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.

Regulatory Status

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 & Referrals (278) Data Content Rule vPA.1.0

CAQH CORE Prior Authorization (278) Infrastructure Rule v4.1.0 (Phase IV)

CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule vPA.2.0

CAQH CORE Connectivity Rule v4.0.0 (Phase IV)

CAQH CORE Connectivity Rule vC3.1.0*

 

*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

CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule vPA.2.0

       CAQH CORE v5010 Master Companion Guide

CAQH CORE Prior Authorization & Referrals (278) Data Content Rule vPA.1.0

CAQH CORE Prior Authorization & Referrals Web Portal Rule vPA.1.0

CAQH CORE Connectivity Rule vC3.1.0 

        • XML Schema v3.1.0 

        • WSDL Schema v3.1.0 

        • CAQH CORE-Required Processing Mode Payload Type Tables

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.

Implementation Resources

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

 

Type
Audience
CAQH Program