CAQH CORE Certification Impact: Simplifying Payer–Provider Information Exchange

Buster Elrod, a senior manager with Change Healthcare Consulting, has more than 40 years of business management and information technology (IT) and systems experience including the last 20 years in the healthcare industry. He has broad based experience in project management, IT assessments, system implementations, operations integration, strategic IT and business planning, and process re-engineering. His primary responsibilities include Change Healthcare Consulting’s ICD-10 service line and the CAQH CORE Certification service line. Mr. Elrod is actively involved as Change Healthcare Consulting’s Workgroup for Electronic Data Interchange (WEDI) representative.
The Council for Affordable Quality Health Committee on Operating Rules for Information Exchange is making great strides in certifying health plans for implementing electronic information exchange between payers and providers. The good news for providers is that very little is required of them to reap the benefits of these certification efforts.
The Council for Affordable Quality Health (CAQH) Committee on Operating Rules for Information Exchange (CORE) is making great strides in certifying health plans for implementing electronic information exchange between payers and providers. The good news for providers is that very little is required of them to reap the benefits of these certification efforts. Those benefits may include standardized, paperless transactions across those CORE-certified health plans for speedier payments with potentially fewer rejections associated with non-standard or paper-based transactions.
 
While CORE certification is voluntary for health plans, the process validates compliance with the Operating Rules adopted by the secretary of HHS that apply to the Administrative Simplification requirements of Section 1104 of the Affordable Care Act.1 Compliance with the adopted Operating Rules was effective as of January 2014 and, therefore, enforcement for noncompliance is in place. As a result, many of the major health plans have achieved CORE certification, and others are quickly working through certification.
 
Providers who are contracted with health plans that have earned certification as signified by receiving the CAQH CORE Seal for Phases I, II and III are assured that the health plans have the capacity for standardized electronic 270/271, 276/277, and 835 transaction exchanges and online enrollment for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA). This addresses the current issue of providers needing to enroll for EFT separately with each health plan, and aligns EFT and ERA submissions. That means providers can receive payments quicker, with electronic remittances that correlate to the payments. Providers can also determine claim and eligibility status without a phone call or having to access a web portal.
 
As an added bonus for providers, CAQH CORE certification ensures that the health plan has implemented operating rule standardization for the 4 most common claim adjustment/denial business scenarios. We’re leaving behind an era in which a provider may get differing Claim Adjustment Reason Code (CARC)/Remittance Advice Remark Code (RARC) combinations from the various health plans that reference the same adjustment.
 
The 4 most common claim adjustment/denial business scenarios identified by CAQH CORE are:
  • Additional Information Required—Missing/Invalid/Incomplete Documentation
  • Additional Information Required—Missing/Invalid/Incomplete Data from Submitted Claim
  • Billed Service Not Covered by Health Plan
  • Benefit for Billed Service Not Separately Payable
 
This simple unification means that as more health plans achieve compliance, it will become easier for providers and billing services to consume information with a consistent approach. Instead of having to interpret claim adjustments based on individual CARC/RARC combinations, providers will receive the same codes from all CORE-certified health plans.
 
Because responsibility for CORE certification resides primarily with the health plans, providers receive these benefits for very little effort. They may need to make simple changes to their systems to accommodate the new CARC and RARC standards, which will ultimately minimize the need to maintain cross references for varying combinations from the health plans.
 
CAQH CORE certification can be viewed as the healthcare industry catching up with other industries that have benefited from the speed and accuracy that comes with standardized electronic data interchange. Health plans that have achieved compliance with the Administrative Simplification requirements of Section 1104 of the Affordable Care Act have taken an important step to simplify data-sharing between providers and those health plans that have obtained CAQH CORE certification.
 
The information and materials provided and referenced to herein are not intended to constitute legal, regulatory, accounting, medical or financial advice and do not create an attorney-client or other fiduciary relationship between Change Healthcare Operations, LLC or its representatives and any third party. Additionally, Change Healthcare Operations, LLC does not guarantee the accuracy of the information contained herein. The interpretations, extrapolations, views and opinions of each individual presenter are not necessarily the views of Change Healthcare Operations, LLC. Change Healthcare Operations, LLC disclaims any and all liability for any reliance you may place on the information contained herein.
 
Reference
1. Operating Rules. (2016). Retrieved November 17, 2016, from http://www.caqh.org/core/operating-rules.

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