Fall 2012

Redesigned CAQH.org Website Coming in 2013 

CAQH is preparing to unveil a redesigned website in 2013 to better serve the wide range of individuals and organizations across the healthcare industry with relevant information through CAQH.org.

As part of this effort, CAQH conducted a website survey in August. Thank you to everyone who responded. These findings are helping inform structure, design, and functionality of the website. While the primary reason for visiting CAQH.org varied widely among respondents, there was consensus that the most important web attributes are ease of use, navigability, and the inclusion of relevant and up-to-date information.

The redesigned CAQH.org website will offer a simple and user-friendly design, improved navigation to streamline the visitor experience and make it easier to locate and share content, as well as dedicated sections for news and updates.

Watch for an announcement about the completed CAQH.org redesign in 2013.

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U.S. Healthcare Efficiency Index Update 

The U.S. Healthcare Efficiency Index (USHEI) is preparing to issue an update to its National Progress Report in the second quarter of 2013. The Report will aggregate results from its contributors to enable benchmarking, track progress and project the cost savings associated with the adoption of electronic transactions in healthcare. Using interactive calculators to input transaction volumes and current levels of adoption, health plans and providers will be able use the Index website to estimate their own potential cost savings and compare their progress in the adoption of electronic transactions to national measures for the industry as a whole.

In September the Index Advisory Council, whose members represent all facets of the healthcare industry, met to thoroughly review the USHEI Reporting Standards and Data Submission Guide. Contributors to the Index will use the Guide to collect and normalize their data for submission. Data collection for the next National Progress Report will occur between February and early March 2013.

Health plans are encouraged to contribute data to the Index in order to gain insight into their own electronic transaction adoption levels and potential cost savings. Index data will be reported only in aggregate form, but contributing health plans will receive customized individual reports comparing organizational performance alongside national results for benchmarking and cost savings opportunities. Broad stakeholder participation in USHEI will improve the amount and validity of data, growing the Index as the healthcare “gold standard” for measuring the gap between manual and electronic transactions.

For more information and to learn how to participate in the U.S. Healthcare Efficiency Index, please visit http://www.ushealthcareindex.org/ or contact Reid Kiser.

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CAQH Welcomes New Staff 

CAQH recently welcomed James Morey as the UPD Business Manager of Technology & Innovation. Prior to joining CAQH, he worked with the UPD system vendor, Affiliated Computer Services (ACS), a Xerox Company, for 12 years. During this time, James served as Project Manager for the ACS CAQH transition team in 2008 and later moved into an Operations Manager and Sr. Business Analyst role. He has worked with various commercial and government accounts to implement "best practices" and process improvement using Six Sigma and Lean methodologies. James may be reached at jmorey@caqh.org.

Mark Uherek is a new UPD Account Manager. He is assisting participating organizations with inquiries and helping manage participant accounts to take full advantage of provider data collected in UPD. Mark has 30 years of experience in the healthcare business sector, working in IT sales, account management and project management. He earned a Bachelor’s degree from Central Michigan University and an M.B.A. from George Mason University. Mark may be reached at muherek@caqh.org or (202) 955-4391.

Inez Johnson brings several years of experience in financial management and analysis to the role of UPD Billing/Financial Analyst. She is performing varied UPD billing, receivables management and accounting work to support account management for participating organizations and the UPD system. Inez most recently worked as a Business Manager with Imagine Hope Community Charter School in Washington, DC. She earned a B.S. from the University of Maryland College Park and an M.B.A. from Johns Hopkins University. Inez may be reached at ijohnson@caqh.org or 202-861-1446.

Alisa Chester has joined CAQH CORE staff as a Project Associate. She is serving as the intake coordinator for the CORE request process and assists with a variety of CORE projects related to operating rules development and implementation. Prior to working at CAQH, Alisa interned at the National Family Planning & Reproductive Health Association and the Institute for Women’s Policy Research. She earned her B.A. from the University of California, Santa Barbara and M.A. from the George Washington University. Alisa may be reached at achester@caqh.org or (202) 861-6368.

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Upcoming CORE Activities

CAQH CORE Town Hall Call;

CAQH CORE and CMS 'Open Mic' Session;

CAQH CORE and NeHC Webinar;

Healthcare Payments Innovations;
1/28 - 1/29/13

Visit CAQH.org often to learn of
upcoming events.

New CORE Certifications

Dorado Systems (Phase I & II) -
Insurance Validator

HealthFusion (Phase II) -
HealthFusion Real-Time

New CORE Participants

Ortho NorthEast (ONE)

California Department of Health Care Services

NASW Risk Retention Group

North Dakota Medicaid

CAQH launched the Committee on Operating Rules for Information Exchange® (CORE®) to develop a 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.

Streamlined Eligibility and Claim Status Transactions Becoming a Reality Across the Healthcare Industry 

Healthcare organizations can expect streamlined eligibility and claim status transactions with the start of 2013. By January 1, HIPAA-covered entities must implement the CAQH CORE Operating Rules for Eligibility and Claim Status transactions, which were adopted for a federal mandate under the Affordable Care Act (ACA). These operating rules help ensure consistent and accurate administrative data exchanges that enable providers to determine whether a patient is eligible for coverage and the status of healthcare claims submitted to partnering health plans.

As the Department of Health and Human Services (HHS) designated operating rules author, CAQH CORE is continuing to offer a variety of tools to help organizations with their operating rules implementation. Visit www.caqh.org to access numerous free resources such as, a compilation of Frequently Asked Questions and an archive of helpful presentations.

Tell the industry that your organization is ready to test!
Organizations that have adopted the CAQH CORE Eligibility and Claim Status Operating Rules and are ready for testing implementation with trading partners can promote their readiness. Trading Partner Testing Readiness WebpageAdd your organization and a contact name to this webpage list to tell the industry your organization is prepared to test. View others that have also completed operating rules implementation efforts and connect with trading partners to identify any challenges before the January 1, 2013 deadline.

After testing the CAQH CORE Eligibility and Claim Status Operating Rules implementations with trading partners, organizations may publicize their adoption of the first set of federally mandated operating rules by becoming voluntarily CORE-certified. Many organizations have accomplished voluntary CORE-certification, which tests operating rules implementation through an independent CORE-authorized testing vendor and earns a CORE Seal upon successful completion. Like the “Good Housekeeping Seal of Approval,” a CORE Seal demonstrates to the industry that an organization is conducting transactions using the CAQH CORE operating rules.

To learn more, contact CORE@caqh.org.

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CAQH CORE EFT and ERA Operating Rules Federally Mandated in Interim Final Rule 

On August 10, 2012 the Centers for Medicare and Medicaid Services (CMS) issued an Interim Final Rule with comment period (IFC) – Administrative Simplification: Adoption of Operating Rules for Health Care Electronic Funds Transfers (EFT) and Remittance Advice (ERA) Transactions. The IFC adopts the Phase III CAQH CORE EFT & ERA Operating Rule Set, which was developed by CORE Participants with industry input and in collaboration with NACHA – The Electronic Payments Association. NACHA maintains operating rules for the financial services industry, governs the ACH Network and is the author of the EFT standard mandated by the Department of Health and Human Services (HHS). All HIPAA-covered entities must be in compliance with the EFT & ERA Operating Rule Set by January 1, 2014.

By keeping all five areas in the EFT & ERA Operating Rule Set intact, the IFC supports the interdependencies of the rules and enables the industry to achieve optimum efficiency. Comments on the IFC were accepted by the Centers for Medicare & Medicaid Services, HHS through October 9. No changes to the HHS IFR have been announced. HHS has publically stated that interim final rules stand as final rules. Entities should be working towards the January 2014 adoption date.

CAQH CORE and NACHA will continue to work in partnership to educate the healthcare industry as it moves to adopt the mandated healthcare EFT standards and EFT and ERA operating rules.

For more details, contact CORE@caqh.org.

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CORE Transition Committee Update 

Draft CAQH CORE Board CompositionThe CORE Transition Committee has finalized a new draft CORE governance model based on feedback and commitments from critical stakeholders. Since its inception, CAQH CORE has been a multi-stakeholder collaboration that embraces input from the entire industry and provides an open and transparent process for addressing concerns and sharing feedback. Further reflecting this approach, the new CORE governance model builds on the commitment for all entities in the chain of data exchange to engage in operating rules development and drive adoption of the rules in order to achieve ROI.

The draft composition of the new CORE Board and governance model is available HERE. Nominations for the CORE Board are currently being completed. In early 2013 CAQH CORE will begin its transition to the new governance model.

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UPD is the industry utility for self-reported provider data collection. On average, 7,000 providers join the service each month.

Totals as of December 6, 2012:

Providers Using UPD to Reduce Administrative Costs:

Annual Provider Administrative Savings:
$147 million (4.9 million hours)

Paper Applications Eliminated Since Service Inception:
3.6 million

Environmental Impact:
Estimated 129 million pieces of paper or 15,500 trees


Adena Health System
Agewell New York, LLC/ Parker
    Jewish Institute
Alliance Behavioral Healthcare
Amerigroup Kansas
Apple Care Medical Management
Athena Health System
Bronx United IPA
Corvel Corporation
East Carolina Behavioral Health
Eye Associates Network
Healthcare Partners of California
Heritage Vision Plan
Holzer Health System
Mercy Care Plan
Mercy Physicians Medical Group
MetroPlus Health Plan
NYU Langone Medical Center
Occupational Managed Care
    Alliance/Provider Net
Old Pueblo Medical Management
PBH Solutions
Phoenix Health Plan/Abrazo
    Health Plan
PIPN Personal Injury Provider
Primary Care Associates Medical
Primary Partner Care Network
PrimeCare Medical Network, Inc
Professional Health Choice
Smoky Mountain Center
Solstice Benefits
Southwest Network
St Mary's of Michigan PHO
Steward Medical Group
Sunflower State Health Plan
Western Highlands Network

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 one million providers and over 650 health plans and hospitals across the United States.

Provider Data Workgroup Update 

The Summit on the Future of Provider Data was hosted by CAQH and convened healthcare stakeholders to discuss the challenges and opportunities associated with administrative provider data. CAQH followed up on recommendations shared during the Summit by organizing a Provider Data Workgroup and leading research activities to identify provider data related efforts across the healthcare landscape. The research reaffirms that there is very little coordination among provider data efforts across the industry, which results in duplicative service offerings and minimum leveraging of data format standards.

In the coming weeks CAQH will release a whitepaper summarizing current industry work on administrative provider data. A catalogue of efforts representing numerous use cases will be included.

The Provider Data Workgroup will review the research to assess how the industry can better collaborate in the collection, maintenance and distribution of common data with the intent of eliminating redundant efforts that add unnecessary cost and complexity. Looking at the amassed databases and data standards, the Workgroup will be tasked with determining:

    • Where do redundancies exist among industry efforts?
    • Which data collection models are most efficient?
    • How can best practices be shared?
    • How can the industry impact provider data quality and maintenance?

There is a clear opportunity to create meaningful provider data efficiencies that can be shared among stakeholders. The goal of this work is to identify solutions that can benefit the provider community, reduce costs, decrease duplicative efforts and lead to improved data quality.

Additional participation in the Provider Data Workgroup is welcome. To get involved or learn more, contact Christine Stroup.

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Maintaining Provider Directories  

In response to the growing requirement for accurate and timely provider directories, CAQH is introducing a UPD Directory Maintenance Report. Delivered weekly to all UPD participating organizations, the Report will review provider rosters and capture all changes related to directory data, such as practice locations, hospital affiliations and other pertinent information.

While the UPD Extract Data Summary will continue to provide all information changes related to the entire CAQH UPD application, the Directory Maintenance Report includes only those elements that would appear in a directory. The succinct data file highlighting these specific changes from week to week will help UPD participating organizations streamline the process for maintaining accurate and timely provider directories.

For more information on this new Report, contact Christine Stroup.

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Industry News  

NeHC University Offers Education Opportunities 

National eHealth Collaborative (NeHC) is a public-private partnership that accelerates secure and meaningful use of health IT through education and stakeholder engagement to advance health and transform healthcare.

Through its NeHC University online education program, its Consumer Consortium on eHealth patient engagement initiative, and its ongoing study of critical success factors for health information exchange through the HIE Learning Network, NeHC works to educate, connect and encourage healthcare stakeholders in efforts to promote the successful deployment of health IT and health information exchange nationwide.

In the coming months, NeHC will be hosting some exciting new programs through NeHC University, including classes that will explore the rapidly changing health information exchange (HIE) landscape and the resources and programs available for providers in rural and underserved communities.

On Tuesday, December 18, CAQH CORE and NeHC will offer a joint education session, "Countdown to Compliance: An In-Depth Look at the Federally Mandated Eligibility and Claim Status Operating Rules Deadline". This online event will be held 3:00 - 4:30 pm ET.

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