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. 

CAQH CORE Operating Rules Proposed to NCVHS – 2020

Updated Business Transaction-based Operating Rule Name

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

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

CAQH CORE Connectivity Rule vC3.1.0*

 

*CAQH CORE proposed 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 also proposed 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.

In August 2020 NCVHS held a hearing to review and hear industry feedback on the proposed rules. April Todd, SVP of CORE & Explorations, Tim Kaja, Board Chair, and Sue Turney, Immediate Past Board Chair, presented on behalf of CAQH CORE. The agenda also included presentations from CMS National Standards Group, X12, a patient advocate, four health plans/associations, six providers/associations, and four vendors/associations. Thirty-six organizations submitted written comment letters. The perspectives and comments presented at the hearing and submitted in comment letters match closely to those shared, debated, and voted on during the rule development process.

NCVHS submitted a recommendation letter to the Secretary of HHS in November 2020. Recommendations included:

  1. Adopt an attachments standard.
  2. Support and encourage voluntary use of the two proposed operating rules for prior authorization prior to an action for adoption. Recommended a 12-month voluntary use phase, during which HHS could evaluate real world experience with the operating rules. Based on the results, HHS could consider adopting the operating rules through the notice and rulemaking process.
  3. Do not adopt the proposed operating rule for connectivity and encourage CAQH CORE to complete its new version to bring forward newer security standards and support for emerging technologies including REST, APIs, and OAUTH.
  4. Increase visibility of enforcement information related to operating rules. 

 

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