Frequently Asked Questions - I. Overview of CAQH CORE

The Committee on Operating Rules for Information Exchange (CORE) is a multi-stakeholder initiative of CAQH. CAQH CORE was established in 2005 with the mission to build consensus among healthcare industry stakeholders on a set of operating rules that facilitate administrative interoperability between providers and health plans.

Since its inception, CAQH CORE has been structured around a model that operating rules authoring entities should take the responsibility of going above and beyond authorship to help drive adoption. To do this, CAQH CORE applies an integrated model in which CAQH CORE:

• Develops operating rules through broad-based stakeholder input that supports using standards.
• Develops and offers a certification program that ensures operating rules are objectively and rigorously tested and, thus, there is a solid base of early implementers.
• Builds broad-based awareness of the operating rules.
• Provides in-depth, detailed technical knowledge and assistance through early adopters.
• Promotes operating rules adoption by a majority of all stakeholders.
• Tracks industry progress on adoption and return on investment (ROI).
• Maintains the operating rules as business needs change.
• Provides regular status updates to the industry and Federal oversight committees and agencies.

CAQH, an unprecedented nonprofit alliance of health plans, networks and trade associations, is a catalyst for industry collaboration on initiatives that simplify healthcare administration. CAQH solutions:

• Promote quality interactions between plans, providers and other stakeholders
• Reduce costs and frustrations associated with healthcare administration
• Facilitate administrative healthcare information exchange
• Encourage administrative and clinical data integration

See www.caqh.org for more details.

Section 1104(1) of the Patient Protection and Affordable Care Act (ACA) defines operating rules as “the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications.” Operating rules build on existing standards to make electronic transactions more predictable and consistent, regardless of the technology. By addressing the rights and responsibilities of all parties, security, transmission standards and formats, response time standards, liabilities, exception processing, error resolution and more, operating rules facilitate interoperability among parties who exchange healthcare data. Beyond reducing cost and administrative hassles, operating rules foster trust among all participants.

CAQH CORE Operating Rules are based on principles similar to those that govern ATM networks and direct deposit banking in the banking industry, as well as those that maintain and facilitate electricity flow in the power industry.

The initial HIPAA standards provide a foundation for the exchange of administrative information, but do not go far enough to promote interoperability. Operating rules address gaps in standards, help refine the infrastructure that supports electronic data exchange, and recognize interdependencies among transactions. Current healthcare operating rules build upon a range of standards – healthcare specific (e.g., ASC X12) and industry neutral (e.g., OASIS, W3C, NACHA CCD+) – and support the national HIT agenda.

Operating rules promote interoperability between the numerous stakeholders that create, send, and/or transmit administrative healthcare information and address both data content of transactions and infrastructure. Interoperability ensures that information can be uniformly requested, provided, and understood by all stakeholders. The Phase I and Phase II CAQH CORE Operating Rules, for example, streamline the way eligibility/benefits and claim status healthcare administrative information is exchanged electronically. Easier, more reliable access to this information at the point of care can reduce the amount of time providers spend on administration by improving the accuracy of claims submitted, providing enhanced information on patient financial responsibility, and checking the status of a patient claim electronically.

CAQH CORE rule-writing and other interdependent activities are based upon a clear set of Guiding Principles. The CAQH CORE Guiding Principles drive rule development, maintenance, modification, and CORE Certification. The Guiding Principles were applied throughout Phase I, II, III, IV and V rules development efforts and the updating of the CAQH CORE Operating Rules for v5010. 

No. CAQH CORE is solely focused on developing operating rules that will guide the exchange of healthcare administrative data and an integrated model that supports implementation and rule maintenance. In practical terms, this exchange will happen through existing or new infrastructure, such as clearinghouses or direct from provider to health plan. The CAQH CORE Operating Rules are vendor agnostic; providers use the vendor system of their choice to request and receive information.

Operating rules typically do not specify technology or tools that must be used in communicating information; rather they govern how that information is exchanged. Entities that create, transmit, or use the transactions can implement the CAQH CORE Operating Rules. The CAQH CORE Operating Rules specify both data content (e.g., patient financial information) and infrastructure requirements (e.g., response time, connectivity, system availability) for the following healthcare administrative and financial transactions:

• Phase I:
  • X12N v5010 270/271 Eligibility and Benefits Inquiry/Response
• Phase II:
  • X12N v5010 270/271 Eligibility and Benefits Inquiry/Response
  • X12N v5010 276/277 Claim Status Inquiry/Response
• Phase III:
  • X12N v5010 835 Claim Payment/Remittance Advice
  • Healthcare EFT Standards (NACHA CCD+ and X12N v5010 835 TR3 TRN Segment)
• Phase IV:
  • X12N v5010 837 Health Care Claim
  • X12N v5010 834 Benefit and Enrollment Maintenance
  • X12N v5010 820 Payroll Deducted and Other Group Premium Payment for Insurance Products
  • X12N v5010 278 Health Care Services Review - Request for Review and Response
• Phase V:
  • X12N v5010 278 Health Care Services Review - Request for Review and Response

The CAQH CORE Governing Procedures^[1] establish a multistage quorum-based voting process for development and approval of the CAQH CORE Operating Rules.

• Phase I CAQH CORE Operating Rules development took place from January 2005 to March 2006. Per the CAQH CORE Voting Process, over several months the CAQH CORE Work Groups created and refined draft rules for review by the CORE Steering Committee. In February 2006, the CORE Steering Committee approved the draft rules for ballot by the Full CAQH CORE Voting Participating Organizations. The following month the rule set was approved by the Full CAQH CORE Voting Participating Organizations via official ballot.
• Phase II CAQH CORE Operating Rules development took place from May 2006 to June 2008. Building upon the Phase I CAQH CORE Operating Rules, the CAQH CORE Work Groups created a set of draft rules for review by the CORE Steering Committee. In June 2008, the CORE Steering Committee approved the draft rules for ballot by the Full CAQH CORE Voting Participating Organizations and the rules were approved by the Full CAQH CORE Voting Participating Organizations.
• Phase III CAQH CORE Operating Rules development took place from April 2011 to June 2012. Building upon the Phase I & II CAQH CORE Operating Rules, the CAQH CORE Work Groups created a set of draft rules for review by the CORE Steering Committee. The CORE Steering Committee approved the draft rules for Full CAQH CORE Voting Participating Organizations ballot and the rules were then approved by the CAQH CORE Voting Participating Organizations.
• Phase IV CAQH CORE Operating Rules development took place from December 2013 to September 2015. Building upon the infrastructure requirements in the prior Phases of CAQH CORE Operating Rules, the CAQH CORE Work Groups created a set of draft rules for review and ballot by the Full CAQH CORE Voting Participating Organizations. The complete set of Phase IV CAQH CORE Operating Rules was approved per the formal CAQH CORE voting process in September 2015.
• Phase V CAQH CORE Operating Rules development took place from April 2017 to March 2019. Building on prior phases of CAQH CORE Operating Rules including the Phase IV CAQH CORE 452 Health Care Services Review - Request for Review and Response (278) Infrastrucure Rule, the CAQH CORE Work Groups created a set of draft rules for review and ballot by CAQH CORE Voting Participating Organizations. The complete set of Phase V CAQH CORE Operating Rules was approved per the formal CAQH CORE voting process in March 2019.

Changes to the CAQH CORE Operating Rules are categorized as major (for example, additional rule requirements or clarifications to a rule, or a new CAQH CORE Operating Rules Phase) or minor (for example, changes due to a typo or grammatical error). Minor modifications do not require CORE-certified entities to complete re-certification. Major changes (e.g., a new set of operating rules) may require completing the applicable CORE Certification or Endorsement process and payment of all applicable fees. Major changes will only occur after the Full CAQH CORE Voting Participating Organizations approve, by formal vote, major modifications, changes, or deletions to the rules.

Generally, CAQH CORE Operating Rules will not be amended between CAQH CORE Operating Rule versions unless government regulations are issued that impact the rules or problems arise upon implementation which need to be addressed. In this scenario, adoption of the modified rule(s) by CORE-certified entities will be within a reasonable timeframe, but will acknowledge/comply with Federal mandates. See the CAQH CORE Certification Policies (Phase I, Phase II, Phase III, Phase IV, and Phase V) for more information.