Fall 2013
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The CAQH Committee on Operating Rules for Information Exchange® (CORE®) is a multi-stakeholder industry collaboration of more than 140 participating organizations developing and driving the adoption of a set of uniform business rules that streamline administrative transactions. CORE participating organizations collectively cover more than 150 million lives or approximately 75 percent of the commercially insured, plus Medicare and Medicaid beneficiaries.
Online Resources and Early Implementers Help HIPAA-Covered Entities Understand and Benefit from EFT & ERA Operating Rules
CAQH CORE offers a wide-ranging collection of online resources to assist providers, health plans and vendors as the federally mandated January 2014 Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) Operating Rules implementation deadline approaches. Promoted through a digital campaign by CAQH CORE this fall, the resources help healthcare professionals understand the benefits of universal EFT and ERA capabilities and make it easier for organizations to prepare for the changes and realize the full benefits.
Online Resources: A new action-oriented EFT and ERA web pagelaunched by CAQH CORE highlights critical operating rule deadline dates and segments CAQH CORE and external resources for analysis and planning, implementation, and adoption and certification processes. Among the resources featured on this new webpage, CAQH CORE added two template letters that providers may use to contact their health plans and banks. The letter to health plans enables providers to easily request payments via EFT and inquire about the status of operating rules implementation. The letter to banks is a useful tool for providers looking to maximize the benefits available to them through the CAQH CORE Reassociation Rule. Since the current HIPAA-mandated standards for EFT and ERA travel separately from the health plan to the provider, providers must reassociate the two transactions. Providers can use the CAQH CORE sample letter to reach out to their financial institutions and request that the necessary data for reassociation be sent with each payment. Industry stakeholders are encouraged to share these template letters with providers in order to assist them with gaining the benefits of the EFT & ERA Operating Rules.
Early Implementers: Beyond the free online tools, CAQH CORE coordinates opportunities for early implementers to share their approach to the Operating Rules. CAQH CORE continues to partner with other organizations to offer up to four live implementation-focused webinar education sessions each month. From January – November, over 17,000 individuals have registered for these sessions. The sessions are designed to appeal to a variety of audiences, ensuring every stakeholder group can learn from actual implementers about how Operating Rules impact real-world business. Presenters review critical details about the CAQH CORE Operating Rules and share case studies about their organizations' various stages of Operating Rule conformance – from early planning through implementation and certification. Fourth-Quarter speakers have included Aultcare, Blue Cross and Blue Shield of North Carolina, Cambia Health Solutions, CMS OESS, Michigan Department of Community Health, NACHA, and more. Archived recordings of these sessions are available athttp://www.caqh.org/CORE_Education_Events.php.
Questions for CAQH CORE may be directed to CORE@caqh.org.
Several major organizations have recently completed the CAQH CORE voluntary certification program or signed the CORE Certification Pledge. These achievements bolster the value of operating rules implementations throughout the industry and reaffirm the importance of CORE Certification. Nearly 70 organizations and products, including health plans covering more than 120 million individuals, have now become voluntarily CORE-certified for one or more phases of the CAQH CORE Operating Rules.
This year, there have been significant accomplishments for the certification program. For the first time, a health information exchange (HIE) – HealtheNet - achieved CORE Certification. With HIEs connecting various stakeholders exchanging administrative transactions, this is an opportunity for all participants touching the data to utilize the Operating Rules in order to realize the full value of the rules. Many entities continue to be voluntarily certified for Phase I and II – Eligibility and Claim Status Operating Rules, including Cigna and Horizon Healthcare Services.
CAQH CORE also awarded the first-ever Phase III CORE Certifications. Additional Phase III CORE Certifications soon followed by other organizations successfully conforming to the CAQH CORE Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) Operating Rules. InstaMed became the first organization to earn Phase III CORE Certification, achieving the clearinghouse distinction for the InstaMed Network. Humana became the first health plan to achieve Phase III CORE Certification. Most recently, Phase III CORE Certifications were awarded to Blue Cross Blue Shield of Nebraska and vendor products from Echo Health - National EFT/ERA Simplicity Payment Solution v8.1, and Pay-Plus Solutions - Pay-Plus Direct. A number of other organizations, such as Emdeon (for its clearinghouse product, Remittance and Payment Management) and Centene Corporation, have submitted Phase III CORE Certification pledges.
The value of implementation accelerates as more participants in the data exchange implement and certify use of the operating rules. The new CORE Certifications and a robust queue of organizations committed to earning a certification soon indicate that the industry continues to value CORE Certification. Please refer to the adjacent box for a complete list of organizations and products recently achieving CORE Certification.
The federal mandate for Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA) Operating Rules includes direction to evolve and maintain the Uniform Use of Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs) Rule (CAQH CORE 360 Rule), which involves codes regarding claim adjustments and denials. This Rule creates a national, uniform set of code combinations and associated Business Scenarios that the industry is mandated to use with the CARCs, RARCs, and Claim Adjustment Group Codes (CAGCs). Every HIPAA-covered entity should prepare a maintenance plan for this continuous quality improvement process that addresses evolving industry needs and published code list updates which occur three times per year.
Comprehensive resources are available online to help those tasked with implementing and maintaining compliance with the Rule. The Rule identifies a minimum set of four CORE-defined Business Scenarios with a maximum set of code combinations to convey claim denial/adjustment details under each Business Scenario. The CORE Code Combinations document, an accompanying document to the Rule, includes the code combinations and the underlying defined universal Business Scenarios addressed by the code combinations. Two actions are used each year to update the CORE Code Combinations document in accordance with the maintenance process:
Market-based Reviews: Market-based Reviews (MBR) occur once a year. The MBR process addresses evolving industry business needs for using the CORE Code Combinations. For the first year, the MBR will consider industry submissions addressing additions and removals to the existing CORE-required Code Combinations for existing CORE-defined Business Scenarios. All CORE Participants plus non-CORE Participants that create, use, or transmit HIPAA-covered transactions may submit potential Market-based adjustments via the onlineMarket-based submission form (MBR Form), which was created by the CAQH CORE Code Combinations Task Group (CCTG). MBR Forms must be completed by 5 pm ET on Friday, February 14, 2014.
All HIPAA-covered entities should have a process in place to update their code and code combinations three times per year. The current CORE Code Combinations and other resources needed to maintain compliant systems, as well as additional information about the industry-based maintenance process, timeline, and how to request a change are available at http://caqh.org/CORECodeCombinations.php.
With the first two sets of federally mandated operating rules issued, focus is now on supporting broad adoption of the existing operating rules and applying industry efforts to the development of the third set. This year, CAQH CORE has built industry awareness of the existing operating rules, ACA goals, CORE Guiding principles, and the option to participate in rule-writing. Additionally, significant public surveying for opportunities was conducted to gather ideas from the industry. The remaining ACA-driven operating rule mandate for the third set will address the following transactions:
Through continuous monitoring and interaction with the industry, CAQH CORE has been researching key opportunities, identifying out-of-scope items, analyzing environmental scans, and collating the results of public surveys.
Development for the third set is underway with the understanding that the timeline is slightly delayed given all of the other existing requirements for providers, health plans and others. As with existing operating rules, the third set will address both content and infrastructure requirements. On Tuesday afternoons, the content related Subgroups will be meeting. On Thursday afternoons, the Connectivity and Infrastructure Subgroup has been reviewing market trends, how to align with other large scale adoption initiatives, and potential rule options. Its work will be shared for public input. CAQH CORE Connectivity and other infrastructure rules currently apply to all operating rules (with the exception of EFT which uses different infrastructure – the ACH network). As the market moves towards increased adoption of electronic transactions, the market is also moving towards increased connectivity approaches to address related business needs. CAQH CORE will consider all general CORE Connectivity criteria that are applicable to the third set including a range of principles related to security, reliable messaging, implementation, business needs, and interoperability. CORE participating organizations are encouraged to join these Subgroups.
CAQH CORE Operating Rule development for the third set will continue through 2014. CAQH CORE anticipates draft rules mid-year and final rule requirements developing throughout the remainder of the year. A full CORE vote will then follow.
CORE participation is open to any entity. Organizations interested in contributing to CAQH CORE Operating Rule development may learn more about CORE participation here.
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Launched in 2002 by CAQH, the Universal Provider Datasource®(UPD®) is achieving its vision of simplified provider data collection, maintenance, and distribution by reducing paperwork and millions of dollars of annual administrative costs for nearly 1.2 million providers and more than 700 health plans and hospitals across the United States.
The New Jersey Department of Banking and Insurance has approved use of the Universal Provider Datasource (UPD) as a primary source of provider credentialing and directory information. Health plans are required to ensure the information in their provider directory is based on CAQH data or the most recently submitted information from the provider. The ruling gives health plans and providers a universally reliable and trusted source of essential administrative data and eliminates repetitive tasks that add cost to the healthcare system.
Additionally, the rule sets timeframes for the provider credentialing process and provider directory updates. For instance, the rule requires health plans to complete the provider credentialing process within 90 days of receiving a completed provider application. It also specifies a 20-day deadline for health plans to update electronic directories when UPD information changes or when inaccuracies are identified.
The need for accurate provider information is well understood across the healthcare system. This approach by New Jersey underscores the quality of data found in UPD, positioning this source as equivalent to receiving information directly from the provider.
For more information about UPD, contact Christine Stroup atcstroup@caqh.org.
CAQH launched the Directory Maintenance Report (DMR) in 2012 to simplify the process for capturing provider data changes. The Report eases the integration of data changes into the systems of participating organizations and also helps address the New York Attorney General requirements for provider directory quality.
The DMR reviews active rosters from participating organizations to determine which providers had attestations in the previous week, and also to identify which data elements have been changed, added and deleted. The initial data elements being reviewed were chosen based on their appropriateness for inclusion in a member directory. Additional elements have been added to the DMR to address the needs of Medicaid enrollment.
Based on user feedback, CAQH recently launched enhancements to the DMR. The enhancements add flags for locations where providers are currently practicing and also lock sequence IDs so that data can be more easily mapped between the corresponding record and the system used by the participating organization.
Available at no additional cost to participating organizations, the DMR is refreshed weekly and can be downloaded through the FTP site or by logging in to the CAQH UPD account and going to the Download Files page. The DMR format is an easy to use text file that identifies the location of the change, the element, the old data, and the new data.
For assistance, contact your UPD Account Manager or the Help Desk.
CAQH recently welcomed nine additional staff members, filling new and key positions as the organization continues to grow.
Sheila Bowman has joined CAQH as Manager of Major Accounts, bringing more than 20 years of healthcare and insurance industry experience to the role. Sheila is working with existing and prospective participating organizations to identify opportunities for streamlining administrative processes and assist with utilization of CAQH initiatives. Prior to joining CAQH, Sheila served Humana as an Account Services Executive, where she managed new business, as well as renewals of large commercial accounts with diverse needs. Before joining Humana, Sheila spent more than eight years with one of the nation’s largest healthcare clearinghouses, where she implemented electronic data interchange (EDI) for its clients. Sheila can be reached at sbowman@caqh.org.
Ruth Chigwada has joined CAQH as Billing and Financial Analyst. Her responsibilities include billing, revenue recognition, receivables management and other accounting work to support CAQH operations. Ruth previously worked as Senior Revenue and GL Accountant at FileTek Inc., a software company. She holds an Honors degree in Accounting from the University of Zimbabwe, has successfully completed the CPA exam, and is currently studying to earn an M.B.A. Ruth can be reached at rchigwada@caqh.org.
Andy Fox has joined CAQH as Senior Manager, Business Development. Andy is engaging with existing and prospective participating organizations to consult about CAQH initiatives, help manage provider EFT/ERA enrollments, and support the integration of COB Smart into the healthcare system. He most recently worked with RelayHealth, a McKesson Company, serving as a payer-facing Senior Sales Executive. Andy holds a B.S. from Millersville State University. He can be reached at afox@caqh.org.
Aditi Jariwala has joined the CAQH CORE staff as Associate Director of Education, Outreach, and Partner Relations. Her responsibilities include developing live online CAQH CORE education sessions and cultivating organizational partnerships. Before joining CAQH, Aditi spent eight years as Director of Certification for Surescripts, which operates the nation's largest clinical health information network. In that leadership role, she was responsible for certification of all Surescripts services. Aditi earned an M.B.A. from Georgetown University and a B.S. in computer science and mathematics from Purdue University. She can be reached at ajariwala@caqh.org.
John Lombardi has joined the CAQH CORE staff as Senior Associate of Education, Outreach, and Partner Relations. John coordinates CAQH CORE education sessions and works with organizational partners to engage stakeholders in CAQH CORE activities. John previously worked as a Project Manager for the National Quality Forum and as a Senior Advisor at the Advisory Board Company for its Physician Engagement Initiative. He earned a Bachelor’s degree from George Washington University and a Master’s degree from Marymount University. He can be reached at jlombardi@caqh.org.
Joe Murphy has joined CAQH as Controller. Joe is primarily responsible for preparing monthly financial statements, budgets, and forecasts, in addition to processing payroll. He has more than 20 years of financial experience with previous roles at Pearson, The Washington Post Company and Ernst and Young, among others. He earned a Bachelor’s degree from Georgetown University and is a Certified Public Accountant. Joe can be reached at jmurphy@caqh.org.
Charlie Winters has joined CAQH as Managing Director of Finance and Administration. With more than 25 years of experience in finance, Charlie has helped a range of organizations manage rapid growth and change. His responsibilities include finance, human resources, office services, and information technology. He is a healthcare industry veteran, with 15 years of experience in the industry, as well as five years in public accounting. Charlie earned a B.B.A. from Siena College and is a Certified Public Accountant. He can be reached at cwinters@caqh.org.
Mazen Yacoub has joined the CAQH CORE staff as Senior Manager of Rule-Writing and Certification. Mazen works closely with the CAQH CORE team to facilitate CAQH CORE rule development and manage the CORE Certification program. Prior to joining CAQH, he was a Project Director with the Centers for Medicare & Medicaid Services Office of Enterprise Business. Previously, Mazen held a range of project management and strategic consulting positions, which included six years in the Global Health Services practice at Booz Allen Hamilton. He has a B.A. from Boston College and M.B.A. from Babson College. Mazen can be reached at myacoub@caqh.org.
Jalal Zamanali has joined CAQH as Director of Information Security to oversee the information security program and policies that safeguard CAQH information. Jalal has more than 25 years of experience building innovative, industry-leading technology solutions. He has held IT Security executive positions at notable companies such as IBM, Freddie Mac, Dell, JPMorgan, and Temple Inland. A recognized authority on cyber security, he has chaired several cyber/IT security conferences and forums, and has spoken numerous times at the security conferences around the country. Jalal has served as Chairman of the Institute of Electrical and Electronics Engineers (IEEE) nuclear division for five years. He holds a B.S. in Physics, an M.S. in Nuclear Engineering, and an M.B.A. Jalal can be reached atjzamanali@caqh.org.
CAQH is actively expanding its team to support its increasing portfolio of initiatives. CAQH offers a diverse and innovative work environment with competitive compensation and benefits. Talented individuals committed to achieving the CAQH vision of an efficient healthcare system are encouraged to view and apply to open career opportunities; click here.
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