Phase IV CAQH CORE 400 Guiding Principles v4.0.0

Transcription

1 v4.0.0 CAQH 2016 Page 1 f 5

2 Table f Cntents CAQH CORE GUIDING PRINCIPLES... 3 UNDERLYING ASSUMPTIONS FOR ALL PHASE IV CAQH CORE OPERATING RULES... 4 UNDERLYING PRINCIPLES AND ASSUMPTIONS FOR SPECIFIC OPERATING RULES... 4 CAQH CORE Pledge... 4 Vluntary CORE Certificatin... 5 CAQH CORE Enfrcement... 5 CAQH 2016 Page 2 f 5

3 This dcument prvides the Phase IV CAQH CORE Guiding Principles and underlying assumptins that are assciated with all Phase IV CAQH CORE Operating Rules. CAQH CORE GUIDING PRINCIPLES All CAQH CORE Participating Organizatins and CORE-certified entities will wrk twards achieving CORE s missin. All stakehlders are key t CAQH CORE s success; n single rganizatin, nr any ne segment f the industry, can d it alne. CAQH will strive t include participatin by all key stakehlders in the CAQH CORE rule making prcess. CAQH CORE has established Gverning Prcedures; under these Prcedures, each CAQH CORE Participant that meets CORE vting criteria will have ne vte n CAQH CORE issues and rules. CAQH CORE Participants draft and vte n the rules. Participatin in CAQH CORE des nt cmmit an rganizatin t adpt the resulting CAQH CORE Operating Rules. Use f and participatin in CAQH CORE is nn-exclusive. CAQH CORE will nt be invlved in trading partner relatinships, and will nt dictate relatinships between trading partners. T prmte interperability, rules will be built upn HIPAA, and CAQH CORE will crdinate with ther key industry bdies (fr example, X12 and the Blue Crss Blue Shield Assciatin). Where apprpriate, CAQH CORE will address the emerging interest in XML r ther evlving standards. Whenever pssible, CAQH CORE has used existing market research and prven rules. CAQH CORE Operating Rules reflect lessns learned frm ther rganizatins that have addressed similar issues. CAQH CORE Operating Rules will supprt the Guiding Principles f HHS s Natinal Health Infrmatin Netwrk (ehealth Exchange). CAQH research indicated that there will be benefit t the health care industry as a result f adpting perating rules. CAQH CORE will have Measures f Success fr Phase IV (methdlgy t measure success and evaluate market impact) and CAQH will reprt aggregate findings by stakehlder type. CAQH CORE will prvide guidance t stakehlders regarding staff implementatin and training needs. Safeguards will be put in place t make sure that a health plan s benefit and payment infrmatin is shared nly with the requested prvider and is nt available t ther participating health plans. CAQH CORE will nt build a switch, database, r central repsitry f infrmatin. All CAQH CORE recmmendatins and rules will be vendr neutral. All f the CAQH CORE Operating Rules are expected t evlve; Phase I was a starting pint and each phase builds upn earlier phases. Rules will nt be based n the least cmmn denminatr but rather will encurage feasible prgress. CAQH CORE will prmte and encurage vluntary adptin f the rules. CAQH CORE Participants d nt supprt phishing. CAQH 2016 Page 3 f 5

4 UNDERLYING ASSUMPTIONS FOR ALL PHASE IV CAQH CORE OPERATING RULES Phase IV CAQH CORE Operating Rules apply t the fllwing transactins; web-based transactins are nt part f the Phase IV scpe. ASC X12N X222 Health Care Claim (837) Prfessinal, ASC X12N X223 Health Care Claim (837) Institutinal, and ASC X12N X224 Health Care Claim (837) Dental transactins and their respective errata (cllectively the ASC X12N v Claim) ASC X12N X217 Health Care Services Review Request fr Review and Respnse (278) and assciated errata ASC X12N X220 Benefit and Enrllment Maintenance (834) transactin ASC X12N X218 Payrll Deducted and Other Grup Premium Payment fr Insurance Prducts (820) All Phase IV CAQH CORE Operating Rules assume a successful cmmunicatin cnnectin has been established and that all parties in the transactin ruting path are CORE-certified. Phase IV CAQH CORE Operating Rules are a flr, nt a ceiling; certified entities can g beynd the Phase IV rules, e.g., real time respnse time less than 10 secnds. CAQH CORE cmplies with all antitrust prvisins f the law. Organizatins may sign the CAQH CORE Pledge at any time after the CAQH CORE Operating Rules are develped and apprved by the CAQH CORE Full Vting Membership, and may withdraw frm the Pledge at any time. N individual CAQH CORE Participant wns the rules r the underlying intellectual prperty; CAQH CORE wns the rules and intellectual prperty. The CAQH CORE Operating Rules will nt specify hw participants implement any changes t current prcesses and prcedures. CAQH CORE will nt assume any f the expenses that an rganizatin incurs in making such changes. Neither CAQH CORE nr CAQH CORE Participating Organizatins will be liable if incrrect infrmatin is transmitted. Cmplying with CAQH CORE Operating Rules des nt release any rganizatin adpting the rules frm ensuring that it is in cmpliance with all ther applicable rules, regulatins and legal requirements. All rganizatins that perate under the CAQH CORE Operating Rules are HIPAA cmpliant, and rganizatins intending t cmplete Vluntary CORE Certificatin under the CAQH CORE Operating Rules will be asked t attest t this fact. Hwever, CAQH CORE will nt test fr HIPAA cmpliance. CAQH CORE Operating Rules address bth real-time and batch transactins, with mvement twards realtime. There will nt be any substantive changes r amendments t the rules unless apprved by a CAQH CORE vte. CAQH CORE Operating Rules will supprt mandated versins f the HIPAA transactins. UNDERLYING PRINCIPLES AND ASSUMPTIONS FOR SPECIFIC OPERATING RULES CAQH CORE Pledge Signing the CAQH CORE Pledge des nt autmatically allw the rganizatin t participate in the CAQH CORE rule making prcess; t becme invlved in the CAQH CORE rule making prcess, the rganizatin must be a CAQH CORE Participant. CAQH 2016 Page 4 f 5

5 All stakehlders that sign the CAQH CORE Pledge will be added t a web-based listing f entities that have signed the Pledge. A separate signed CAQH CORE Pledge Addendum is required fr Phase IV. Vluntary CORE Certificatin There will be a web-based listing f entities that are CORE-certified. Vendrs and clearinghuses need nly certify fr the transactin type(s) ffered (i.e., healthcare claims, prir authrizatin, emplyee premium payment, and enrllment and disenrllment in a health plan). CAQH CORE Enfrcement An rganizatin certified under the CAQH CORE Operating Rules will be party t the CAQH CORE Enfrcement Prcess. The CAQH CORE Enfrcement Prcess requires all parties invlved in the cmplaint t be CORE-certified, except fr prviders that are nt CORE-certified but are an end-user f a CORE-certified prduct. CORE-certified entities are permitted t wrk with any entity f their chice, including entities nt participating in CAQH CORE. CAQH 2016 Page 5 f 5