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 120 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.
Transition Committee
The Transition Committee has been launched to make recommendations regarding multi-stakeholder governance of CORE. The Committee was formed as part of a 2010 commitment made by the CAQH Board to increase industry participation in operating rules development and adoption. The group is charged to develop a three-year plan that outlines governance structure and revenue models for CORE. Additionally, it will propose ideas for enhancing the current CORE multi-stakeholder approach by increasing participation by states, physicians, hospitals and other healthcare providers. It is anticipated that the Committee will complete its work and implement its recommendations by the end of 2011.
The CORE Transition Committee members represent various stakeholder groups and include senior-level executives from the following organizations:
- Allscripts
- America’s Health Insurance Plans (AHIP)
- American Hospital Association (AHA)
- American Medical Association (AMA)
- Blue Cross and Blue Shield of North Carolina
- GE Healthcare
- J.P. Morgan
- Medical Group Management Association (MGMA)
- Minnesota Department of Health
- Montefiore Medical Center
- National Governors Association (NGA)
- UnitedHealthcare
- WellPoint, Inc.
More details about representatives and the Committee, which is being facilitated by the CORE Chair, are available online at http://www.caqh.org/CORE_Transition_Committee.php.
Read the CORE Transition Committee release here.
For more information, contact Gwen Lohse at glohse@caqh.org
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UnitedHealth Group Achieves CORE Certification
UnitedHealth Group recently achieved CORE-certification for its implementation of the CAQH CORE Phase I and Phase II rules. UnitedHealth Group is the first organization to complete certification using an updated testing platform, which builds on non-mandated aspects of the Health Insurance Portability and Accountability Act (HIPAA) version 5010 requirements.
CORE certification verifies that UnitedHealth Group can deliver more predictable patient-eligibility and claims-verification information to physicians, hospitals and other care providers, according to operating rules developed by CORE. The certification will apply to UnitedHealth Group systems covering 37 million members.
A CORE-authorized testing vendor, Edifecs, provided the independent platform to validate that UnitedHealth Group systems operate in accordance with the CORE Phase I and II rules. UnitedHealth Group has its v5010 production transactions in process and will continue to migrate its trading partners to these new systems through the January 2012 deadline.
More than 50 organizations are CORE-certified and have completed testing for the CORE rules. Montefiore Medical Center recently became the first provider group to achieve CORE Phase II certification. Other recent Phase I and/or II certifications include: HealthTrio LLC, Ingenix, Practice Insight, Recondo Technology, The SSI Group, and ZirMed. Organizations that do not exchange eligibility, benefits, and claims status information may endorse CORE. The latest organizations to endorse the initiative include eMids Technologies Inc., FIS Global, HIPAA Ready LLC, and NACHA – The Electronic Payments Association.
Over the last few months a number of new organizations have begun participating in the development of the CORE rules: Allina Health System; Allscripts; American Hospital Association; Bank of America; Cognosante (Fox Systems); Deloitte Consulting LLP; DST Health Solutions; Fifth Third Bank; FIS Global; HBCS; HERAE, LLC; Hospital Corporation of America; Hubbert Systems Consulting; Kaiser Permanente; Minnesota Department of Health; NYU Langone Medical Center; OptumHealth Financial Services; OneHealthPort; The Clearing House; Tufts Health Plan; US Bank; US Department of Treasury Financial Management Service; and VeriSign, Inc. – a Symantec Business. More than 120 multi-stakeholder organizations are participating in the collaboration.
For information how your organization can achieve CORE Phase I or II certification, contact Erin Richter at erichter@caqh.org.
Read the UnitedHealth Group release here.
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Rules Updated for HIPAA v5010
The federal mandate deadline for adoption of HIPAA Version 5010 standards is January 1, 2012. Per the CORE guiding principles, CORE operating rules are updated to coordinate with federally mandated requirements. The voluntary CORE Phase I and Phase II policies and rules have been updated to reflect HIPAA v5010 requirements and associated errata. A summary of the changes, as well as each of the adjusted CORE rules, is available on the CAQH website: http://www.caqh.org/COREv5010.php.
For questions pertaining to the CORE rules and HIPAA v5010, please contact Bob Bowman at rbowman@caqh.org.
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EFT-ERA White Paper
In collaboration with NACHA, CAQH recently issued a white paper examining the adoption of electronic funds transfer (EFT) and electronic remittance advice (ERA) by health plans and providers. The paper is based on research conducted to better understand the current status of government, health plan and provider use of EFT and ERA, and to facilitate development of robust EFT and ERA operating rules.
The findings explore barriers to industry-wide, rapid adoption of EFT and ERA, as well as initial recommendations on topics that operating rules and other industry efforts must address in order to facilitate adoption. The details behind these findings are being presented to the CORE EFT and ERA Subgroups as they develop healthcare operating rules; the financial services industry is also considering the findings as it amends the NACHA Operating Rules for EFT.
The white paper is available online at http://www.caqh.org/Host/CORE/EFT-ERA/WhitePaper.pdf.
Contact Erin Richter at erichter@caqh.org with any questions.
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National Operating Rules Update
Section 1104 of the Patient Protection and Affordable Care Act (ACA) requires the Health and Human Services (HHS) Secretary to adopt and regularly update standards, implementation specifications, and operating rules for the electronic exchange and use of health information for the purposes of financial and administrative transactions. The ACA requires the National Committee on Vital and Health Statistics (NCVHS) to make recommendations regarding operating rules to the HHS.
EFT and ERA
On March 23, 2011, NCVHS sent a letter to Secretary Sebelius, HHS, making a recommendation to name "CAQH CORE in collaboration with NACHA as the candidate authoring entity for operating rules for all healthcare EFT and ERA transactions..."
The letter also recommends that the Secretary:
- Require CAQH CORE, in collaboration with NACHA, submit to NCVHS fully vetted Electronic Funds Transfer (EFT) and Health Care Payment and Remittance Advice (ERA) operating rules for consideration by the Committee by August 1, 2011.
- Require CAQH CORE to establish mechanisms for greater direct engagement of X12, NCPDP, HL7 and other standards development organizations (SDOs) in order to support a more open, collaborative and multi-stakeholder consensus process.
- Call on X12, NCPDP, HL7 and other SDOs to actively engage with CAQH CORE and to provide timely input and feedback on EFT and ERA operating rules.
- Further clarify the scope, focus, and limitations between operating rules and standards.
- Require CAQH CORE to identify more effective means to engage greater and broader provider participation and input.
In response to the March 23rd recommendations, CORE participants are working diligently towards the August 1, 2011 deadline to develop EFT and ERA operating rules. Discussions have started to determine the potential rule opportunity areas based on:
- The scope of operating rules as defined by ACA Section 1104; e.g., build upon existing standards.
- Existing activities that showcase current priorities; e.g., CAQH CORE and NACHA research, draft CAQH CORE rules, current state efforts (e.g., MN State Administrative Uniformity Committee, WA State Healthcare Forum) and work done by key collaborators like ASC X12 and WEDI.
A public survey was issued to gain more industry input about which areas are best to pursue. Over 115 organizations completed the survey. The findings are helping to inform the EFT and ERA Subgroup on how to focus efforts given the criteria used for CORE rule writing, e.g.:
- Remain within the scope of the operating rules as defined by ACA Section 1104.
- Support CORE Guiding Principles; e.g., align with Federal HIT efforts.
- Balance between anticipated industry benefit relative to the industry adoption cost (ROI).
- Can be developed within the NCVHS time frame (08/01/11 deadline).
Seven high priority areas have been selected, and rule approaches have been selected for the majority of these areas.
For more information on the CAQH CORE operating rules for EFT and ERA, contact Erin Richter at erichter@caqh.org.
Eligibility and Claim Status
Given the NCVHS recommendation on September 30, 2010 for CAQH CORE to consider potential enhancements to the Phase I and II rules, CAQH staff collected suggestions from states, providers and other key stakeholders on potential enhancements from October, 2010 through the end of the year. Additional feedback was solicited from CORE and non-CORE participants via an open survey and “Tiger Team” calls. (View a summary of the survey results or a high-level summary of the discussions.) The appropriate CORE Subgroups and Work Groups then met to discuss the potential enhancements to the Phase I and II CORE rules based on the NCVHS recommendation.
Per the CORE voting process, both the Rules and Technical Work Groups held ballots on potential enhancements to the CORE rules. The Work Groups approved enhancements to the CORE Phase II rules based on three Phase III draft rules:
- Use of 277CA for acknowledging v5010 837 claims.
- Uniform use of claims status category and claims status codes.
- Replace 997 Functional Acknowledgement with 999 Implementation Acknowledgement.
All CORE rules that are not included in packages for potential mandates due to timing constraints and/or other regulatory parameters will be supported by CORE via a voluntary certification process.
NCVHS: April 27, 2011 Testimony
On April 27, 2011, the NCVHS Subcommittee on Standards heard testimony from numerous organizations on "The Acknowledgment Transaction Standard and Maintenance and Modifications to Standards and Operating Rules (the present and the future)".
Acknowledgements:
Based on its experience, CAQH CORE provided testimony about standard acknowledgement transactions. CAQH CORE highlighted the opportunity being provided by Section 1104 of the ACA for the industry to drive national adoption of consistent use of acknowledgements through mandated operating rules.
Since its inception, the CORE rules have and continue to require acknowledgements. As the CORE operating rules are developed in phases, each set of rules complements the others by recognizing interdependencies. This approach is essential when considering acknowledgements. For example, if operating rules require real-time response to an inquiry, an acknowledgement of the same inquiry is not necessary and, in fact, could add unnecessary costs to the system given vendor fees and provider work flow resources related to acknowledgements.
Modifications:
Regarding current maintenance and modifications for standards and operating rules, CAQH CORE described four inter-related themes that define what is working and what can be improved.
- The rapidly changing world of HIT for administrative simplification must support vision for innovation and cost reduction –alignment on key tools and milestones.
- Strong governance and solid funding are both critical in order to guide what must be modified and maintained; leadership is key.
- Tactical processes for updating operating rules must be guided by the strategic vision and governance.
- Consistent, yet iterative, coordination will be needed between authoring entities for operating rules and SDOs.
Before concluding, CAQH CORE highlighted the concept that operating rules can come before or after a version of a standard, emphasizing that this is already occurring and the result is more robust adoption of electronic transactions.
Visit http://www.ncvhs.hhs.gov/110427ag.htm for a presentation and audio archive of the Acknowledgements and Modifications testimony.
Voluntary CORE Rules
Work on developing voluntary CORE operating rules continues. Following the release of nationally mandated operating rules, CORE will determine which of its draft voluntary rules are appropriate for voluntary certification. A summary of CORE Phase III draft rules may be found at http://www.caqh.org/CORE_phase3.php.
For more information on CORE operating rules, please contact Erin Richter at erichter@caqh.org.
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EFT and ERA Subgroup Chairs
Four industry leaders are co-chairing the CAQH CORE EFT and ERA Subgroup. The chairs represent provider, bank, vendor and health plan organizations and are helping guide the discussions and efforts being pursued by the Subgroup.
- Doug Downey is assistant vice president in treasury at HCA, one of the first U.S. hospital companies. Much of his work has focused on streamlining the payment process.
- Stuart Hanson is vice president, healthcare solutions product line manager for Fifth Third Bank. He has a background in medical banking at multiple financial services organizations.
- Tom Turi is senior vice president of financial services with Emdeon Business Services. He has worked to transform financial business processes across multiple industries.
- Peter Walker is the manager of Provider eServices at Aetna, Inc. His background includes experience providing direction for the creation and maintenance of electronic transactions used by healthcare providers.
For more information about the efforts of the EFT and ERA Subgroup, contact Omoniyi Adekanmbi at oadekanmbi@caqh.org.
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Education Opportunities
Presentations and Participation at Industry Conferences
Outreach and education are an essential component of the CORE integrated model. CORE representatives regularly speak at healthcare events to help inform the industry about the role of operating rules and how the changing environment is impacting CORE efforts. View a list of upcoming presentations.
Town Hall Calls
Additionally, CAQH CORE is holding open Town Hall Calls every four-to-six weeks which all stakeholders, both CORE participating and non-participating entities, are invited to attend. The purpose of these calls is to provide an informal update on CORE activities over recent weeks and months. More information and the Town Hall call schedule are available online.
Educational Sessions
CAQH CORE also offers several online education events through webinar and audiocast presentations. Many of these e-learning opportunities are in collaboration with other industry leaders, such as the American Medical Association (AMA); Edifecs, a CORE-authorized testing vendor; NACHA – The Electronic Payments Association; and the Workgroup for Electronic Data Interchange (WEDI). Visit www.caqh.org/CORE_Education_Events.php to view an archive of these presentations.
Contact Ezra Rosenberg at erosenberg@caqh.org for more details on these education opportunities.
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