Operating Rules to Support Eligibility and Claim Status Transactions (Phase II)

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Comment

CAQH CORE Comments on 2018 Interoperability Standards Advisory

  • “Operating Rules” should be included as one of the structures under “Type,” which presently only includes “Standard” or “Implementation Specification.” Although there are other utilities referenced in the ISA (e.g. Integrating the Healthcare Enterprise (IHE)’s Integration Profiles) that also technically do not meet the definition of either a standard or implementation specification, operating rules are distinct in this regard. The Centers for Medicare and Medicaid Services (CMS) notes, in its definition of operating rules, that they are “the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications” (emphasis added).
  • Operating Rules to Support Eligibility and Claim Status Transactions (Phase II): “Adoption Level” for these operating rules is currently listed as 3 out of 5. CAQH CORE updated its market share data in 2018 and determined that 65 percent of the commercial and publicly insured population in the United States are covered by Phase II CORE-certified health plans. Given the Phase I CAQH CORE Operating Rules are federally mandated and CORE Certification is voluntary, it is reasonable to conclude that more health plans have implemented the rules than have pursued CORE Certification. Therefore, CAQH CORE suggests increasing the industry adoption level of the Phase II CAQH CORE Operating Rules to 4 out of 5.

(Above content is an except of the full CAQH CORE Comment Letter).