CAQH CORE Phase V Operating Rules

The Phase V CAQH CORE Operating Rules focus on standardizing components of the prior authorization process, closing gaps in electronic data exchange to move the industry towards a more fully automated adjudication of a request. To develop the Phase V Operating Rules, CAQH CORE conducted an environmental scan of over 100 entities, participated in industry meetings and convened multi-stakeholder groups to agree on opportunities for operating rule development and refine rule requirements. 

The Phase V CAQH CORE Operating Rules were approved by CAQH CORE Participating Organizations in April 2019 and by the CAQH CORE Board in May 2019, the final step in the CORE voting process. The Department of Health and Human Services (HHS) will determine if the Phase V CAQH CORE Operating Rules will be included in any regulatory mandates.

Moving Forward: Building Momentum for End-to-End Automation of the Prior Authorization Process, a CAQH CORE white paper published in July 2019, highlights how the Phase IV and V CAQH CORE Prior Authorization Operating Rules are a significant step in addressing the prior authorization challenge.

Phase V CAQH CORE Operating Rules 

View the complete set of Phase V CAQH CORE Operating Rules HERE.

Phase V CAQH CORE Prior Authorization (278) Request / Response Data Content Rule v5.0.0

Phase V CAQH CORE Prior Authorization Web Portal Rule v5.0.0

Phase V CAQH CORE Guiding Principles, CORE Certification Policies and Forms

As with prior phases of CAQH CORE Operating Rules, CAQH CORE has developed a set of policies and forms to accompany the Phase V CAQH CORE Operating Rules. 

Phase V CAQH CORE Certification Test Suite Version 5.0.0

NOTE: This document is provided for informational purposes only. CORE Certification on the Phase V CAQH CORE Operating Rules is expected to launch Q4 2019.

For more information about the operating rules process or CORE Certification, contact CAQH CORE at CORE@caqh.org.

Implementation Resources for the Phase V CAQH CORE Operating Rules

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

Impact of the Phase V CAQH CORE Operating Rules

The Phase V CAQH CORE Prior Authorization Operating Rules are a significant step in addressing the prior authorization challenge. In particular, the rules:

  • Build on the Phase IV CAQH CORE Operating Rule which ensures electronic prior authorization information is shared in an organized, trusted and consistent way.
  • Enhance and standardize the data shared between plans and providers, eliminating unnecessary back and forth.
  • Enable the health plan to clearly communicate next steps in the prior authorization process, including what additional documentation is needed.
  • Apply to procedures, laboratory testing, medical services, devices, supplies and medications within the medical benefit including cancer drugs and other complicated conditions.
  • Support an interim strategy to bring greater consistency to web portals given current widespread industry use, with a long-term goal of driving adoption of standard transactions. 

Beyond Phase V, CAQH CORE will continue to focus on prior authorization including potential requirements to reduce the timeframe for a prior authorization determination, improve accessibility of health plan requirements and enhance the way supplemental clinical information and attachments are exchanged.

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