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CAQH CORE and its partners have resources and tools to assist with CAQH CORE Operating Rule implementation. See below for links to resources for:
General CAQH CORE Operating Rule Implementation Resources (Phase I-V)
- Analysis & Planning Guides: Guides for Project Managers, Business Analysts, System Analysts, Architects, and other project staff for systems analysis & planning. Outlines key tasks for analysis and planning for adoption of the CAQH CORE Operating Rules, with three practical tools: Stakeholder & Business Type Evaluation, Systems Inventory & Impact Assessment Worksheet, and Gap Analysis Worksheet. Click below to access the CAQH CORE Analysis and Planning Guides:
- Phase I & II CAQH CORE Eligibility & Claim Status Operating Rules Analysis & Planning Guide
- Phase III CAQH CORE EFT & ERA Operating Rules Analysis & Planning Guide
- Phase IV CAQH CORE Operating Rules Analysis and Planning Guide
- Phase V CAQH CORE Prior Authorization Operating Rules Analysis & Planning Guide
- National Webinars: CAQH CORE holds frequent sessions with industry partners, associations, and Medicaid workgroups that include speakers from organizations that have implemented the CAQH CORE Operating Rules.
- FAQs: Address typical questions regarding the CAQH CORE Operating Rules (as well as other topics).
- CORE Certification: CORE Certification means an entity has demonstrated that its IT system or product conforms with the CAQH CORE Operating Rules.
- CORE Certification Master Test Suites: Originally developed to support voluntary CORE Certification, the CORE Certification Test Suites include information about key concepts that apply to general adoption of the CAQH CORE Operating Rules.
- General/Clarifying Questions: Review these tools and resources, and email CORE@caqh.org with any general questions or for additional clarification.
Additional Phase III CAQH CORE EFT & ERA Operating Rule Resources
- Enrollment Data Sets Maintenance Process for CAQH CORE 380 & 382 Rules Webpage: A “one stop shop” for all the necessary tools and information to comply with CAQH CORE 380 & 382 Rules and the ongoing maintenance process. Highlights from the new webpage include:
- Access to current and past versions of the Enrollment Data Rules
- Timeline for updates and compliance
- Process for submitting potential adjustments
- Key Considerations by Stakeholder Type
- Ongoing Maintenance of the CORE Code Combinations for CAQH CORE 360 Rule Webpage: A "one stop shop" for all the necessary tools and information you will need to comply with CAQH CORE 360: Uniform Use of CARCs and RARCs Rule, one of five EFT & ERA Operating Rules, and the ongoing maintenance process. Highlights from the webpage include:
- Access to current and past versions of the CORE Code Combinations
- Timeline for updates and compliance
- Instructions related to the Market-based Review process
- Key Considerations by Stakeholder Type
- CAQH CORE EFT & ERA Tools for Providers
- Contact Your Health Plans - Sample Provider EFT Request Letter: A sample letter, with instructions, that providers can send to health plans or use as talking points with health plans to request payment via EFT and status of EFT & ERA Operating Rule implementation, which support faster, more automated and secure payments from health plan to provider.
- Contact Your Banks - Sample Provider EFT Reassociation Data Request Letter: A sample letter, with instructions, that providers may customize and send or use as talking points with their banks to request delivery of the ACH Payment Related Information via a secure, electronic means. The ACH Payment Related Information contains the necessary data to reassociate EFTs and ERAs, and is not automatically delivered to providers unless requested.
- Excel Versions of the EFT & ERA Enrollment Data Sets: To help entities implement the CAQH CORE 380 Rule and the CAQH CORE 382 Rule, two Excel Workbooks are available containing the CORE-required Maximum EFT & ERA Enrollment Data Sets, i.e., Table 4.2-1 in the CAQH CORE 380 Rule and the CAQH CORE 382 Rule; these Excel copies make it easy to load data element names and descriptions as HIPAA covered entities update their paper and electronic enrollment forms.
Additional Phase IV CAQH CORE Operating Rule Resources
- On-Demand Webinar: New Phase IV CAQH CORE Connectivity Rule – Drill Down on Requirements: This webinar reviews the requirements of the Phase IV CAQH CORE Connectivity Rule. This rule applies to all of the Phase IV transactions and enhances interoperability as well as efficiency and security. It also brings forward existing CORE technical requirements, such as real time vs. batch processing modes and the Guiding Principle of Safe Harbor Connectivity among trading partners. The webinar also addresses how the Phase IV Connectivity works in unison with the earlier phases and how it applies to your stakeholder type. Recorded on 04/20/16.
- On-Demand Webinar: New Phase IV CAQH CORE Operating Rules - Focus on Infrastructure: This webinar gives a detailed overview of the four Phase IV Infrastructure Rules which address HIPAA transactions including Claims, Prior Authorization, Enrollment, & Premium Payment. It also provides an overview of resources and tools to support industry implementation of the Phase IV operating rules. Recorded on 03/22/16.
- On-Demand Webinar: New Phase IV CAQH CORE Operating Rules – Overview: The Complete Set of Phase IV CAQH CORE Operating Rules was approved through the CAQH CORE voting process in September 2015. This webinar gives a high-level overview of Phase IV Operating Rules and resources and tools to support industry implementation of the operating rules. Recorded on 12/10/15.
Additional Phase V CAQH CORE Operating Rule Resources
- On-Demand Tutorial: Phase V CAQH CORE Prior Authorization (278) Request/Response Data Content Rule – Drill Down on Requirements: This 10 minute tutorial provides a detailed overview of the scope and requirements of the Phase V CAQH CORE Prior Authorization (278) Request/Response Data Content Rule. Recorded on 05/16/19.
- On-Demand Tutorial: Phase V CAQH CORE Prior Authorization Web Portal Rule: This 10 minute tutorial provides a detailed overview of the scope and requirements of the Phase V CAQH CORE Prior Authorizations Web Portal Rule. Recorded on 05/16/19.
General Implementation Resources from the Centers for Medicare & Medicaid Services (CMS)
CMS also offers materials and tools that support industry implementation of the operating rules and other Administrative Simplification initiatives.
- CMS Resources on Operating Rules and Administrative Simplification
- Administrative Simplification Transaction Testing Checklists: These checklists were developed by industry stakeholders to support key segments (Small Provider, Large Provider, Payer, Vendor to Provider, and Vendor to Payer) conducting multiple levels of testing, including end-to-end testing; and provides specific tasks to consider as the industry prepares to conduct Administrative Simplification transaction testing.
- Medicaid Guidance from CMS: This Center for Medicaid and State Children’s Health Insurance Program Services letter provides state Medicaid programs guidance on Section 1104 of the Affordable Care Act, and the requirements for the adoption of the operating rules for Eligibility for a Health Plan and Health Care Claim Status Transactions.
EFT Implementation Resources from NACHA - The Electronic Payments Association
NACHA – The Electronic Payments Association is the standards development organization (SDO) that maintains the ACH Corporate Credit or Debit with Addenda Record (CCD+) standard format. NACHA develops rules, published in the NACHA Operating Rules & Guidelines, which govern electronic transmissions conducted through the ACH Network. The HHS Final Rule adopting the Healthcare EFT Standard (CCD+ and X12 v5010 835 TR3 TRN Segment) adopts the implementation specifications in the NACHA Operating Rules & Guidelines as the HIPAA-mandated standard for the CCD+. NACHA offers resources to support the healthcare industry’s adoption of EFT.
- Healthcare Payments Resources Website: A repository of topics for both financial institutions and the healthcare industry. Includes links to many other resources, as well as customized information to help “translate” concepts from one industry to the other (FAQs, reports, presentations).
- Healthcare Payments Resource Guide: Designed to help financial institutions in implementing healthcare solutions, the guide gives a basic understanding of the complexities of the healthcare industry, identifies key terms, reviews recent healthcare legislation, and discusses potential impacts on the financial services industry. Order from the NACHA eStore “Healthcare Payments” section.
- Revised ACH Primer for Healthcare Payments: This primer introduces the healthcare industry to the Automated Clearing House (ACH) Network, explains ACH transaction flow and applications, and includes two “next steps checklists,” one each for origination and receipt.
- Ongoing Education and Webinars: Check the Healthcare Payments Resource Website for “Events and Education”.