Phase V CAQH CORE Operating Rules

The Phase V CAQH CORE Prior Authorization Operating Rules focus on standardizing components of the prior authorization process, closing gaps in electronic data exchange to move the industry toward a more fully automated adjudication of a request. The Phase V Operating Rules build on prior phases of CAQH CORE Operating Rules, including the Phase IV CAQH CORE 452 Health Care Services Review – Request for Review and Response (278) Infrastructure Rule. To develop the Phase V Operating Rules, CAQH CORE conducted an environmental scan of over 100 entities, participated in industry meetings and convened multi-stakeholder groups to agree on opportunities for operating rule development and refine draft requirements.

The Department of Health and Human Services (HHS) will determine if the Phase V CAQH CORE Operating Rules will be included in any regulatory mandates.

 

Draft Phase V CAQH CORE Operating Rules: Status 

The Final Vote on the Draft CAQH CORE Phase V Operating Rules Package for Full CAQH CORE Voting Participating Organizations (i.e. entities that create, transmit or use healthcare administrative data) launched Tuesday 03/12/19 and will close on Wednesday 04/03/19.

Per the formal CAQH CORE Voting Process, approval by the Full CAQH CORE Voting Participating Organizations is necessary before the rules can move forward for final approval by the CAQH CORE Board Vote. It is anticipated that the final version of the Phase V CAQH CORE Operating Rules will be available for industry implementation in Q2 2019.

For more information about the Final CAQH CORE Vote, Phase V CAQH CORE Operating Rules or CORE Certification, contact CAQH CORE at CORE@caqh.org.

 

Draft Phase V CAQH CORE Operating Rules Package out for Ballot

Click here for a one-page overview of the Rules Package contents out for Ballot.

NOTE: These links are to draft versions out for Ballot; an updated version of the draft rules and test suite will be posted as the Phase V CAQH CORE Operating Rules are finalized or if any additional steps are agreed to by CAQH CORE prior to finalization.

 

Phase V CAQH CORE Policies 

As with prior phases of CAQH CORE Operating Rules, CAQH CORE has developed a set of policies and forms to accompany the Phase V CAQH CORE Operating Rules. The final versions of the Phase V CAQH CORE Policies and Certification Forms are available via the links below.

NOTE: These documents are provided for informational purposes only; CORE Certification on the Phase V CAQH CORE Operating Rules is not yet available. CORE Certification on the Phase V CAQH CORE Operating Rules is expected to launch Q4 2019.

Phase V CAQH CORE Guiding Principles, CORE Certification Policies and Forms 

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