CAQH grows its effort to streamline healthcare administration

CAHQ says a new batch of healthcare organizations - including The American Academy of Family Physicians, MD On-Line and Gateway EDI - have committed to simplifying electronic administrative data through the CORE operating rules for information exchange.

CAQH is a nonprofit alliance of health plans and trade associations, focused on simplifying healthcare administration through industry initiatives.

CAQH launched CORE to create an all-payer solution that enables provider access to patient insurance information before or at the time of service using the electronic system of their choice. The organization has brought together more than 100 industry stakeholders to collaborate on a multi-phase set of uniform business rules to achieve that goal.

Also recently endorsing the CORE rules are mPay Gateway, Inc.; RealMed Corp.; Secure EDI Health Group, LLC; and Summit Medical Group.

The organizations have stepped up their commitment to improving provider and hospital access to consistent electronic patient administrative data through the CAQH Committee on Operating Rules for Information Exchange (CORE)

MD On-Line, Inc.; RealMed Corp.; and Summit Medical Group have completed a testing process to certify their systems or product meet CORE Phase I rules requirements.  

MD On-Line, a clearinghouse processing more than 2 million electronic transactions per month, certified its ACCE$$ - Patient Eligibility Verification product.  

RealMed, a healthcare revenue cycle management services vendor serving approximately 22,000 physicians and healthcare professionals representing nearly 900 distinct medical groups including physician practices, academic medical centers, national laboratories and medical billing services certified its RealMed Revenue Cycle Management Internet-based product.  

Summit Medical Group, which includes 200 physicians in 50 office locations and 10 hospitals serving patients in nine Tennessee counties, was certified as a large provider group.  

The three organizations join more than 30 other entities, including health plans covering approximately 65 million or one-third of U.S. commercially insured members that are certified as operating in compliance with the CORE Phase I rules.

CAQH officials say the CORE rules are built upon national standards, including HIPAA. CORE rules make electronic administrative data communications seamless, streamlined and predictable, regardless of the technology - in many cases eliminating the need for time-consuming phone calls and paperwork, they say.

In anticipation of the industry moving from HIPAA Version 4010 to Version 5010, CORE Phase I and Phase II rules incorporate many of the features found in the X12 5010 TR3s to address the common information needs for patient eligibility.  

Gateway EDI; mPay Gateway, Inc.; and Secure EDI Health Group, LLC; all health IT vendors, joined CORE to participate in developing additional phases of the CORE rules.  

AAFP received CORE Phase II rules Endorser status last summer.

CORE participants have begun to develop Phase III rules, which will focus on improving the electronic exchange of additional administrative transactions, such as prior authorization and remittance advice.