CAQH CORE Operating Rules in Development

II. Development of Voluntary Operating Rules

1. Will CAQH CORE continue to develop operating rules for voluntary industry adoption in addition to the operating rules being developed to fulfill the Affordable Care Act (ACA) mandate?

Yes. CAQH CORE was established in 2005 to build consensus among healthcare industry stakeholders on a set of voluntary operating rules that facilitate administrative interoperability between providers and health plans. Interoperability ensures that information can be uniformly requested, provided, and understood by all stakeholders. Additionally, interoperability reduces the amount of time and resources providers must exert on administrative functions – time better spent with patients.

Given the ROI to be achieved, CAQH CORE is committed to continuing to use the CAQH CORE Guiding Principles to develop healthcare operating rules for voluntary adoption by the industry. This voluntary work includes:

  • Maintenance of CAQH CORE Operating Rules not adopted by HHS (e.g., CAQH CORE 150 and 151 Acknowledgments Rules)
  • Completing the rule approval process for the existing draft voluntary CAQH CORE Operating Rules
  • Drafting new voluntary operating rules to address industry pain points and evolving business needs
2. Are there any draft CAQH CORE Operating Rules in development that have not been adopted by HHS?

Yes. CAQH CORE was established in 2005, prior to the passage of the ACA, to develop healthcare operating rules for voluntary adoption by the industry. From 2005 to 2008, the Phase I and II CAQH CORE Eligibility and Claim Status Operating Rules were developed and approved. Thereafter, the CAQH CORE Participants have developed a number of other draft voluntary operating rules including the following operating rules that have not been adopted by HHS:

Per CAQH CORE’s commitment to continue development of voluntary operating rules, these draft CAQH CORE Operating Rules will be subject to review and balloting via the CAQH CORE voting process for voluntary industry adoption.

3. How can my organization be involved in development of the voluntary CAQH CORE Operating Rules?

CAQH CORE uses an open, transparent process to draft its operating rules and any organization is welcome to join this process. Currently, over 140 entities participate in CAQH CORE rules development, representing different stakeholder types including health plans, providers, technology companies, government entities, trade associations, vendors, and standard-setting organizations.

There are several avenues through which organizations can contribute to development of the voluntary CAQH CORE Operating Rules:

  • Become a CAQH CORE Participating Organization: The most effective way for individual organizations to assure they have direct input on the development of either voluntary or mandated operating rules is by becoming a CAQH CORE Participating Organization.
    • Participation in the CAQH CORE rules development process is open to any interested stakeholder, including health plans, providers, technology companies, government entities, trade associations, vendors, financial institutions, and standard-setting organizations.
    • Benefits available to CAQH CORE Participating Organizations include:
      • Participation on Subgroup/Work Group calls, straw polls, and eligibility to Chair groups
      • Organizational vote on CAQH CORE Work Group and Full CAQH CORE Voting Participating Organization levels
      • Access to CAQH CORE Education Sessions specific to CAQH CORE Participating Organizations
    • The cost of CAQH CORE Participation is extremely low or free; participants pay an annual fee based on based on the organization’s stakeholder type and net annual revenues. Refer to the CAQH CORE Participation Application for information on how to become a CAQH CORE Participating Organization.
  • Contribute as a Non-CAQH CORE Participating Organization: While only CAQH CORE Participating Organizations may vote directly on the CAQH CORE Operating Rules, Non-CAQH CORE Participating Entities can also indirectly contribute through public activities such as:
    • Public CAQH CORE Town Hall Calls
      • CAQH CORE holds Town Hall calls which provide attendees an update on recent activities including status of rule development and opportunities for public involvement; email core@caqh.org to be added to the distribution list.
    • CAQH CORE Industry Surveys
      • CAQH CORE periodically conducts industry-wide surveys to obtain directional feedback on operating rule opportunities; email core@caqh.org to be added to the distribution list.
    • Submitting comments to CAQH CORE, via email at core@caqh.org.