CAQH CORE and its partners have resources and tools to assist with CAQH CORE Operating Rule implementation. See below for links to resources for:
- Eligibility & Benefits Analysis & Planning Guide
- Claim Status Analysis & Planning Guide
- Payment & Remittance Analysis & Planning Guide
- Prior Authorization & Referrals Analysis & Planning Guide
- Health Care Claims Analysis & Planning Guide
- Benefit Enrollment Analysis & Planning Guide
- Premium Payment Analysis & Planning Guide
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 initiative.
- 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”.
Payment & Remittance 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.