CAQH CORE Operating Rules in Development

I. Development of Remaining ACA-Mandated Operating Rules

  1. Of the operating rules mandated by the Affordable Care Act (ACA), which have yet to be adopted?
  2. Is CAQH CORE the authoring entity for the remaining ACA-mandated operating rules?
  3. What is the development status for CAQH CORE Operating Rules addressing the remaining ACA-mandated operating rules for health claims or equivalent encounter information, health plan enrollment/disenrollment, health plan premium payments, and referral certification and authorization?
  4. What is the development status for CAQH CORE Operating Rules addressing the health claims attachment transaction?
1. Of the operating rules mandated by the Affordable Care Act (ACA), which have yet to be adopted?

ACA Section 1104 requires the Secretary of the Department of Health and Human Services (HHS) to adopt and regularly update operating rules for each of the HIPAA-mandated healthcare administrative transactions. HHS has not adopted operating rules for the following HIPAA-mandated administrative transactions:

  • Health claims or equivalent encounter information
  • Health plan enrollment/disenrollment
  • Health plan premium payments
  • Referral certification and authorization
  • Health claims attachments
2. Is CAQH CORE the authoring entity for the remaining ACA-mandated operating rules?

On September 12, 2012, the Secretary of HHS concurred with the recommendation from the National Committee on Vital and Health Statistics (NCVHS) that CAQH CORE be designated the authoring entity for the remaining operating rules mandated under ACA Section 1104.

3. What is the development status for CAQH CORE Operating Rules addressing the remaining ACA-mandated operating rules for health claims or equivalent encounter information, health plan enrollment/disenrollment, health plan premium payments, and referral certification and authorization?

From December 2013 – June 2015, the CAQH CORE Participants used the open CAQH CORE rules-making process to produce a set of operating rules for the following transactions: health claims or equivalent encounter information, health plan enrollment/disenrollment, health plan premium payments, referral certification and authorization, and health claims attachments. The complete set of Phase IV CAQH CORE Operating Rules was approved per the formal CAQH CORE voting process in September 2015. The Phase IV CAQH CORE Operating Rules include:

For more information on the Phase IV CAQH CORE Operating Rules, see the CAQH website HERE. For information regarding development of CAQH CORE Operating Rules addressing the health claims attachments, please see “What is the development status for CAQH CORE Operating Rules addressing the health claims attachment transaction?”

NOTE: Currently, the Phase IV CAQH CORE Operating Rules are voluntary and have not been adopted by HHS for mandatory use by HIPAA covered entities. HHS will determine if the new Phase IV Operating Rules will be included in any regulatory mandates. Any such considerations will include an HHS public comment period.

4. What is the development status for CAQH CORE Operating Rules addressing the health claims attachment transaction?

ACA Section 1104 requires HHS to adopt a standard, and applicable operating rules, for the health care attachments transaction. To date, HHS has not adopted a standard for health care attachments or indicated what standard(s) it might consider for the transaction.

Since 2012, CAQH CORE has maintained a focus on attachments, collaborating with more than 300 healthcare organizations to provide education and gather insights on industry opportunities via operating rule development input, national webinars and surveys. In 2018, CAQH CORE launched an attachments environmental scan to understand industry pain points and identify ways to support and accelerate the adoption of electronic attachment transactions. Findings from the environmental scan were published in the CAQH CORE Report on Attachments: A Bridge to a Fully Automated Future to Share Medical Documentation.

The report identified five opportunity area categories to improve processes and accelerate the adoption of electronic attachments.

  • Workflows
  • Data Variability
  • Exchange Mechanisms
  • Infrastructure
  • Resources

In September 2019, CAQH CORE launched an Attachments Advisory Group to research and prioritize opportunities for potential attachment operating rules based on the five opportunity area categories across varying use cases such as claims, prior authorization, value-based payments, audits, and coordination of benefits. The Advisory Group is expected to finish its work efforts by January 2020 and hand off a list of recommendations for attachment operating rules to be addressed by a Subgroup.