CMS to adopt CORE rules for eligibility and claims status transactions

An interim final rule set to publish July 8 will define standard sets of information to be used in insurance eligibility and claims status transactions. The new CMS operating rules are expected to reduce excessive administrative work in physician practices.

Some payers already are using the standards voluntarily. But starting Jan. 1, 2013, all health plans, providers and claims clearinghouses will have to apply them in electronic transactions. 

CMS adopted the CORE operating rules under the authorization of the Affordable Care Act. That law specifies that CMS must adopt rules for eligibility and claims status transactions by July 1, 2011, and put them into effect by January 1, 2013. CMS is required to promulgate similar rules for electronic funds transfer, remittance advice, claims enrollment, premium payments and referral authorizations. The Council for Affordable Quality Healthcare's Committee on Operating Rules for Information Exchange (CAQH CORE), a group of industry stakeholders, worked with CMS to develop the standards. 

When CMS released the HIPAA 4010 transaction set a few years ago, the government hoped it would simplify administrative transactions between providers and payers. It did in some ways; but payers retained unique requirements that made it impossible to exchange standard transactions with all plans without going through a clearinghouse. This is the problem that CORE has set out to address.

The Medical Group Management Association, a longtime champion of administrative simplification, hailed the CMS adoption of the CORE rules.

"This is an important first step in realizing the simplification opportunities included in the ACA," MGMA President William Jessee said in a statement. "We urge CMS to expedite the process of designating entities that will develop the remaining ACA standards and operating rules for the health plan identifier, electronic funds transfer, claims attachments, and other critical initiatives and encourage their rapid development and deployment."

To learn more:

- Check out the CMS interim final rule
- Read the Health Data Management article
- See the Government Health IT piece

Related content:
CAQH partnership focuses on synchronizing med, pharmacy e-transaction rules 
CAQH committee looks to broaden CORE governance

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