Priority Topics
CAQH CORE strives to improve the efficiency, accuracy and effectiveness of industry-driven business transactions by working on the following priority topics.
Claim Status
After submitting a claim, healthcare providers often follow up with health plans for updates on its status. They can do this by phone, online portal, or electronic standard (X12 276/277). The electronic standard can show if a claim is paid, pending, or, if it has errors – how to fix and resubmit the claim. However, the standard is not used consistently, and there is an opportunity for operating rules to make this process more streamlined and reliable.
According to the 2024 CAQH Index, adoption of the electronic claim status transaction is 80% for medical plans and only 28% for dental plans. Issues like data misalignment and varied integration methods hinder adoption. These problems increase manual administrative burden and drive costs up. By helping to streamline consistent use of the claim status electronic standard, CORE operating rule development can help to save the industry billions of dollars. The CAQH Index estimates that there is $2.8 billion in annual cost savings opportunity for medical and dental industries by fully adopting electronic claim status transactions.
The CORE Claim Status Infrastructure Rule sets requirements for timely response to a claim status inquiry, reducing the need for manual follow-up. The CORE Claim Acknowledgement Rule outlines reassociation and error data requirements for claim acknowledgement responses. These rules aim to create a consistent framework for understanding claim status responses, making workflows more efficient. This year, CORE is convening industry to develop new operating rules that further align data requirements for these transactions.
In early 2025, CORE Participants will meet to draft new operating rules that address key issues in the claim status process. The work group will focus on standardizing error code combinations, aligning data requirements, and enabling real-time data exchange. Industry research shows that providers want clear insights into claim processing to improve operations and billing practices, while health plans want to cut costs like call center expenses. Aligning data requirements will help automate processes for both providers and health plans. These efforts will reduce administrative burden and improve the efficiency of the healthcare revenue cycle, benefiting everyone involved, including providers, health plans, vendors, and patients.
Interested in joining the Claim Status Subgroup? Email core@caqh.org.
Eligibility Verification
Eligibility and benefit verification occurs when a provider asks a health plan about a patient’s coverage or benefits, and the health plan responds. Most of this is done electronically, however, there are still improvements needed, like better system availability, alignment on how to address telehealth services, and standardizing return data like prior authorization requirements. In addition, there is an opportunity to expand eligibility verification operating rules in the pharmaceutical and dental spaces, where providers currently have trouble accessing patient benefit information.
The 2024 CAQH Index shows a steady increase in electronic adoption of eligibility and benefit verification transactions over the past few years. In 2023, 96% of medical and 82% of dental eligibility verification transactions were fully electronic. This high adoption is driven by federal mandates of the X12N 270 and 271 transactions and their companion CORE Operating Rules and the industry-wide desire to reduce manual work, like phone calls. Despite this, there is still a potential of $12.3 billion in annual savings for the medical and dental industries by switching to fully electronic transactions, highlighting gaps in current business processes.
The CORE Eligibility & Benefit Operating Rules set requirements for exchanging patient insurance coverage and benefits between providers and health plans. Current federally mandated rules require real-time responses, return of patient financial responsibility, defined error reporting, and 86% system uptime. In 2022, CORE Participating Organizations updated the Eligibility & Benefit Operating Rules to include telehealth eligibility, improve uptime to 90% and, return of more detailed benefit information. CORE is working with the industry to promote the benefits of implementing these updated rules which are currently available for industry adoption.
Additional enhancements to the eligibility transaction can drive even greater automation. In 2024, in collaboration with the National Council for Prescription Drug Programs (NCPDP), American Dental Association (ADA) and National Dental EDI Council (NDEDIC), CORE drafted updates to the eligibility data content rule to:
- Improve access and exchange of medication coverage details under the medical benefit, matching patients with the most effective treatment options.
- Enhance dental care coordination, facilitating appropriate and timely services.
- Ensure appropriate and timely services through provision of benefit details for internal medicine, primary care, maternal health, and renal care.
This updated draft rule is currently undergoing CORE’s formal voting process.
Prior Authorization
Prior authorization (PA) occurs when providers need approval from a health plan before providing a specific treatment or service to a patient. This process is often labor-intensive, manual, and time consuming, with each step adding extra work and risking delays to patient care. Automating this process would make it more efficient, reducing provider and patient burden, and delivering cost and time savings.
According to the 2024 CAQH Index, only 35% of medical industry prior authorizations are conducted fully electronically using the X12 278 transaction. Barriers to electronic adoption include the structure of the transaction, lack of mandated operating rules that support electronic exchange, and limited infrastructure for electronic submissions of clinical documentation. Vendor readiness, web portals, and state laws add further complexity. However, recent federal actions mandating the use of HL7 FHIR-based APIs to support prior authorization workflows offer hope for automation and reduced administrative burden, but this requires careful implementation of uniform, consensus-based requirements.
CORE Participants have set requirements to streamline prior authorization workflows and support secure, uniform data exchange. The CORE Prior Authorization & Referrals Operating Rules align with industry-standards for communication of prior authorization status, establish processes for exchanging electronic attachments, and set expectations for submission and response timelines. These rules were developed to support the HIPAA-mandated X12 278 transaction, however key inclusions can also be applied to use of HL7 FHIR-based APIs to expand and augment federal requirements. Standard approaches, regardless of the technology used, help reduce unnecessary back and forth between providers and health plans, promoting timely patient care.
In support of federal requirements, CORE issued a white paper outlining key considerations for an effective and standardized implementation. To support industry implementers, CORE, in collaboration with CAQH Insights, launched an initiative to track return-on-investment (ROI) and measure the impact on patient and provider satisfaction, workflow accuracy, and process efficiency. The collaborative team will help organizations to pinpoint workflow enhancements and reduce the need for manual interventions.
Email core@caqh.org if your organization is interested in joining our measurement initiative.