Phase V CAQH CORE Operating Rules

Web portal use for prior authorization is widespread and the pain points associated with usage are vast. Mitigating some of these pain points today via an operating rule allows for near-term relief and builds a bridge towards familiarity and consistency with the transaction standard. The standardization of portals supports an interim strategy to bring greater consistency to web portals given current widespread industry use, with a long-term goal of driving adoption standard transaction.

The focus of the is on the system availability requirements and using X12/v5010 278 Request and Response TR3 or base standard implementation names and standard labels for data fields to standardize portal usage for providers, which supports the HIPAA-mandated standard transaction.

Note: The term IMPLEMENTATION NAME is used in the X12 Technical Report Type 3 (TR3) to describe the data field label name. The names are influenced by the intended use of the segment in a specific position of the transaction set and the industry names for data elements in the segment.  Examples of IMPLEMENTATION NAMES can be found in the X12 005010 X217 (278) Health Care Services Request for Review and Response TR3.

In the event of a new version of the X12 Technical Report Type 3 Implementation Specifications (or other standards supported by the operating rules) is adopted in alignment with federal processes, there may be updated published changes to the rule. The CAQH CORE processes to update and publish changes to an operating rule depend on the nature of the changes: substantive, non-substantive, or routine, periodic maintenance that is an ongoing part of CAQH CORE’s regular work. If a new version of the X12 TR3 Implementation Specifications or other standards are mandated under HIPAA, appropriate revisions to the CAQH CORE Rules are made and a draft available for public input. (Example: the CAQH CORE Rules were updated when HIPAA mandates moved from v4010 to v5010 of the X12 standards.)

The rule requires web portal operators to map data field labels to their corresponding 5010X217 278 Request and Response TR3 or base standard IMPLEMENTATION NAME or Alias. It also requires web portal operators to adhere to the data content rule requirements if it maps the data collected from the web form to the 5010X217 278 Request and Response transaction.

The Phase V CAQH CORE Prior Authorization Web Portal Rule is applicable to any entity that currently offers prior authorization through a web portal application; this can include health plans, clearinghouses, vendors, etc., regardless of whether they utilize a 5010X217 278 Request and Response. One goal of this rule is to provide uniformity and consistency to web portal data field labels via the existing standard data element names; this benefit can be applied regardless of whether or not the web portal operator conducts the HIPAA-mandated standard transaction.

No, the bulleted list only contains examples of potential next steps that may take place (not rule requirements). It is not comprehensive, nor does it indicate other processing requirements that may need to occur at the health plan, e.g. medical necessity review, etc.

Yes, the holiday schedule is included in the system uptime of the system availability requirement.

No, the rule does not require the web portal operator to map the data collected from the web form to the X12/v5010X217 278 Request or Response transaction. The rule does require that if a web portal operator maps the data collected from the web form to the X12/v5010X217 Health Care Services Review – Request for Review and Response (278) Transaction, it must conform with the Phase V CAQH CORE Prior Authorization (278) Data Content Rule.

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 Phase V CAQH CORE Prior Authorization (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 no 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 Phase V CAQH CORE Prior Authorization 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.