CORE Phase III Rules

The CORE Phase III rule development process is underway. CORE-participant organizations working with CAQH developed the scope of work for the CORE Phase III Operating Rules. As with all CORE Phases, the Phase III scope was developed based on input from multiple sources and using a priority selection process to assess a large list of Phase III scope options against key filters.

Determining the scope of Phase III rules involved broad representation, both in number and stakeholder type, from CORE participant organizations. More than 150 individuals, representing over 60 CORE-participant organizations, participated in at least one of three Phase III group-discussion exercises. Several other discussions with CORE participants and industry partner organizations also contributed to the Phase III scope considerations.

CORE Phase III Scope:

The following areas are in the CORE Phase III rules scope:

1. 276/277 Claims Status Transaction: Build out data content requirements
2. 270/271 Eligibility/Benefits Transaction: Further enhance this transaction’s data content requirements, e.g., develop rules related to provider network identification and improved patient identification
3. New Transactions (835 Payment/Remittance Advice and 278 Authorizations, Precertifications & Referrals:
   • Apply Phase I and II infrastructure rules to electronic remittance advices (real-time response time, system availability, connectivity and acknowledgements), and build out these transactions’ data content requirements
4. Connectivity: Build upon connectivity given it allows for connections to all other health IT applications and is a key aspect for interoperability
5. Insurance ID Cards: Address rules on standard ID careds (WEDI ID Card Implementation Guide will be key)

The CAQH staff has created Subgroup discussion documentation for several areas that have strong support, e.g., claims status and payment/remittance advice. CORE participating organizations are asked to identify any individuals within their organization whose skills sets are needed for Phase III to supplement the expertise of your existing representatives, who may be more eligibility- or connectivity-focused. Please forward any additional names and contact information to Tim Cochran at tcochran@caqh.org.

Please contact CAQH staff with your questions and suggestions.