CAQH CORE Health Care

CAQH CORE Health Care Operating Rules Mandated Under HIPAA

Operating rules support a range of standards to make electronic data transactions more predictable and consistent, regardless of the technology. CAQH CORE is designated by the Secretary of the Department of Health and Human Services (HHS) as the National Operating Rule Authoring Entity for the administrative transactions covered by HIPAA.

Three sets of CAQH CORE Operating Rules are federally mandated under HIPAA. CAQH CORE Operating Rule requirements are a floor, not a ceiling, with updated versions of the rules building on the existing requirements. Therefore, all federally mandated operating rule requirements are included in the current versions of the CAQH CORE Operating Rules.

Connectivity. Establishes key connectivity, security and authentication requirements including acknowledgements, error handling, and the CAQH CORE Connectivity “Safe Harbor” creating a national connectivity mechanism that trading partners can be assured will be supported when healthcare information is exchanged.

Eligibility & Benefits. Establishes consistent infrastructure and data content requirements when health plans and providers exchange information regarding a patient’s insurance coverage and benefits.

Payment and Remittance. Addresses requirements associated with electronic funds transfers (EFT) and electronic remittance advice (ERA), and establishes consistent use of claim adjustment and denial codes. A set of these rules is federally mandated.

Prior Authorization & Referrals. Standardizes components of the prior authorization process and moves the industry towards full automation.

Health Care Claims. Streamlines and standardizes the exchange of information related to the submission, acknowledgement and adjudication of healthcare claims.

Attributed Patient Roster. Attributed patient rosters are used by health plans, providers and employers to share lists of patients attributed to a provider under a value-based contract.

Benefit Enrollment. Creates consistent processes and infrastructure requirements for employers, unions, government agencies and other organizations to enroll members in a healthcare benefit plan.

Premium Payment. Establishes consistent infrastructure and processes for transmitting information relating to payments.

All CAQH CORE Operating Rules are developed through a collaborative, transparent process that ensures balanced representation among participants.

To learn more about HIPAA EDI and become a CEDIAP® (Certified EDI Academy Professional), please visit our course schedule page.

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