As the national operating rule author, CAQH CORE strives to improve the efficiency, accuracy, and effectiveness of industry-driven business transactions by working on priority topics.
Additional Medical Documentation/Attachments
Healthcare leaders have long worked to more closely align administrative and clinical systems. While many believe the capacity for greater interoperability is now within reach, data in clinical and administrative systems has remained siloed. The electronic exchange of attachments to communicate medical information and supplemental documentation between health plans and providers is an opportunity to change this in a significant way. Electronic attachments open a line of communication between administrative and clinical systems and hold the key to unlocking the next level of interoperability by making the use of integrated data routine. Attachments provide health plans with vital information for adjudication of a subset of claims, prior authorizations, referrals, post-adjudication appeals, audits and other critical use cases.
Read more about CAQH CORE's attachments efforts.
The healthcare industry has seen several laws and regulations related to price transparency over the last years, including the Centers for Medicare & Medicaid Services (CMS) Hospital Price Transparency Rule, CMS Transparency in Coverage Rule, the No Surprises Act, and related regulations. The purpose of these policies is to increase consumer awareness of the cost of care and limit surprise billing practices.
Read more about CAQH CORE's Price Transparency efforts.
Prior authorization (PA) began as a way to manage the utilization of healthcare resources. It requires providers to request approval from a health plan before a specific procedure, service, medication or device is provided to the patient. Each step of the process generates administrative burden and can delay patient care.
Read more about CAQH CORE's prior authorization efforts.
Value-based payment models are transforming a sizable portion of the U.S. healthcare economy by aligning provider compensation with improvements in care and cost controls. However, innovation and experimentation are ongoing and operational challenges may create barriers to adoption. Processes and systems in place to administer fee-for-service payment models do not always support value-based payments. Consequently, a patchwork of proprietary approaches and work-arounds is emerging.
Read more about CAQH CORE's value-based payments efforts.