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CAQH CORE Phase IV Operating Rules
CAQH CORE Phase IV Rules
The Phase IV CAQH CORE Operating Rules were approved by CAQH CORE Participants in September 2015 for four healthcare business transactions: healthcare claims, prior authorization, employee premium payment and enrollment and disenrollment in a health plan. The Department of Health and Human Services (HHS) will determine if the Phase IV CAQH CORE Operating Rules will be included in any regulatory mandates.
Complete Set of Phase IV CAQH CORE Operating Rules and Policies
Phase IV CAQH CORE Operating Rules
View the complete set of Phase IV CAQH CORE Operating Rules HERE.
Phase IV CAQH CORE Policies
Phase IV: Certification Test Suite Version
ACA Mandated Operating Rules
Section 1104 of the Affordable Care Act (ACA) requires the Secretary of HHS to adopt and regularly update operating rules for each of the HIPAA-mandated healthcare administravice transactions. The remaining ACA-mandated operating rules address the following five HIPAA-mandated administrative transactions:
- Health claims or equivalent encounter information
- Health plan enrollment/disenrollment
- Health plan premium payments
- Referral certification and authorization
- Health claims attachments
HHS will determine if the new Phase IV Operating Rules will be included in any regulatory mandates. Any such considerations will include an HHS public comment period.
NOTE: For more information on the ACA-mandated timelines see the CMS website HERE.
What is Not Included in the Phase IV CAQH CORE Operating Rules: Health Claims Attachments
Section 1104 of the Affordable Care Act (ACA) includes the health claims attachments transaction in the list of electronic healthcare transactions for which the Secretary of HHS must adopt a standard under HIPAA. To date, HHS has not adopted a standard for health claims attachments or indicated what standard(s) it might consider for the transaction, and an effective date for these operating rules is not included in the ACA. As such, the Phase IV CAQH CORE Operating Rules do not cover requirements for health claims attachments.
Interim CAQH CORE Activities Related to Attachments
Since 2012, CAQH CORE has conducted extensive research to identify how regulatory requirements can help drive the adoption of electronic attachments. CAQH CORE supports an incremental, flexible use of operating rules to move attachments from paper to electronic documents, as recommended by the National Committee on Vital and Health Statistics (NCVHS) in its June 21, 2013 letter to the Secretary. For example, CAQH CORE Operating Rules could adopt requirements around a limited set of industry-neutral electronic document formats to quickly (within two years) provide the industry with efficiencies and movement toward electronic formats; e.g., use of JPG and requiring a trace number or other tracing mechanism to link an attachment to its request.
For more information about the operating rules process or Voluntary CORE Certification, contact CAQH CORE at CORE@caqh.org.