Operating Rules for Claims, Enrollment, and Premium Payments (Phase IV)

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CAQH CORE Comments to ONC ISA 2020 Ref Edition - Phases IV & V

2. Implementation Maturity and Adoption Level for Operating Rules for Claims, Enrollment, and Premium Payments (Phase IV)    CAQH CORE recommends changing the Implementation Maturity for the Phase IV Operating Rules from “Pilot” to “Production”. Entities are actively implementing this rule set and achieving Phase IV CORE Certification. Additionally, we recommend updating the Adoption Level to 1 out of 5.      3. Addition of the Phase V Operating Rules for Prior Authorization    CAQH CORE is pleased to announce the release of the final Phase V Operating Rules for the prior authorization transaction and recommends ONC expand the ISA content in Section IV: Administrative Standards and Implementation Specifications - Operating Rules to Support Administrative Transactions to include this rule set.     The Phase V CAQH CORE Operating Rules, approved in May 2019, include: • Phase V CAQH CORE Prior Authorization (278) Request / Response Data Content Rule v5.0.0 • Phase V CAQH CORE Prior Authorization Web Portal Rule v5.0.0 The Phase V CAQH CORE Operating Rules focus on standardizing components of the prior authorization process, closing gaps in electronic data exchange to move the industry towards a more fully automated adjudication of a request. To develop the Phase V Operating Rules, CAQH CORE conducted an environmental scan of over 100 entities, participated in industry meetings and convened multi-stakeholder groups to agree on opportunities for operating rule development and refine rule requirements.   CAQH CORE recommends the following additional content for the Phase V Rules:    • Type: Operating Rules • Standard / Implementation Specification: CAQH CORE Phase V Operating Rule Set • Standards Process Maturity: Final • Implementation Maturity: Pilot • Adoption Level: 1 out of 5 • Federally Required: No • Cost: Free • Test Tool Availability: Yes    The Limitations, Dependencies, and Preconditions for Consideration section can mirror that for the other operating rule sets with the exception of the fourth bullet which should read:    • The Phase V CAQH CORE Operating Rules, available for use on a voluntary basis as of May 2019, include:    o Phase V CAQH CORE Prior Authorization (278) Request / Response Data Content Rule v5.0.0    o Phase V CAQH CORE Prior Authorization Web Portal Rule v5.0.0 
CAQH CORE Comment Letter to ONC ISA_2.pdf