Providers and hospitals can now access consistent health insurance coverage information in seconds

Washington 03 April 2007Health care providers and hospitals can now access in seconds consistent eligibility and benefits information required to verify patient health insurance coverage thanks to new standard business rules developed by the CAQH Committee on Operating Rules for Information Exchange (CORE). Currently, provider practice staffs often spend hours researching and making follow-up calls at significant cost to obtain and verify insurance information. The CORE rules, which build on the HIPAA eligibility (X12 270/271) transaction, make electronic administrative data communications seamless, streamlined and predictable, regardless of the technology - in many cases eliminating the need for practice staff phone calls.


This significant improvement was made possible because nearly 20 health organisations have begun voluntarily exchanging patient administrative data in accordance with the CORE rules. Those organisations are ACS EDI Gateway Inc.; Aetna Inc.; athenahealth Inc.; AultCare Corporation; Emdeon Business Services; Emerging Health Information Technology; Health Net; HTP Inc.; Mayo Clinic; McKesson Provider Technologies; MedAvant Healthcare Solutions; Medical Informatics Engineering Inc. (MIE); Montefiore Medical Center; NaviMedix Inc.; Passport Health Communications; Siemens Medical Solutions; and WellPoint Inc. and its 14 Blue Cross and Blue Shield-licensed subsidiaries.

All of these organisations recently completed CORE certification testing, a process ensuring that their IT systems and products comply with the CORE rules. They join the SSI Group Inc., which was the first health care organisation to receive CORE certification seals. More than 50 million Americans are covered by the health plans now using the CORE rules.

"Quick access to reliable patient insurance information eliminates a huge administrative headache for all health care providers", stated William F. Jessee, M.D., FACMPE, FACPM, President and Chief Executive Officer of the Medical Group Management Association. "All of the CORE-certified organisations and those seeking certification are to be applauded for taking a bold step to fix an age-old problem."

CAQH launched CORE to simplify eligibility and benefits data transactions, promote better health plan/provider interoperability and improve provider access to administrative information. CORE's vision is provider access to eligibility and benefits information before or at the time of service using the electronic system of their choice for any patient or health plan, effectively reducing administrative burden and costs. To date, the voluntary industry-wide CAQH initiative has brought together nearly 100 industry stakeholders - health plans, providers, vendors, CMS and other government agencies, associations, regional entities, standard-setting organisations and other health care entities - to collaborate on the rules.

"Interoperability should be at the heart of any long-term solution for improving health care administration", stated Bob Greczyn, CAQH Board chairman and Blue Cross and Blue Shield of North Carolina President and CEO. "The CORE rules are a revolutionary step toward that goal. They are a foundation and model for all health plan/provider electronic administrative communications."

Several other health care entities, including Blue Cross and Blue Shield of North Carolina; Blue Cross and Blue Shield of Tennessee; GHN-Online; Health Plan of Michigan; MedData;; the United States Department of Veterans Affairs; and VisionShare Inc. are committed to CORE rules compliance by no later than June 30, 2007.

"Today's announcement is the product of a unique collaboration in health care administration", added Jay Gellert, Health Net Inc. President and CEO, and Chair of the CAQH Administrative Simplification Committee. "Adoption of the CORE rules by these pioneering organisations proves that the industry is actively contributing ground-breaking solutions. We encourage all organisations with an interest in insurance verification to pursue CORE certification as soon as possible."

The CORE rules were recently included in the Health Information Technology Standards Panel (HITSP) Consumer Empowerment Interoperability Specifications as part of a national model for populating and maintaining robust patient insurance information in patients' personal health records. CORE's second set of rules, expected to be announced later this year, will address additional eligibility components (X12 270/271) and claims status (X12 276/277), both of which are addressed under HIPAA.

More than 20 organisations have endorsed the CORE rules, including Accenture, the American Academy of Family Physicians; the American College of Physicians; the American Health Information Management Association; CalRHIO; Claredi, an Ingenix Division; Edifecs Inc.; the eHealth Initiative; Foresight Corp.; the Greater New York Hospital Association; the Healthcare Financial Management Association; the Healthcare Information and Management Systems Society; the Medical Group Management Association; Michigan Public Health Institute; Microsoft Corporation; MultiPlan Inc.;NACHA - The Electronic Payments Association; Pillsbury Winthrop Shaw Pittman LLP; the International Smart Card Alliance Council; URAC and the Workgroup for Electronic Data Interchange.

CAQH is a catalyst for health care industry collaboration on initiatives that simplify and streamline health care administration. CAQH solutions help promote quality interactions between plans, providers and other stakeholders, reduce costs and frustrations associated with health care administration, faciliate administrative health care information exchange and encourage administrative and clinical data integration.

Leslie Versweyveld

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