Multi-stakeholder Collaboration

CAQH CORE Operating Rules are helping streamline administrative transactions for health plans, healthcare providers and vendors.

More than 130 participating organizations representing healthcare providers, health plans, government agencies and the organizations setting the standards for healthcare and data exchange are part of the CAQH CORE multi-stakeholder collaboration. The health plans participating in CAQH CORE alone cover more than 75% of all Americans with commercial insurance, as well as those covered by Medicare and Medicaid.

The greatest value and

return on investment

from the operating rules

is realized when there

is broad adoption

throughout the entire

healthcare system by

each critical player.

Patient Protection and Affordable Care Act (ACA)

The ACA has taken operating rules to a new level. It mandated healthcare operating rules for HIPAA claims-related electronic transactions, and CAQH CORE was named by the Secretary of Health and Human Services (HHS) as the authoring entity of these operating rules.

As of January 2013, all HIPAA-covered entities must adhere to the federally mandated Phase I and II CAQH CORE Operating Rules, which relate to patient eligibility and claim status.

The CAQH CORE Phase III Operating Rules for EFT & ERA have been mandated by HHS and since January 2014 any provider is able to request the streamlined electronic transactions that can result due to these operating rules and their affiliated standards.

CAQH CORE is the author of the final set of ACA-mandated operating rules for remaining HIPAA transactions, which include healthcare claims, enrollment and disenrollment in a health plan, premium payments, prior authorization and claims attachments. 

CORE Certification

The CAQH CORE Certification program is the most robust, independent testing program available. The program consists of five phases of operating rules, most of which are federally mandated. Becoming CORE-certified offers many benefits, including assurance of optimal data exchange capabilities. CORE Certification saves organizations time and money.

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