CAQH launched the Committee on Operating Rules for Information Exchange^® (CORE^®) to develop an all-payer solution that ensures electronic healthcare administrative data exchange is streamlined and consistent, regardless of the technology. CORE is more than 130 industry stakeholders collaborating on a set of uniform business rules that are built on existing industry requirements. CORE participating organizations collectively cover more than 150 million lives or approximately 75 percent of the commercially insured, plus Medicare and Medicaid beneficiaries.

CORE Transition Committee Update 

Responding to the changing healthcare environment in which operating rules are mandated, the CORE Transition Committee members met in-person in September. The Committee, which includes senior-level executives representing various stakeholder groups, is preparing governance and revenue model options for feedback. The Committee plans to finalize and launch the new governance and funding model in early 2012 after considering industry input from both CORE and non-CORE participants on its draft models.

The CORE Transition Committee was launched by CAQH CORE in early 2011 with the charge to make recommendations regarding multi-stakeholder governance of CORE.

View more information about the CORE Transition Committee.

For more details, contact Gwendolyn Lohse at glohse@caqh.org.

Back to Table of Contents

CMS Developing Final Rule on Eligibility and Claim Status Transactions Operating Rules  

The CAQH CORE Phase I and II Operating Rules are being considered for a national mandate required by Section 1104 of the Patient Protection and Affordable Care Act (ACA). Following a series of hearings, the National Committee on Vital and Health Statistics (NCVHS) provided recommendations on proposed nationally mandated operating rules to the Department of Health and Human Services (HHS). Under HHS, the Centers for Medicare and Medicaid Services (CMS) used these recommendations to draft an Interim Final Rule with Comment (IFC) for industry feedback. The IFC requires the use of the CAQH CORE Phase I and II Operating Rules for non-retail pharmacy eligibility and claim status transactions (updated for the Version 5010 HIPAA standards), with the exception of those rules for acknowledgements. CAQH CORE certification remains voluntary.

CAQH CORE submitted comments directly relating to the content of the IFC for CMS to consider in its development of the final rule. The CAQH CORE letter commends CMS for recognizing and defining the valuable role of operating rules in achieving administrative simplification. The letter also requests several updates and clarifications regarding acknowledgements, operating rules authoring entities, voluntary certification, Companion Guides, and timing on issuance of the final rule.

View the complete CAQH CORE comment letter to CMS.

On September 6, 2011, CMS closed the comment period pertaining to the IFC on Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transactions. CMS is due to issue a final rule by January 1, 2012. The industry will need to implement the operating rules by the ACA deadline of January 1, 2013.

For more information on the CAQH CORE operating rules, contact Erin Richter at erichter@caqh.org.

Back to Table of Contents

UPD STATS AT A GLANCE UPD is the industry standard for self-reported provider data collection. On average, 7,000 providers join the service each month. Totals as of October 27, 2011: Providers Using UPD to Reduce Administrative Costs: 967,276 Annual Administrative Savings: $120 million (4 million hours) Paper Applications Eliminated Since Service Inception: 3 million Environmental Impact: Estimated 106 million pieces of paper or 12,800 trees NEW UPD PARTICIPANTS Arizona Health Advantage/     AZ Priority Care Plus CAP Management CHS America Community Eye Care Elderplan Kentucky Spirit Health Plan Louisiana Office of Group Benefits Medcost Mt Carmel Health Plan/Medigold Multiplan Neighborhood Health Plan     Royal Health Primary Care of Northern Ohio QualCare Salubris, Inc. Sendero Health Plan Total Health Care Online University Physicians NYU     Medical Langone Center Valley Baptist Health Plans

Launched in 2002 by CAQH, the Universal Provider Datasource^® (UPD^®) is achieving its vision of simplified credentialing by reducing paperwork and millions of dollars of annual administrative costs for more than 965,000 providers and over 600 health plans and hospitals across the United States.

The Summit on the Future of Provider Data Scheduled for December 6 

Thought leaders from across the healthcare industry will be engaging in insightful panel discussions and interactive dialogue about administrative provider data at The Summit on the Future of Provider Data. The Summit will be hosted by CAQH in Washington, D.C. on December 6, 2011. Attendees will explore the challenges and opportunities of managing administrative provider data today and in the future to improve data accuracy and efficiency, while addressing how different stakeholders perceive and use the data.

Through collaborative discussions among the broad spectrum of healthcare industry stakeholders, the Summit will facilitate an understanding of common and different administrative provider data needs as well as the way data is currently collected, maintained, and managed in various organizations. Summit participants will explore the future of provider data in light of health reform, the emergence of new delivery systems, and health information exchange, among other trends and drivers.

Contact Brett Lieberman at blieberman@caqh.org with questions.

Back to Table of Contents