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CAQH Core Operating Rules

Section 1104 of the Patient Protection and Affordable Care Act (ACA) (H.R.3590) establishes new requirements for administrative transactions that will improve the utility of the existing Health Insurance Portability and Accountability Act (HIPAA) transactions and reduce administrative costs. ACA defines operating rules as “the necessary business rules and guidelines for the electronic exchange of information that are not defined by a standard or its implementation specifications”. These operating rules address gaps in standards, help refine the infrastructure that supports electronic data exchange, and recognize interdependencies among transactions.

Alabama Medicaid is CAQH CORE Certified

Alabama Medicaid Agency has received CAQH (Council for Affordable Quality Healthcare) Committee on Operating Rules for Information Exchange (CORE®) certification for Affordable Care Act (ACA) Operating Rules Phases I, II and III. The Agency has committed to become CORE-certified. As a valued trading partner, we strongly encourage you to also complete CORE-certification. Access to eligibility, benefits, and claims data is improved with every organization that completes the process.

Click here to access additional information on how to become CORE-certified and the benefits to vendors, clearinghouses and providers.

ACA Section 1104 applies to HIPAA covered entities and business associates engaging in HIPAA standard transactions on behalf of covered entities. The legislation requires that the standards and associated operating rules will:
Enable the determination of an individual’s eligibility and financial responsibility for
   specific services prior to or at the point of care;
Be comprehensive, requiring minimal augmentation by paper or other communications;
Provide for timely acknowledgment, response, and status reporting that supports a
   transparent claims and denial management process (including adjudication and
   appeals); and
Describe all data elements (including reason and remark codes) in unambiguous terms,
   require that such data elements be required or conditioned upon set values in other  
   fields, and prohibit additional conditions (except where necessary to implement State or
   Federal law, or to protect against fraud and abuse).

CAQH CORE has been named as Operating Rules Authority Entity for transactions within Section 1104 of the ACA.
CAQH - Committee for Affordable Quality Healthcare is a nonprofit alliance of health
   plans and trade associations which provides a catalyst for industry collaboration on
   initiatives that simplify healthcare administration
CORE - Committee on Operating Rules for Information Exchange is a multi-stakeholder
   collaboration developing industry-wide operating rules, built on existing standards, to
   streamline administrative transactions and reduce administrative burdens. CORE focuses
   on a subset of the areas that the larger CAQH organization engages in.

Phase I/II - Eligibility and Claim Status Operating Rules

Phase III - EFT & ERA Operating Rules