

  • Adds support for REST, strengthening application to HL7 FHIR-based APIs.

Do I need to wait for the HHS decision to begin adopting CORE Operating Rules?

Organizations can begin implementing CORE Operating Rules at any time. To learn more about the impact operating rules can have for your organization, and the industry at large, click here.

Industry-led, 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. CORE Participating Organizations represent more than 75 percent of insured Americans, and include plans, providers, vendors, government entities and standard setting organizations. 

To learn more about CORE, visit caqh.org/CORE.