Resources to Increase Your Organization's Productivity
CAQH CORE has produced a variety of online resources to provide education on operating rule implementation and CAQH CORE initiatives.
Recent CORE Papers & Issue Briefs
The Claim Status Transaction: Enabling Provider and Health Plan Burden Reduction
The Claim Status Transaction is essential for improving claims processing efficiency, yet inconsistent implementations have led to costly manual workflows—averaging $15.96 per transaction—and limited electronic adoption (74% for medical, 28% for dental providers). This issue brief highlights key inefficiencies, including data misalignment and error code confusion, and demonstrates how CAQH CORE Operating Rules can drive cost savings, operational improvements, and better patient experiences.
Navigating the CMS 0057 Final Rule: A Guide for Implementing Prior Authorization Requirements
This paper explores key aspects of implementing the CMS 0057 Final Rule to help stakeholders meet regulatory requirements and enhance healthcare interoperability. It provides guidance based on CAQH’s extensive experience with industry standards, collaboration with key stakeholders, and the development of operating rules through CORE and Insights initiatives.
Streamlining CPT II Billing through Automation: Unveiling Efficiencies
CORE partnered with athenahealth to evaluate use of their CPT II Automation Tool, and to understand how automation impacts the resources allocated quality data coding activities. The findings reinforce the importance of automation to transform workflows to minimize burdensome tasks. CPT II codes are commonly used by providers to document care outcomes, utilization of care and adherence to standards of care or other best practices. Inclusion of these codes on a claim can involve time consuming and expensive manual processes that add administrative burden to the provider workflow. To help reduce burden, improve the data capture, and ensure that practices earn contracted financial incentives, athenahealth created an automated platform that identifies, records, and includes CPT II codes on claims.
CORE Operating Rules Recommended to HHS for Federal Adoption
On June 30, 2023, the National Committee on Vital and Health Statistics (NCVHS) – a public advisory body to the Department of Health and Human Services (HHS)– recommended a set of new and updated CORE Operating Rules for federal mandate under HIPAA. These rules modernize requirements related to the exchange of data for telehealth, prior authorization, complex benefit design and value-based payments. This set of new and updated CORE Operating Rules promote interoperability and ease the burden of workarounds and manual processes.
Unifying Value: Industry Opportunities to Streamline Value-based Payment Data Exchange
In 2022, CAQH CORE conducted a comprehensive environmental scan to understand obstacles to the adoption and automation of value-based payment (VBP) models. Multiple industry stakeholders were engaged during this initiative, with CAQH CORE seeking insights in one-on-one interviews and through the formation of a Value-based Payments Focus Group. These efforts validated the relevance of the five operational opportunity areas outlined in the 2018 report, All Together Now: Applying the Lessons of Fee-for- Service to Streamline Adoption of Value-Based Payments, while also revealing emerging priorities impacting the VBP landscape. New opportunities largely fell into one of two categories, the first being related to the incorporation of methodologies and data to address health disparities. The second being related to program complexity and its influence on the streamlined administration of payment models. The current report outlines these findings in detail and proposes potential directions that CAQH CORE and its Participating Organizations can take to develop operating rules governing data content and infrastructure requirements in VBP.
Opportunities to Enhance the Utility of Electronic Health Care Claims
In mid-2022, CAQH CORE launched an environmental scan to better understand the impact of non-uniform data on first-pass denial rates. Interviews were conducted with a range of industry stakeholders including providers, health plans, vendors, government agencies, and standards development organizations. A CAQH CORE focus group provided feedback on research findings. This issue brief summarizes key findings from that work and outlines opportunities for operating rules to support claim submission, acknowledgement, and error reporting; VBP and SDOH; and telehealth POS assignment. Learn more by reviewing the full brief.
Establishing the Building Blocks for Price Transparency: Industry Guidance on Provider to Payer Approaches for Good Faith Estimate Exchanges
This guidance document is the first of a series of recommendations developed by the CAQH CORE Advanced Explanation of Benefits (EOB) Advisory Group. The Advisory Group launched in August 2021 as a forum for stakeholders across the healthcare industry to collaborate and build consensus around recommendations for how to implement components of the No Surprises Act, signed into law in December 2020. The Advisory Group included over 60 participants representing over 30 diverse healthcare organizations including providers, health plans, vendors, clearinghouses, associations, government entities, and standards development organizations. The initial scope of the Advisory Group, and the focus of this guidance document, are recommendations pertaining to messaging standards, connectivity protocols, and related data content to support the exchange of Good Faith Estimates between providers and payers. These recommendations are for use by healthcare industry stakeholders and policy regulators.
Keeping it Together: Lack of Uniformity for Exchanging Medical Documentation Costs the Industry Time, Money and Frustration
The Connectivity Conundrum: How a Fragmented System is Impeding Interoperability and How Operating Rules can Improve it
Over the years, healthcare industry stakeholders have implemented a multitude of methods connecting applications, systems and networks to exchange administrative and clinical healthcare data. This has resulted in a fragmented ecosystem that is impeding interoperability and administrative simplification. The Connectivity Conundrum white paper, published in December 2019, is an in-depth study of the challenges and opportunities associated with connectivity.