CAQH CORE Operating Rules for PA and Referral Updates

Changes to Operating Rules for Prior Authorization and Referrals are on pages 10-11 in the attached document. CAQH CORE proposes an update to change the name of this section from “CAQH CORE Operating Rules for Prior Authorization” to “CAQH CORE Operating Rules for Prior Authorization and Referrals.”  Other changes are primarily non-substantive and address consistency, conciseness, and grammar and syntax. Changes are highlighted in gray with proposed deletions shown as strikethrough text.

CAQH CORE ISA Letter 2022_3.pdf

NCPDP Comments

  1. Add the following:
Type-Implementation Specification Standard Implementation/Specification- NCPDP SCRIPT Standard, Implementation Guide, Version 2017071 Standards Process Maturity – Final Implementation Maturity- Production Adoption Level – 5 Federally Required – No Cost – $ Test Tool Availability – Yes Test Tool Link:
  1. NCPDP operating rules are in the NCPDP SCRIPT Standard, Implementation Guide Version 2017071

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CAQH CORE Comments to ONC ISA - Phase V

Aligning ISA with New Operating Rule Structure: In Spring 2020, CAQH CORE restructured its operating rules from phase-based rule sets to rule sets based on the business processes supported by the rules. No substantive changes were made to existing rule requirements. As a result of the restructuring, CAQH CORE recommends updates to the following sections of the ISA: Operating Rules for Prior Authorization (Phase V) -- Prior Authorization & Referrals Operating Rules

ISA Comments from CAQH CORE 11.1.20 FINAL_4.pdf