CAQH CORE Phase IV Operating Rules

CAQH CORE Phase IV Rules

The Phase IV CAQH CORE Operating Rules were aproved by CAQH CORE Participants in September 2015 for hour healthcare business transactions: healthcare claims, prior autorization, 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 450 Health Care Claim (837) Infrastructure Rule v4.0.0

Phase IV CAQH CORE 452 Health Care Services Review – Request for Review and Response (278) Infrastructure Rule v4.0.0

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

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 contact CAQH CORE at CORE@caqh.org.

 

 

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