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	Final	Production		No	Free	Yes

Limitations, Dependencies, and Preconditions for Consideration	Applicable Security Patterns for Consideration
Operating rules for prior authorization and referrals have not been proposed for adoption by NCVHS, nor have any been adopted by HHS. Some proposed operating rules developed by CAQH CORE and published in September 2020 are available for voluntary use but may not be required. NCVHS recommendation letters to HHS may be found on the website at www.ncvhs.hhs.gov Operating rules are intended to support the use of adopted standard transactions under the Health Insurance and Portability Act of 1996 (HIPAA). They include additional requirements to help health plans and providers implement each transaction in a more uniform way and ensure more consistent use of the transactions. 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. Testing, or certification for operating rules - adopted and voluntary - is available through a vendor contracted to the authoring entity. A testing checklist is available on the CAQH CORE website. CAQH CORE maintains free implementation tools to support operating rule implementation. Additionally, CAQH CORE offers regular educational webinars which are archived on its website to support implementation.

Limitations, Dependencies, and Preconditions for Consideration

Applicable Security Patterns for Consideration

Operating rules for prior authorization and referrals have not been proposed for adoption by NCVHS, nor have any been adopted by HHS. Some proposed operating rules developed by CAQH CORE and published in September 2020 are available for voluntary use but may not be required.
NCVHS recommendation letters to HHS may be found on the website at www.ncvhs.hhs.gov
Operating rules are intended to support the use of adopted standard transactions under the Health Insurance and Portability Act of 1996 (HIPAA). They include additional requirements to help health plans and providers implement each transaction in a more uniform way and ensure more consistent use of the transactions.
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.
Testing, or certification for operating rules - adopted and voluntary - is available through a vendor contracted to the authoring entity. A testing checklist is available on the CAQH CORE website.
CAQH CORE maintains free implementation tools to support operating rule implementation. Additionally, CAQH CORE offers regular educational webinars which are archived on its website to support implementation.

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