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CAQH CORE Operating Rules Adopted By HHS

December 30, 2011

Tthe 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 the rules, which will make electronic transactions more predictable and consistent, by Jan. 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,” Robin Thomashauer, executive director at CAQH, said in a statement. “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 initiative that is streamlining electronic healthcare administrative data exchange and improved health plan-provider interoperability. CAQH CORE rules build on existing standards, such as those in HIPAA 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,” Thomashauer said.

To date, nearly 60 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 plans to continue to serve in the role as author of ACA mandated operating rules given its commitment to improving the efficiency of healthcare transactions.


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