Skip to content

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.

Health Care Claims

Every day, millions of health care claims are transacted between providers, vendors and payers. Providers across the country have been equipped to manage electronic transmission of the X12N 837 for decades, and for just as long, providers have been burdened with the need to manage unique payer requirements. At the same time, payers want clean claims and seek to provide enough granularity to providers for timely claim re-submission. Revisiting the operating rules that govern health care claims to address new developments and support future innovations through our most basic transaction can move the industry forward via means already familiar to stakeholders across the healthcare spectrum.

State of the Industry
CAQH CORE Health Care Claim Operating Rules
Aligning Industry on a Path Forward

Additional Medical Documentation/Attachments

Attachments refer to the exchange of patient-specific medical information or supplemental documentation to support an administrative healthcare transaction and are a bridge between clinical and administrative data. Currently, the exchange of attachments is mostly a long, manual process. 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 and open a line of communication between administrative and clinical systems.

State of the Industry
CAQH CORE Attachments Operating Rules
Aligning Industry on a Path Forward

Eligibility Verification

Eligibility and benefit verification involves an inquiry from a provider to a health plan or from one health plan to another to obtain eligibility, coverage or benefits associated with the plan and a response from the health plan to the provider. Electronic adoption of eligibility and benefit transactions is widely adopted across the industry, however, there is a need to additionally adopt pressing updates to existing operating rules to improve system availability, address telehealth services and standardize the return of additional relevant data, such as requirements for prior authorization. In addition, there is an opportunity to expand eligibility verification operating rules in the pharmaceutical space, where there are currently provider barriers to accessing their patients’ drug benefit information covered under the medical benefit.

State of the Industry
CAQH CORE Eligibility & Benefits Operating Rules
Aligning Industry on a Path Forward

Prior Authorization

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. The healthcare industry relies heavily on labor-intensive manual methods to complete the prior authorization process and each step of the process generates administrative burden and can delay patient care. A move towards automation would deliver savings in time and money, but multiple barriers exist including the need for consistent data content and a lack of integration between clinical and administrative systems.

State of the Industry
CAQH CORE Prior Authorization Operating Rules
Aligning Industry on a Path Forward

Value-based Payments

Value-based payment (VBP) models are transforming a sizable portion of the U.S. healthcare economy by aligning provider compensation with the quality of the care they deliver. However, innovation and experimentation are ongoing and operational challenges may create barriers to adoption. The healthcare industry is reliant on a fee-for-service system, one that is not always compatible with value-based payments. Consequently, a patchwork of proprietary approaches and workarounds is emerging to implement and administer these complex programs.

State of the Industry
CAQH CORE Attributed Patient Roster Operating Rules
Aligning Industry on a Path Forward
To get involved in helping industry address these priority topics, please e-mail core@caqh.org.