- About CAQH CORE
- Operating Rules
- New Operating Rule Structure
- Eligibility & Benefits
- Claim Status
- Payment & Remittance
- Prior Authorization & Referrals
- Health Care Claims
- Benefit Enrollment
- Premium Payment
- Mandated Operating Rules
- CORE Certification
- Priority Topics
- Join CAQH CORE
- Resource Library
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Prior Authorization & Referrals Operating Rules
This set of CAQH CORE Operating Rules focuses on standardizing components of the prior authorization process, closing gaps in electronic data exchange to move the industry towards a more fully automated adjudication of a request. Moving Forward: Building Momentum for End-to-End Automation of the Prior Authorization Process, a CAQH CORE white paper, highlights how the CAQH CORE Prior Authorization & Referrals Operating Rules are a significant step in addressing the prior authorization challenge.
In February 2020, the CAQH CORE Board sent a letter to the National Committee on Vital and Health Statistics proposing a set of CAQH CORE Prior Authorization and Connectivity Operating Rules for federal adoption outlined in the table below. NCVHS will hold a virtual hearing on August 25 and 26th to gather industry input on the proposed rule set. For more detail on the proposed rule set, CAQH CORE developed a two-page overview of the proposed rule set.
CAQH CORE Operating Rules Proposed to NCVHS – 2020
In May 2020 CAQH CORE adopted a New Operating Rule Structure organized by business transaction rather than phases.
No substantive changes were made to the rule requirements however naming and versioning conventions have changed.
Former Phase-based Operating Rule Name
Updated Business Transaction-based Operating Rule Name
CAQH CORE Prior Authorization (278) Data Content Rule v5.0.0 (Phase V)
CAQH CORE Prior Authorization (278) Infrastructure Rule v4.1.0 (Phase IV)
CAQH CORE Connectivity Rule v4.0.0 (Phase IV)
*CAQH CORE is proposing the CAQH CORE Connectivity Rule vC3.1.0 be adopted to replace the existing federal mandates for CAQH CORE Connectivity Rules vC1.1.0 and vC2.2.0 for the HIPAA-mandated eligibility, claim status, and ERA transactions. CAQH CORE is also proposing the CAQH CORE Connectivity Rule vC3.1.0 apply to the prior authorization transaction for federal mandate per the CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule.
Complete Set of Prior Authorization & Referrals Operating Rules
CORE Certification & Endorsement
CORE Certification for Prior Authorization & Referrals is available to all entities that create, transmit or use prior authorization transactions. Entities that do not use, create or transmit prior authorization transactions can demonstrate their support for CAQH CORE’s mission and its operating rules through CORE Endorsement.
Visit the Resource Library webpage to access FAQs, Analysis & Planning Guides, Webinars and more to support implementation of the CAQH CORE Operating Rules. For more information about the operating rules process or CORE Certification, contact CAQH CORE at CORE@caqh.org.