- Operating Rules
- CORE Certification
- Industry Topics and Comment Letters
- Education and Implementation Resource Center
- HHS HIPAA Compliance
- Join CORE
- Provider Data Management
- CAQH ProView
- Provider Directory - DirectAssure
- COB Smart
- Provider Data Management
CORE State-Level Information
State-based approaches to reducing healthcare administrative costs continue to develop in relation to operating rules.
The Centers for Medicare and Medicaid Services (CMS), Center for Medicaid and SCHIP services (CMCS) distributed a letter providing Medicaid agencies with specific implementation guidance on Section 1104 of the Affordable Care Act, which describes requirements for the adoption of operating rules for Eligibility for a Health Plan and Health Care Claim Status Transactions.
- Medicare Administrative Contractors
Medicare undertook efforts to implement the ACA-mandated CAQH CORE EFT & ERA Operating Rules by the January 2014 compliance date. In May 2013, CMS issued a Change Request (CR 8182) that sets guidelines for Medicare Administrative Contractors (MACs) and Shared System Maintainers (SSMs) to implement the ACA-mandated CAQH CORE 360: Uniform Use of CARCs and RARCs (835) Rule and Code Combinations for CORE-defined Business Scenarios version 3.0.1 January 2013. The requirements apply to both Electronic Remittance Advices and Standard Paper Remittances.
Per CR 8182, Full Implementation was completed by October 7, 2013 for the Intermediary Standard System (FISS) and Multi-Carrier System (MCS), and by January 6, 2014 for the ViPS Medicare System (VMS). By October 7, 2013, Medicare Remit Easy Print (MREP) and PC Print software will also be modified as needed.
This instruction does not constitute a change to MACs Statement of Work; contractors must complete implementation within existing operating budgets.Guidance for physicians, other providers, and suppliers submitting claims for services to Medicare beneficiaries on the guidelines set in CR 8182 is available via MLN Matters® Number: MM8182. As with other CMS Transmittals, CR 8182 can be obtained on the CMS website.
CAQH has and is continuing to present CORE to multiple CA stakeholders, including the state government.
In Amended Regulation 4-2-32, Standardized Electronic Identification and Communication Systems Guidelines For Health Benefit Plans, effective July 1, 2012, the Colorado Department of Regulatory Agencies Division of Insurance requires that, as of January 1, 2013, all carriers and providers of health benefit plans operating in the state of Colorado:
- Shall be able to show the ability of their systems to allow real time data exchange including benefits eligibility, coverage determinations, and other appropriate provider-carrier transactions and interoperability following all CAQH CORE operating rules for data formats and system requirements.
- Shall, within 60 days of becoming licensed, adjust their systems to follow all CORE guidelines for data formats and system requirements if their systems do not already allow real time data exchange including benefits eligibility, coverage determinations, and other appropriate provider-carrier transactions following all CAQH CORE operating rules.
Additionally, the regulation notes that:
- Phase I CORE certification shall be accepted as evidence of compliance with the rules above. Those carriers using CORE certification to comply with the provisions of this rule shall be required to become Phase II CORE-certified within one year of completing Phase I CORE Certification.
- All carriers and providers shall uniformly use the CAQH CORE data content and infrastructure rules in the exchange of HIPAA compliant healthcare information and infrastructure improvements.
- When installing new operating systems after December 31, 2012, all carriers are required to use CORE-certified systems for communications, those systems which meet CORE certification standards, or contract with a vendor who has applied by January 1, 2013 to be CORE-certified.
- Those systems used solely for internal integrated systems between a carrier and a provider group may be granted an exemption from this requirement so long as CORE certification standards of systems that provide information exchange functionality for carrier interactions related to consumers, out of network providers, and non-dedicated providers is maintained.
A community-based collaboration is identifying healthcare administrative complexities that generate unnecessary expenses for providers, payers, and employers. Eligibility has been identified as a key area needing improvement and CAQH has been asked to provide education on CORE.
The Ohio Advisory Committee on Eligibility and Real Time Claim Adjudication recommends adoption of the CAQH Committee on Operating Rules for Information Exchange (CORE) rules in its January 2009 Report on Eligibility and Real Time Claim Adjudication (pursuant to HB125, section 7). The CORE rules are to be used for payer and provider exchanges of patient eligibility information. Additionally, CAQH has been communicating with a broad range of stakeholders regarding the potential role for the CORE rules in Ohio's HIE plans.
In the Fall of 2011, the Oregon Department of Consumer and Business Services adopted a State Companion Guide, Oregon Companion Guide for the Implementation of the ASC X12N/005010X279 Health Care Eligibility Benefit Inquiry and Response (270/271), for conduct of the X12 270/271 eligibility & benefits transactions by “health plans licensed or doing business in Oregon and health care providers providing services for a fee or as an encounter in Oregon”(see Companion Guide Section 2.1.3 Applicability). The state mandate regarding the companion guide applies to “all health insurers, providers, third-party administrators, and clearinghouses licensed or operating in Oregon that process financial and administrative transactions between a health care provider and payer.”
The regulation allows the Oregon Department of Consumer and Business Services to exempt from compliance any applicable healthcare entity that demonstrates completion of voluntary CORE Certification. Per the regulation, a healthcare entity granted a waiver through completion of voluntary CORE Certification shall be deemed in compliance with the Oregon X12 270/271 Companion Guide.Otherwise, all applicable healthcare entities must conform to the requirements set forth in the State Companion Guide per the following timeline:
- Effective January 1, 2012, all trading partners that currently conduct electronic eligibility and benefits inquiries must conform to the State Companion Guide
- Effective October 1, 2012, all trading partners must conduct all eligibility and benefits inquiries electronically and in conformance with the State Companion Guide
NOTE: The Oregon Companion Guide addresses only the data content of the X12 270/271 transactions. The CAQH CORE Operating Rules, however, address both CAQH CORE-required data content of the transactions as well as CAQH CORE-required infrastructure rules, e.g., connectivity, system availability, etc., for the exchange of the transactions.
- Rhode Island
In June 2012, Rhode Island enacted legislation, H 7784 Sub A (P.L. 390), directing the Health Insurance Commissioner to establish a healthcare providers and payers workgroup to develop “processes, guidelines, and standards to streamline health care administration” for mandatory adoption by providers and insurers operating in the state.
The legislation charges this Administration Simplification Workgroup to develop and issue recommendations for establishing a uniform State standard and processes for electronic eligibility and benefits verification that:
- Is consistent with the Federally recognized standards
- Enables data exchange on a system-to-system basis and via the internet
- Provides detailed eligibility information including scope of benefits, patient financial responsibility, accumulated or limited benefits, and out-of-pocket maximums
- Protects providers from liability when a patient’s coverage information changes between the date of the eligibility request and the date of service
Additionally, the Workgroup is charged with developing and promoting adoption of guidelines addressing code use, claims review, and preauthorization. Specific items to be addressed include:
- Promoting use of the HIPAA standard Claim Adjustment Reason Codes, Remittance Advice Remark Codes, and Claim Adjustment Group Codes
- Establishing standard processing of claim corrections and health plan claim denial review
- Common processes and time frames for responding to prior authorization, preauthorization, precertification, post service review, medical necessity review, and benefits advisory requests
- Adoption of a single common website to obtain preauthorization, benefits advisory, and preadmission requirements
By March 31st of each year, the Health Insurance Commissioner must submit a progress report to the Rhode Island General Assembly.
CAQH is working with state-based HIEs/RHIOs regarding the role they could serve as catalysts for administrative simplification.
In its December 2008 Report and Recommendations Relating to the Facilitation of Electronic Health Insurance Data Exchange (pursuant to HB 522), the Texas Committee on Electronic Data Exchange recommends insurers in the state of Texas use the CAQH CORE Phase I rules. The CORE Phase I rules are to be used for electronically exchanging eligibility information. In 2009, the Texas Legislature or DOI is expected to address the committee recommendations.
A multi-stakeholder, industry-led effort, with state involvement, has endorsed CORE.
Provisions in SB 5346 establish authority for the Insurance Commissioner to designate one or more lead organizations to coordinate the development of streamlined healthcare administration. CAQH staff has been working with the key stakeholders to provide information about both the CAQH Universal Provider DataSource (UPD) and CORE.
Administrative simplification efforts are in early stages. CAQH is providing education on CORE.