Health Information Management

Phase IV CAQH CORE Operating Rules approved for claims transactions

HIM-HIPAA Insider, November 9, 2015

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A new set of claims transaction rules has been approved by CAQH Committee on Operating Rules for Information Exchange (CORE). Phase IV Operating Rules are designed to increase consistency of information exchange, improve revenue cycle management, expose gaps in data transactions, and result in overall improvements to interoperability.

These new operating rules focus on four types of electronic data transmission:

  • Healthcare claims
  • Prior authorization
  • Employee enrollment and disenrollment
  • Premium payments

Phase IV requires that entities support the use of ASC X12N v5010 277CA Claims Acknowledgment to transmit health claims electronically. Requirements also apply to the claim formats used for professional, institutional, and dental claims. Standards for system availability and the amount of time a system must be available to process transactions are also specified. Systems must publish regularly scheduled downtime, provide notice of non-routine downtime one week in advance and within one hour of emergency downtime. Under the new system, real time response to claim submissions, including sending and acknowledgement, should not be longer than 20 seconds. Claims submitted using batch processing before 9 p.m. (Eastern) must be acknowledged by 7 a.m. (Eastern) the next business day.

CAQH CORE acknowledges that while healthcare claims are one of the most common transactions between providers and health plans, they still represent a significant challenge. Phase IV rules should help providers overcome some of the obstacles to claims processing by instantly notifying providers that their claims have been received and moved into adjudication. This will reduce the time it takes to notify providers of simple errors on claims, allowing them to make corrections and receive payment as quickly as possible. Phase IV rules will also reduce inconsistencies and delays in processing prior authorization requests and changes in employee enrollment and data by requiring acknowledgment that this information has been received. Receipt of premium payment must also be acknowledged.

The new rules also include a CAQH CORE master template for the companion guides used by health plans, providers, and other entities to list their specific transaction requirements. CAQH CORE believes that adoption of the master template will make it easier for users to navigate different entities’ guides.

Phase IV mandates the use of HTTPS protocol for secure electronic communication. All electronic transmissions must be placed in a SOAP v1.2 message envelope. The envelope must identify the sender and receiver and the types of transactions being sent, and include tracking data.

Health claims attachments are not covered
by Phase IV rules. CAQH CORE does support the use of flexible operating rules that encourage the shift from paper to electronic documents. Final rules on health claims attachments will not be made until HHS determines a standard for these transactions.

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