New Operating Rule Structure

Transitioning to a Business Transactions-based Model

Coming in Spring 2020

CAQH CORE has restructured its operating rules from phase-based rule sets to rule sets based on business transactions. 

Opportunities:

  • Creates a flexible framework for adding new rules/requirements, updating existing operating rules, and removing outdated requirements for each business transaction.
  • Eases implementation burden by structuring rules into logical categories with implementation of a rule set no longer dependent on other rule set implementations.
  • Enables application of a uniform connectivity rule across all operating rules.
  • Positions operating rules to be standard-agnostic.
  • With new recertification process, ensures industry stays aligned with most recent updates.
  • Allows organizations to certify on specific transactions related to their products or solutions. For example, all operating rules that support the exchange of eligibility and benefits information will now be part of the CAQH CORE Eligibility & Benefits Operating Rule Set (rather than spread across the Phase I and II CAQH CORE Operating Rule Sets).

Note: No changes will be made to existing rule requirements. 

Former Phase-based Approach: 

Business Transaction-based Approach:

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