HIPAA Regulatory Alert

CORE rules will build on HIPAA

Rules deal with No. 1 administrative complaint, 'access to eligibility and benefits information'

More than 90 health care organizations have come together to develop and implement operating rules for electronically exchanging eligibility and benefits information to make it easier for physicians and other health professionals to verify patient insurance information.

The new rules were developed under the leadership of the Council for Affordable Quality Health Care (CAQH), a health care industry collaboration that seeks to simplify and streamline health care administration. CAQH's executive director, Robin Thomashauer, tells HIPAA Regulatory Alert the change will be a major step away from the current situation in which physicians have had to approach each health plan they deal with individually and have not been able to obtain consistent information from each plan. "The No. 1 administrative problem we hear about is access to eligibility and benefits information," Thomashauer says. "It's a lot of work for providers."

By March 31, 2007, participating organizations, such as Aetna, Blue Cross Blue Shield of North Carolina, Humana, Mayo Clinic, Montefiore Medical Center, and WellPoint and its 14 Blue-licensed subsidiaries, will electronically exchange eligibility and benefits information under the CAQH Committee on Operating Rules for Information Exchange (CORE) operating rules. The rules build on existing standards, such as HIPAA, to make electronic transactions more efficient, predictable, and consistent, regardless of the technology used.

Thomashauer says the inspiration for the new operating rules came from the financial services industry, which has found ways to process ATM transactions, direct deposits, and other activities using operating rules that are independent of specific hardware or software.

"We didn't want all the health care organizations trying to address this problem to end up going down parallel tracks," Thomashauer tells HRA. "We're taking the work done to date on HIPAA and making it more robust so providers have adequate information with which to make decisions."

"Well-developed and widely used information standards are central to realizing our national goals for better quality and efficiency," says former Department of Health and Human Services National Coordinator for Health Information Technology David Brailer. "The CORE standards can simplify health care administration and improve the experience of America's consumers at a critical time in their lives."

Phase I elements

The CORE Phase I operating rules build upon the HIPAA 270/271 transactions for eligibility and benefits and address these information elements:

  • system connectivity safe harbor standard (HTTP/S);
  • standard inquiry acknowledgements;
  • maximum response times (batch and real-time);
  • minimum hours a system must be available (system availability);
  • Standard 270/271 companion guide flow and format;
  • data content, service type codes, and patient financial responsibility; and
  • standard testing, certification, and enforcement processes to ensure CORE compliance.

According to CAQH, operating rules typically don't specify technology or tools that must be used in communicating information. Instead, they govern how that information is exchanged. Any entity that agrees to follow the CORE Phase I operating rules will be able to provide the eligibility and benefits data as outlined in the CORE Phase I rules. Thus, health care providers will select the technology system of their choice and use that system as the connecting point for routing their eligibility and benefits inquiries to payers with whom they have trading partner relationships. Given this, CAQH says, the more payers, vendors, providers, and others who become CORE-certified will enhance the benefits the industry can gain from adopting the CORE Phase I rules.

Voluntary solution

"Use of the CORE rules is voluntary," CAQH says. "Stakeholder entities that wish to adopt the rules are required to sign a pledge committing them to ensure that their IT systems can perform according to the CORE rules. A CORE-authorized vendor will certify that each entity's system(s) complies with the CORE rules. Once an entity obtains its respective CORE seal, each entity can market itself as CORE-certified or a CORE endorser. Any entity that agrees to follow the CORE operating rules will be able to exchange eligibility and benefits information outlined in the rules."

Thomashauer says the intent is for CORE to cover several phases. Phase I will help providers determine which health plan covers the patient, determine patient benefit coverage, and confirm coverage of certain service types and the patient's co-pay amount, coinsurance level, and base deductible levels (as defined in the member contract) for each of those types.

She says Phase II will add another transaction and then additional transactions will be added in future years. This fall, she says, stakeholders were close to agreeing on the scope for Phase II. Once agreement is reached, work would begin with a goal of approving Phase II operating rules in the second quarter of 2007.

A key to success, Thomashauer says, is to ensure agreement among all the stakeholders who are involved. "We learned from the financial services industry that if you don't have everyone involved and working together, someone won't agree," she says. "We didn't move forward until everyone was in agreement. And you need to have approval at every level before you move forward."

Because CORE will be certifying organizations, participants will be guaranteed that they are receiving data that are consistent with the CORE rules. Thomashauer says it was important to have an initial critical mass of major players supporting the project. They can then take the issue to their trading partners and encourage them to become involved so that it will become a voluntary industry standard.

More info is available on-line at http://www.caqh.org. Contact Robin Thomashauser at (202) 861-1492.