The Committee on Operating Rules for Information Exchange (CORE) was proposed by CAQH (the Council for Affordable Quality Healthcare) as an initiative to develop a solution that enables consistent provider access to healthcare administrative information before or at the time of service using their choice of electronic system. CAQH's mission is to drive the creation and adoption of healthcare operating rules for administrative transactions. It has brought together over 140 healthcare industry stakeholders working to facilitate patient insurance information to physicians and hospitals, thereby significantly improving insurance verification and promoting health plan-provider interoperability.

Founded in 2005, CAQH is an American non-profit organization based in Washington, DC that collaborates with healthcare providers, trade associations, and insurers; they create shared initiatives to streamline business in healthcare. Among these initiatives are CAQH CORE, which maximizes business efficiency and savings by developing and implementing federally mandated operating rules. They also provide the CAQH Index, which benchmarks progress and helps to optimize operations by tracking industry adoption of electronic administrative transactions.

CAQH's mission statement is: "To accelerate the transformation of business processes in healthcare through collaboration, innovation and a commitment to ensure value across stakeholders." CAQH CORE certifies and awards CORE Certification Seals to entities that create, transmit, or use the healthcare administrative and financial transactions addressed by the CAQH CORE Operating Rules. CORE Certification means an entity has demonstrated that its IT system, or product, is operating in conformance with applicable requirements of a specific phase of the CAQH CORE Operating Rules. HIPAAsuite obtained the CORE Phase I and Phase II certification for the HIPAA RealTime Server in January 2015.

CAQH CORE Seal Vendor Prod (Phase II)

Members of the CAQH non-profit alliance include Aetna, Anthem, America's Health Insurance Plans, AultCare, the Blue Cross Blue Shield Association, Blue Cross Blue Shield of Michigan, Blue Cross Blue Shield of North Carolina, Blue Cross Blue Shield of Tennessee, CareFirst Blue Cross Blue Shield, Cigna, Health Net, Horizon BlueCross Blue Shield of New Jersey, Kaiser Permanente and UnitedHealth Group.

The availability of information in real-time at the point of care can reduce medical errors, allow physicians and their patients to make informed decisions about treatment options and reduce administrative burdens. The challenges are equally well understood. Technology adoption rates, data security, and inconsistency associated with transactions and interactions between stakeholders limit the ability to realize a complete solution. FTP, a network protocol widely used in the healthcare industry for EDI transfers, is not a real time protocol by design, requiring unnecessary overhead; resources dedicated to providing real time EDI transfer capability using FTP may be better served using a truly real time standard.

Two envelope standards (HTTP MIME Multipart and SOAP+WSDL) were selected by the CORE Phase II Connectivity & Security Subgroup from the initial long list of standards. They were shown to meet the CORE Phase II Connectivity criteria, have significant installed base in this industry, and perform well under real world transaction loads.

Since both these standards have significant merits, the Subgroup debated the advantages and challenges of having a single envelope standard versus both these envelope standards as part of the CORE Phase II Rule and Safe Harbor provisions. The major advantage of a rule based on a single envelope standard is that it would be more definitive and facilitate better interoperability. However, having just one standard would require implementers of the other envelope standard (i.e., the one that was not chosen) to modify their implementations to be CORE Phase II-compliant. Since both standards met the criteria and have large installed bases, convergence on a single standard would create a barrier to adoption of CORE Phase II Connectivity Rule by a large segment of the industry.

In the interest of further facilitating interoperability, CORE expects to move towards a single envelope standard in future phases. Given the current state of healthcare connectivity (i.e., use of many distinct connectivity methods), creating a CORE Phase II Connectivity rule with two envelope methods vastly improves the state of the market, while also providing an opportunity for education and greater experience with two standards that meet the growing market needs for connectivity. Taking this phased step enables the healthcare industry to make a more informed decision as it considers supporting a single envelope.

CORE operating rules are streamlining eligibility, benefits, and claims data by allowing providers to submit a request, using the electronic system of their choice to obtain a variety of coverage information for any insured patient and from any participating health plan. Providers will receive more consistent and predictable data, regardless of health plan.

CORE certification is proof that all CORE Rules and expected scenarios are met and requires an entity to perform testing of the relevant phase of the CORE Certification Test Suite developed by the CORE Testing Subgroup with a CORE-authorized Testing Vendor.

CORE Operating Rules

The Patient Protection and Affordable Care Act (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."

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 adopted by the Secretary 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);

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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).

Section 1104 of the Patient Protection and Affordable Care Act (ACA) mandates this certification process for health plans only.

Per the ACA, health plans must file a statement with the department of Health and Human Services (HHS), in such form as the Secretary may require, certifying that their data and information systems are in compliance with any applicable transaction standards and associated operating rules; financial penalties for health plans are significant.

The adoption deadline for Eligibility and Claim Status EDI transactions (included in Phase I and Phase II of the CORE Operating Rules) was 1/1/2013, so far the HHS has not enforced this deadline with penalties and affected entities are still in the implementation phase.

On December 31, 2013, HHS issued a Notice of Proposed Rulemaking (NPRM) on the ACA-mandated health plan certification. The Department of Health and Human Services (HHS) accepted public comments on the NPRM through April 3, 2014 (previously March 3, 2014). The NPRM includes health plan certification requirements for the eligibility, claim status, electronic funds transfers (EFT), and electronic remittance advice (ERA) transactions. It defines two potential certification options for plans to meet with HHS compliance requirements:

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Option 1: HIPAA Credential: Under the HIPAA credential program it is proposed that health plans will attest to compliance with the HIPAA-mandated transaction standards and operating rules. Once HHS issues the Final Rule later in 2014, CAQH CORE, as the proposed administrator, would offer the ability to complete the necessary HIPAA Credential documentation.

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Option 2: CORE Certification: The NPRM proposes to adopt the existing CORE Certification Program, authored and administered by CAQH CORE. Health plans that successfully complete certification testing with a CORE-authorized testing vendor and submit the required documentation will receive a Phase III CORE Certification Seal demonstrating their compliance.

CORE Operating rules are divided into Phases I, II, and III. This product is compliant with Phases I and II; they are explained below.

Phase I

Phase I CORE Operating Rules apply only to ASC X12 005010X279A1 Eligibility and Benefit Request and Response (270/271) transactions; DDE (Direct Data Entry) transactions and web-based transactions are not a part of the Phase I scope.

Phase II

Phase II CORE Operating Rules apply to ASC X12 005010X279A1 Eligibility and Benefit Request and Response (270/271) and ASC X12 005010X212 Health Care Claim Status Request and Response (276/277) implementation guides; DDE (Direct Data Entry) transactions and web-based transactions are not part of the Phase II scope.