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CORE Operating Rules Recommended to HHS for Federal Adoption

Background

In May of 2022, the CORE Board sent a letter to the National Committee on Vital and Health Statistics (NCVHS), a federal advisory committee to the Secretary of Health and Human Services (HHS), proposing new and updated operating rules for federal adoption. These rules modernize requirements related to the exchange of data for telehealth, prior authorization, complex benefit design and value-based payments.

After an open comment period and industry hearing, in a June 2023 letter to HHS, NCVHS recommended that the new and updated operating rules be mandated. If HHS supports the NCVHS recommendation, an Interim Final Rule (IFR) will be issued with public comment period. Once HHS finalizes the rule, industry stakeholders would have 25 months to implement the newly mandated operating rules.

The table below outlines the CORE Operating Rules recommended by NCVHS to HHS. The rules promote interoperability and ease the burden of workarounds and manual processes.

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Overview of Recommended CORE Operating Rules  
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Data Content

  1. UPDATED CORE Eligibility and Benefits (270/271) Data Content Rule vEB.2.0
  • Expands required service type codes and requires use of procedure codes.
  • Indicates requirements for prior authorization.
  • Enhances required details about benefit structure and patient financial responsibility.
  • Facilitates telehealth coverage through required inclusion of CMS Place of Service Codes.
  1. NEW CORE Eligibility and Benefits (270/271) Single Patient Attribution Data Content Rule vEB.1.0
  • Standardizes communication of a patient’s attribution status to a provider under a value-based contract.
 
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Infrastructure

  1. UPDATED CORE Eligibility and Benefits (270/271) Infrastructure Rule vEB.2.0
  2. UPDATED CORE Claim Status (276/277) Infrastructure Rule vCS2.0
  3. UPDATED CORE Payment and Remittance (835) Infrastructure Rule vPR2.0
  • Increases weekly system availability requirements to 90%.
  • Aligns connectivity requirements with most current version of CORE Connectivity.
  • Supports a version-agnostic Master Companion Guide Template.
 
Connectivity Icon

Connectivity

  1. UPDATED CORE Connectivity Rule vC4.0.0
  • Modernizes certification and authentication requirements, referencing X.509 and OAuth 2.0.
  • Expands payload support to easily facilitate exchange of X12 v6020.
  • Adds support for REST, strengthening application to HL7 FHIR-based APIs.
 

NCVHS Recommendations Roundup Webinar

To hear an explanation of the NCVHS process and rule recommendations from CORE leadership, listen to CORE’s recent NCVHS Recommendation Roundup Webinar.

The operating rules recommended for federal adoption are the result of an industry led, consensus-based process that included health plans, providers, government entities, vendors, clearinghouses, associations, and others. Each requirement represents a step toward automation and the elimination of costly manual workarounds. If you have any questions, please reach out to CORE@caqh.org.