CAQH CORE: Delivering Value through Electronic Healthcare Attachments
Healthcare leaders have long worked to more closely align administrative and clinical systems. While many believe the capacity for greater interoperability is now within reach, data in clinical and administrative systems has remained siloed. The electronic exchange of attachments to communicate medical information and supplemental documentation between health plans and providers is an opportunity to change this in a significant way.
Electronic attachments open a line of communication between administrative and clinical systems and hold the key to unlocking the next level of interoperability by making the use of integrated data routine. Attachments provide health plans with vital information for adjudication of a subset of claims, prior authorizations, referrals, post-adjudication appeals, audits and other critical use cases.
In 1996, HIPAA mandated the adoption of an electronic standard for attachments, and the healthcare industry has been waiting for HHS action on this standard for many years. The extended wait for a federal attachment standard has fueled a sense of uncertainty, deterred vendor development of a standardized approach and resulted in varied electronic solutions and manual workarounds.
Source: 2018 CAQH Index
Through its HHS designation as the Operating Rule Authoring Entity for HIPAA-mandated administrative transactions including attachments, a key goal of CAQH CORE is to accelerate the adoption of electronic transactions and streamline communication of clinical information through the development of operating rules. CAQH CORE has engaged in a variety of work efforts to survey industry utilization and barriers to identify opportunities for greater uniformity and to educate and promote industry adoption of electronic attachments.
In 2019, CAQH CORE launched operating rule development for attachments given the industry clamor for adoption and uniformity. In 2019, CAQH CORE launched an Attachments Advisory Group to officially begin the operating rule development process for attachments given the industry clamor for adoption and uniformity. The group evaluated key pain points caused by the exchange of additional documentation and established opportunity areas to pursue in the CAQH CORE Attachments Subgroup. The CAQH CORE Attachments Subgroup – Prior Authorization Use Case, launched in Q3 2020 with an initial focus on the electronic exchange of attachments for prior authorization. The Attachments Subgroup, focusing on prior authorization as the first use case, will build on CAQH CORE Prior Authorization Operating Rules and evaluate opportunities identified and prioritized by the CAQH CORE Attachments Advisory Group with the goal of developing draft operating rule requirements. Following the conclusion of the Attachments Subgroup – Prior Authorization Use Case, a new attachments subgroup will convene, and shift focus to the electronic exchange of attachments for claims. After the Claims Attachments Subgroup concludes, the Review Work Group will convene to update and refine the prior authorization and claims attachment rules concurrently, given aspects of the prior authorization attachment requirements may be impacted by the claims attachments definitions. The finalized draft rule set will provide consistency and parity across the claims and prior authorization attachments use cases.
For more information on how to get involved with the CAQH CORE Attachment Initiatives, email firstname.lastname@example.org.