Health Reform: EDI Changes, and CAQH CORE Initiatives
The Administrative Simplification section of the Patient Protection and Affordable Care Act (ACA) requires health plans to adopt operating rules. According to the ACA, three sets of healthcare industry operating rules will be approved by the Department of Health and Human Services (HHS) and then implemented by the industry based on a series of deadlines occurring over the next five years. The three sets of nationally mandated operating rules include: (1) Eligibility and Claim Status; (2) Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA); and (3) Enrollment, Referral authorization, Attachments, etc. The operating rules are intended to streamline administrative exchanges and promote interoperability across the healthcare industry.
Since 2005, CAQH CORE has worked to streamline healthcare administration by developing operating rules through a collaboration of more than 120 stakeholders – health plans, providers, vendors, clearinghouses, government agencies, associations. The CAQH CORE operating rules build on standards to give providers access to patient coverage and financial information before or at the time of service using the electronic system of their choice for any patient or health plan. More than 50 organizations, including health plans representing over 120 million lives, have voluntarily adopted and implemented the CAQH CORE operating rules through a CORE-certification process.
Related to the ACA, on July 8, 2011, an interim final rule with comment (IFC) “Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transactions, CMS-0032-IFC” was published in the Federal Register by HHS. The IFC requires adoption of the CAQH CORE Phase I and II operating rules, with the exception of Acknowledgements. Certification for the CAQH CORE rules is voluntary.
CAQH CORE is also developing EFT and ERA operating rules for review by the National Committee on Vital and Health Statistics, an HHS advisory group designated by the ACA to offer insight and suggestions on operating rules. NCVHS will review the draft operating rules to consider recommendations to HHS for the second set of nationally mandated operating rules under the ACA.
This Webinar will explore the current work of CAQH CORE in relation to the ACA operating rules and explain the potential impact on SPBA members’ work.
Who Should Attend:
Direct employees of SPBA member TPA firms and Stop-Loss Partners should attend.
Since 2005, CAQH CORE has worked to streamline healthcare administration by developing operating rules through a collaboration of more than 120 stakeholders – health plans, providers, vendors, clearinghouses, government agencies, associations. The CAQH CORE operating rules build on standards to give providers access to patient coverage and financial information before or at the time of service using the electronic system of their choice for any patient or health plan. More than 50 organizations, including health plans representing over 120 million lives, have voluntarily adopted and implemented the CAQH CORE operating rules through a CORE-certification process.
Related to the ACA, on July 8, 2011, an interim final rule with comment (IFC) “Administrative Simplification: Adoption of Operating Rules for Eligibility for a Health Plan and Health Care Claim Status Transactions, CMS-0032-IFC” was published in the Federal Register by HHS. The IFC requires adoption of the CAQH CORE Phase I and II operating rules, with the exception of Acknowledgements. Certification for the CAQH CORE rules is voluntary.
CAQH CORE is also developing EFT and ERA operating rules for review by the National Committee on Vital and Health Statistics, an HHS advisory group designated by the ACA to offer insight and suggestions on operating rules. NCVHS will review the draft operating rules to consider recommendations to HHS for the second set of nationally mandated operating rules under the ACA.
This Webinar will explore the current work of CAQH CORE in relation to the ACA operating rules and explain the potential impact on SPBA members’ work.
Who Should Attend:
Direct employees of SPBA member TPA firms and Stop-Loss Partners should attend.
- Summarize the health reform legislation, based on the Patient Protection and Affordable Care Act (ACA), relevant to nationally mandated operating rules.
- Explore the potential impact of administrative operating rules for various healthcare stakeholders, including TPA firms.
- Review the value of public and private coordination and the CAQH CORE approach to developing operating rules.
- Outline current and next steps for CAQH CORE related to voluntary and mandated operating rules.
Date Presented:
August 16, 2011 1:00 PM Eastern
Length:
1 hour, 30 minutes
Streaming - Recording
SPBA Price:$175.00