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. Add 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 

The 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 STATS AT A GLANCE 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: 1,081,825 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 NEW UPD PARTICIPANTS 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 CMDP CoastalCare Corvel Corporation East Carolina Behavioral Health Eye Associates Network Healthcare Partners of California Heritage Vision Plan Holzer Health System IntegraNet 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     Network Primary Care Associates Medical     Group 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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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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