New and Updated CAQH CORE Operating Rules for Healthcare Payments and Claims Processing Efficiency

CORE Board has approved new rules to simplify and speed up healthcare payments and claims, backed by strong consensus from industry organizations.

WASHINGTON, D.C. – The CAQH Committee on Operating Rules for Information Exchange (CORE) announces the approval of three new and updated sets of CORE Operating Rules aimed at simplifying healthcare payment and claims processes for providers and health plans. Organizations can start implementing these updates immediately to begin reaping the benefits of streamlined processes and improved operational efficiencies. This milestone reflects the collaborative efforts of hundreds of industry participants who contributed through extensive industry research, active work groups, and a formal ballot process. This collective endeavor adds to the suite of existing CORE Operating Rules and highlights industry commitment to reduce time spent on administrative tasks and increase time for patient care.

Erin Richter Weber, CAQH Chief Policy and Research Officer stated, “These operating rules are more than guidelines; when implemented, the rules streamline healthcare data exchange and reduce provider burden. We are grateful for the dedication and insight of all those who contributed to this important work. This is a win for providers, health plans, and, most importantly, patients."

What this means for the healthcare industry:

• For Value-Based Payments:
  • Standardizes the collection of socio-demographic data and terminology, improving data quality for contracts and easing program management. Also enables providers to address social health determinants through a dependable information-sharing system with value-based care partners.

• For Healthcare Claims:
  • Streamlines coding for telehealth and value-based payments, standardizes diagnosis communication, and improves benefits coordination, reducing errors and simplifying processes.

• For Electronic Payments and Processing:
  • Adds critical data elements, enhances fraud detection, and increases transparency by disclosing fees and opt-out options for alternative payment methods.

These updates have garnered significant support across the industry, with approval rates of 86% and higher during the formal CORE Participant Voting Process.

Linda Reed, SVP and CIO of St. Joseph’s Health and CORE Board Chair, shared her perspective on the significance of the new and updated rules, "The unanimous approval of these operating rules by the plans, providers, and vendors on the CORE Board underscores our commitment to improving healthcare administration. By adopting these rules, we are taking a significant step forward in reducing administrative burdens and enhancing the efficiency of healthcare transactions."

Healthcare operating rules support a range of standards to make sharing data more predictable and consistent, regardless of the technology. CORE is designated by the Secretary of the Department of Health and Human Services (HHS) as the National Operating Rule Authoring Entity for the administrative transactions under HIPAA. CORE is committed to bringing together industry stakeholders to develop and implement operating rules that foster a more efficient healthcare system. Entities that are already CORE-certified will have a two-year period to integrate these new rules into their systems. For more detailed information including implementation resources, please refer to the official CORE Operating Rules website.

For additional information on the new and updated CORE Operating Rules, or to schedule an interview with a CORE spokesperson, please contact sholvey@caqh.org.

About CAQH

CAQH is a leading organization focused on aligning the healthcare ecosystem around essential solutions, creating a more connected and less costly experience for all. For more than 20 years, CAQH has partnered with millions of providers, thousands of health plans, state Medicaid agencies, and leading healthcare stakeholders who leverage the organization's solutions, operating rules, and insights to connect and exchange data every day as a part of the business of healthcare. Learn more at CAQH.org.