As the healthcare industry drives toward a more seamless and automated future, common business rules are critical to success.
Erin Weber
Vice President, Committee on Operating Rules for Information Exchange (CORE), Council for Affordable Quality Healthcare (CAQH)
For years, healthcare has been regarded as lagging behind other parts of the economy in automation, interoperability, and the consumer experience. That is changing. The industry is making meaningful progress toward a seamless experience for health plans, providers, and consumers by coming together to address challenges in healthcare administration.
Healthcare stakeholders have coalesced around creating common business rules and standards that allow organizations to exchange information seamlessly and securely. A single hospital, for example, might need to verify patient coverage, submit and check the status of claims, and conduct several other administrative transactions with potentially hundreds of health plans using a myriad of technology platforms. This challenge requires common, agreed upon business rules to achieve administrative simplification.
A unifying force
Today, CAQH CORE — a collaboration of providers, health plans, vendors, government agencies, and standard-setting bodies — develops protocols, known as operating rules, to enable predictable, consistent, and secure data sharing. CAQH CORE is designated by the Department of Health and Human Services (HHS) as the entity responsible for drafting operating rules for federally mandated administrative transactions.
Since its founding, CAQH CORE has established operating rules in eight key areas related to determining patient eligibility and benefits, submitting and paying claims, and requesting and approving prior authorization, among others. These transactions occur millions of times every day. By streamlining how information is exchanged, the industry has improved the experience for health plans, providers, and patients alike.
In May 2022, CAQH CORE unveiled new and updated rules that focus on:
- Connectivity: Updating key security requirements and ensuring that emerging standards can be exchanged in a uniform manner.
- Infrastructure: Increasing the amount of time per week and per month that systems are available.
- Eligibility and Benefits: Reflecting emerging industry needs related to telemedicine, value-based payments, and prior authorizations.
- Attachments: Establishing workflows for the electronic exchange of attachments that accompany healthcare claims and prior authorizations.
On January 18-19, 2023, the National Committee on Vital and Health Statistics (NCVHS), an advisory body to the Secretary of HHS, will hold a public hearing prior to recommending whether these rules should be federally mandated.
Together, these rules will improve security, increase up-time, and produce cost-savings by enabling greater automation and less manual intervention. Over time, these guidelines will result in less time spent by providers on administrative functions and, consequently, more time for patient care. For health plans, the rules will also reduce costs and delays and provide better connectivity with providers and other partners.
Ultimately, operating rules will enable a superior experience for consumers.