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CAQH CORE operating rules adopted by HHS for patient eligibility and health claim status transactions

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WASHINGTON, DC – December 21, 2011 – CAQH® announced that the Department of Health and Human Services (HHS) adopted the use of many of the CAQH Committee on Operating Rules for Information Exchange® (CORE®) operating rules regarding eligibility for a health plan and healthcare claim status transactions.  All HIPAA covered entities will be required to comply with these operating rules, which will make electronic healthcare transactions more predictable and consistent, by January 1, 2013 as part of the Patient Protection and Affordable Care Act (ACA).  

“We are pleased that HHS has recognized the valuable role of operating rules in achieving administrative simplification,” said Robin Thomashauer, Executive Director of CAQH.  “With the adoption of the CAQH CORE Phase I and Phase II operating rules related to eligibility and claim status transactions, the industry is taking an important step forward as we move to the next level of electronic solutions.”

CAQH CORE is a national industry multi-stakeholder initiative that is working to streamline electronic healthcare administrative data exchange and improve health plan-provider interoperability.  CAQH CORE rules build on existing standards, such as those in the Health Insurance Portability and Accountability Act rules, to make electronic data transactions more predictable and consistent, regardless of the technology.

“The CORE participants are committed to leveraging their experience to assist in the successful implementation of the final operating rules, so health plans, providers, hospitals, vendors and other organizations can exchange more efficient and predictable patient-eligibility and claims-verification information,” said Thomashauer.

To date, nearly 60 leading national healthcare organizations are voluntarily certified as exchanging electronic administrative data in accordance with CORE Phase I and/or Phase II rules.

CAQH CORE is applying and hopes to continue to serve in the role as author of ACA mandated operating rules given its commitment to improving the efficiency of healthcare transactions.

About CORE

CAQH Committee on Operating Rules for Information Exchange (CORE) is a multi-stakeholder industry collaboration developing operating rules that streamline administrative transactions. Over the past six years, CORE participation has grown to more than 130 organizations that represent approximately 75 percent of the commercially insured lives plus Medicare and Medicaid beneficiaries. CORE has a proven track record of operating rules adoption through voluntary certification and stakeholder return on investment.  CAQH CORE was recommended by the National Committee on Vital and Health Statistics (NCVHS), a federal advisory committee to the HHS Secretary (NCVHS), to draft the EFT/ERA operating rules mandated by the ACA, and has testified to NCVHS on other ACA mandates for operating rules.  To learn more about CAQH CORE, visit www.caqh.org/benefits.php.

About CAQH

CAQH serves as a catalyst for industry collaboration on initiatives that simplify healthcare administration for health plans and providers, resulting in a better care experience for patients and caregivers. CAQH solutions help promote quality interactions between plans, providers and other stakeholders; reduce costs and frustrations associated with healthcare administration; facilitate administrative healthcare information exchange; and encourage administrative and clinical data integration. Visit www.caqh.org for more information.


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