CAQH CORE Phase IV Operating Rules

CAQH CORE Phase IV Operating 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.

Updates to Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule

Substantive updates to the Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule passed the final CAQH CORE Vote with 80% support across CAQH CORE voting participating organizations and was approved by the CORE Board in Q1 2020. The rule enhancements set two-day time limits on how quickly health plans must request additional supporting information from providers and to make final determinations on prior authorization requests to support more timely delivery of patient care. Previously the rule only contained requirements for initial response time which could include a pend.

The updated Phase IV CAQH CORE Prior Authorization (278) Infrastructure Rule v4.1.0 and associated Certification Test Suite are now available for industry implementation.

Click here for an overview of the updates to the rule.

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 450 Health Care Claim (837) Infrastructure Rule v4.0.0

Phase IV CAQH CORE 452 Prior Authorization (278) Infrastructure Rule v4.1.0

Phase IV CAQH CORE 454 Benefit Enrollment & Maintenance (834) Infrastructure Rule v4.0.0

Phase IV CAQH CORE 456 Premium Payment (820) Infrastructure Rule v4.0.0

Phase IV CAQH CORE 470 Connectivity Rule v4.0.0

Phase IV CAQH CORE-Required Processing Mode and Payload Type Tables v4.0.0

XML Schema Specification (normative)

Web Services Definition Language (WSDL) Specification (normative)

Phase IV CAQH CORE Policies

Phase IV CAQH CORE 400 Guiding Principles

Phase IV CAQH CORE 401 Pledge

Phase IV CAQH CORE 402 Certification Policy

Phase IV CAQH CORE 403 Health Plan IT System Exemption Policy

Phase IV CAQH CORE 404 Certification Testing Policy

Phase IV CAQH CORE 405 Enforcement Policy

Phase IV: Certification Test Suite Version 4.1.0

Implementation Resources for the Phase IV CAQH CORE Operating Rules

CAQH Core has developed the following implementation resources for the Phase IV CAQH CORE Operating Rules:

Impact of the Phase IV CAQH CORE Operating Rules

Based on industry demand, the Phase IV Operating Rules focus on infrastructure requirements that address the transmission of electronic data to-and-from health plans. The benefits of their use include:

  • Increase consistency and automation across entities.
  • Identify gaps or barriers at any point in the transaction.
  • Increase usage of automated electronic transactions.
  • More efficient processes resulting in reduced administrative costs.
  • Improve customer services to patients and providers.
  • Reduce staff time for phone inquiries.
  • Enhance revenue cycle management, resulting in improved cash flow.

These operating rules provide all participants in the process with basic expectations for each transaction, including:

  • An acknowledgement to ensure the transaction has been received, has not been lost between entities, and will be addressed.
  • Required response times for acknowledgement and processing for both real-time and large record “batch” submissions.
  • Offering at least one common method of connectivity (i.e., a “safe harbor”) among entities transmitting data electronically.
  • A minimal amount of time for system availability to receive and send data.
  • A common format that entities must use when providing information about their proprietary data exchange systems via “companion guides.”

As with all CAQH CORE Operating Rules, these are intended to be a base, or minimum, set of requirements. It is expected that many entities will go beyond these requirements to achieve the benefits of electronic interoperability in business transactions – benefits that extend to their organizations as well as their trading partners.

 

 

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