CORE Competencies

Providers, Hospitals Can Now Access Consistent Health Insurance Coverage Information in Seconds

New CAQH CORE Rules Dramatically Streamline Administrative Healthcare Data Exchange

Washington, DC – (April 3, 2007) – Healthcare 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 leading health organizations have begun voluntarily exchanging patient administrative data in accordance with the CORE rules. Those organizations 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 organizations 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 healthcare organization 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 healthcare providers,” said William F. Jessee, M.D., FACMPE, FACPM, President and Chief Executive Officer of the Medical Group Management Association. “All of the CORE-certified organizations 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 organizations and other healthcare entities – to collaborate on the rules.

“Interoperability should be at the heart of any long-term solution for improving healthcare administration,” said 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 healthcare 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 U.S. 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 healthcare 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 organizations proves that the industry is actively contributing ground-breaking solutions. We encourage all organizations 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 organizations 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.

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