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?

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 claims attachments transaction. To date, HHS has not adopted a standard for health claims attachments or indicated what standard(s) it might consider for the transaction. The CAQH CORE Board will determine the benefit of starting development of health claims attachments operating rules in advance of a transaction standard(s).

Since 2012, CAQH CORE has conducted extensive research to identify how regulatory requirements can help drive the adoption of electronic attachments. A market assessment was conducted in 2013 to identify business needs, data content and format requirements, technical infrastructure, and priorities for the exchange of attachments/additional information using administrative transactions. In 2014, CAQH CORE held listening sessions with over 300 participants to continue dialogue, discuss trends, and obtain data from current industry activities and experience. The findings of this research indicate that the vast majority of entities are still using paper to provide clinical data on a claim or other administrative transactions, and, when attachments are electronic, the most common formats are PDF, JPG, TIF, and Word.

Based on these findings, CAQH CORE supports an incremental, flexible use of operating rules to move attachments from paper to electronic documents, as recommended by NCVHS in its June 21, 2013 letter to the Secretary. For example, CAQH CORE Operating Rules could adopt requirements around a limited set of industry-neutral electronic document formats to quickly (two years) provide the industry with efficiencies and movement toward electronic formats; e.g., use of JPG and requiring a trace number or other tracing mechanism to link an attachment to its request. Additionally, based on CAQH CORE research, it is evident that industry-wide education will be key given the current level of knowledge of specific attachment-related standards such as HL7 C-CDA. CAQH CORE will support such industry education and coordinate with key stakeholders.

After HHS adopts a standard for health claims attachments, there are additional opportunities for CAQH CORE Operating Rules, such as:

  • Use of LOINC attachment type codes to identify specific document/information needed
  • Workflow/business rules for unsolicited attachments
  • Business rules for using Direct Data Entry (DDE) or other source
  • Scenario-based adoption of structured documents
  • Potential ways to reduce the number of attachments