CAQH® CORE Operating Rules for Prior Authorization and Referrals

Type	Standard / Implementation Specification	Standards Process Maturity	Implementation Maturity	Adoption Level	Federally required	Cost	Test Tool Availability
Operating Rules	CAQH® CORE Operating Rules for Prior Authorization and Referrals	Balloted Draft	Feedback requested	Feedback Requested	No	Free	Yes^$

Limitations, Dependencies, and Preconditions for Consideration	Applicable Security Patterns for Consideration
Operating rules were added as a requirement of the Patient Protection and Affordable Care Act of 2010, under Section 1104, Administrative Simplification. Operating rules are intended to support and enhance the use of standard transactions. They include requirements to help implement the transaction in a more uniform way between health plans and providers and ensure a more complete set of information in the response. HHS has adopted operating rules for Eligibility and Benefits, Claim Status (2011), Electronic Funds Transfer and Electronic Remittance Advice (2013). HHS has not adopted Operating Rules for other adopted HIPAA standards, including Prior Authorization, Premium Billing, Claims, Enrollment/Disenrollment. The CAQH CORE Prior Authorization and Referrals Operating Rules are available for voluntary use by covered entities. In 2022, the CAQH CORE Operating Rules for Prior Authorization and Referrals were updated to support the electronic exchange of attachments and medical information. Testing or certification with operating rules is voluntary and available through a vendor contracted to CAQH CORE. There is a fee for certification, however, CAQH CORE maintains free tools to support operating rule implementation. Additionally, CAQH CORE offers educational webinars which are archived on its website.	Feedback requested.

Limitations, Dependencies, and Preconditions for Consideration

Applicable Security Patterns for Consideration

Operating rules were added as a requirement of the Patient Protection and Affordable Care Act of 2010, under Section 1104, Administrative Simplification.
Operating rules are intended to support and enhance the use of standard transactions. They include requirements to help implement the transaction in a more uniform way between health plans and providers and ensure a more complete set of information in the response.
HHS has adopted operating rules for Eligibility and Benefits, Claim Status (2011), Electronic Funds Transfer and Electronic Remittance Advice (2013).
HHS has not adopted Operating Rules for other adopted HIPAA standards, including Prior Authorization, Premium Billing, Claims, Enrollment/Disenrollment.
The CAQH CORE Prior Authorization and Referrals Operating Rules are available for voluntary use by covered entities.
In 2022, the CAQH CORE Operating Rules for Prior Authorization and Referrals were updated to support the electronic exchange of attachments and medical information.
Testing or certification with operating rules is voluntary and available through a vendor contracted to CAQH CORE. There is a fee for certification, however, CAQH CORE maintains free tools to support operating rule implementation. Additionally, CAQH CORE offers educational webinars which are archived on its website.

Feedback requested.

Comment

Submitted by mphillips@caqh.org on 2022-09-27

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

Submitted by pwilson@ncpdp.org on 2021-09-29

NCPDP Comments

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: https://tools.ncpdp.org/erx/#/home

NCPDP operating rules are in the NCPDP SCRIPT Standard, Implementation Guide Version 2017071

Submitted by doodles531 on 2020-12-12

updated weblink

Submitted by jporras on 2020-11-01

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

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