During CAQH CORE’s extensive environmental scan period (which included multi-stakeholder interviews, provider site visits, a vendor product assessment, and an All-CORE Participant Survey), one of the biggest pain points cited involved the scenario where a prior authorization request is pended due to the need for additional information (to prove medical necessity for medical services). Another burden for providers is lack of uniformity across Web Portals, as each plan has a portal tool with inconsistent and non-uniform data requirements, field names, etc.
Based on feedback collected, the CAQH CORE Participants determined that for the use case of prior authorizations pended for the need for additional documentation to prove medical necessity, data content enhancements would be beneficial. The Subgroup developed requirements for the CAQH CORE Prior Authorization and Referrals (278) Data Content Rule that reduce common errors that result in pends or denials and assist with communicating those errors back to the provider in an actionable and consistent manner. Given that research revealed that referrals do not often fall into this particular use case, referrals are not included in the scope of the 278 Data Content Rule.
It should be noted that excluding referrals, emergency/urgent cases from the Data Content Rule does not prevent or prohibit entities from using the 5010X217 278 Request and Response for these requests. Additionally, entities are not required to have a web portal to conduct a referral or use a portal for this purpose if it does not already do so.
Referral requests and prior authorizations for emergency and urgent services are not out of scope for the CAQH CORE Prior Authorization and Referrals Web Portal Rule – the rule requirements do pertain to them. The focus of the Web Portal Rule is on the system availability requirements and using standard labels and names for data fields.