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© 2018 CAQH, All Rights Reserved.
April Todd
SVP, CAQH CORE and
CAQH Explorations
January 31, 2019
CAQH CORE
Prior Authorization
Overview
© 2018 CAQH, All Rights Reserved.
CAQH CORE Rule DevelopmentCAQH CORE Mission & Vision
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MISSION Drive the creation and adoption of healthcare
operating rules that support standards,
accelerate interoperability and align
administrative and clinical activities among providers, payers and consumers.
VISION An industry-wide facilitator of a
trusted, simple and sustainable
healthcare data exchange that evolves
and aligns with market needs.
DESIGNATION Named by Secretary of HHS to be
national author for operating rules
mandated by Section 1104 of the
Affordable Care Act.
BOARD Multi-stakeholder. Members include health
plans, providers (some of which are appointed
by associations such as the AHA, AMA,
MGMA), vendors, and government entities.
Advisors to the Board include SDOs.
© 2018 CAQH, All Rights Reserved.
CAQH CORE Rule DevelopmentStreamlining the Administrative Workflow
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Existing CAQH CORE Operating Rules CAQH CORE Operating Rules in Development
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Operating Rule Development Process
Identify Opportunities Develop Rules Ballot Participants
Advisory Groups CORE Participants
e.g., Prior Authorization Subgroup,
Claim Status Subgroup, etc.
e.g., Connectivity & Security Subgroup,
Certification/Testing Subgroup, etc.
Subgroups
Rules
Work Group (RWG)
Subgroups
Technical
Work Group (TWG)
e.g., Attachments (Additional
Documentation) Advisory Group.
Advisory Groups research
opportunities for potential rules,
prior to a Subgroup commencing rule
writing. Work Groups vote on draft rules developed by assigned
Subgroup(s). Should the rule have a maintenance component,
the Work Group may convene during maintenance periods to
vote on potential substantive changes to the rule.
Subgroups develop and straw poll draft rules for review by
assigned Work Groups (either RWG or TWG). New Subgroups
form as CAQH CORE rule writing focus changes.
Full CAQH CORE Voting Membership
vote requires for a quorum that 60% of all
Full CORE Voting Member organizations
(i.e., CAQH CORE Participants that create,
transmit, or use transactions) vote on the
proposed rule at this stage with a 66.67%
approval vote.
Once CAQH CORE Participants have
recached quorum, the CAQH CORE Board
will vote for final approval.
CORE Board
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Pilot Testing may occur to evaluate operating rule options and
return on investment (ROI) to address higher impact
opportunities and drive to industry consensus.
© 2018 CAQH, All Rights Reserved.
CAQH CORE Operating Rule DevelopmentAdopting a Faster Approach
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© 2018 CAQH, All Rights Reserved.
CAQH CORE Rule DevelopmentProcess for Bringing Rules Forward for Federal Mandatory Adoption
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CAQH CORE Writes
Letter to NCVHSNCVHS Holds Hearing
The NCVHS Subcommittee on
Standards holds hearings on to
gather get industry feedback on the
proposed operating rules.
NCVHS sends a letter to the Secretary
regarding industry feedback given at
the hearing. NCVHS recommends
whether the operating rules should be
mandated.
HHS issues Interim Final Rule (IFR)
to the industry within 90 days of
receiving the NCVHS letter with a 60
day open comment period.
Industry is given 25 months to adopt
the mandated operating rules.
CAQH CORE has been designated by the Secretary of the Department of Health and Human Services (HHS) as the author for federally
mandated operating rules per Section 1104 of the Patient Protection and Affordable Care Act (ACA). Once Operating Rules are approved by the
CORE Board, the following process must occur if the rules are to be mandated.
NCVHS Sends Letter
to Secretary
Expedited Interim Final
Rule MakingFinal Rule Adopted Mandate Implemented
NC
VH
SH
HS
CAQH CORE writes a letter
to NCVHS explaining the
industry need for the
operating rules along with the
CORE Board approved rules.
After the 60 day open comment
period, if no substantial comments
are received, HHS adopts the final
rule and mandates the operating
rule.*
*HHS has the authority to judge whether comments are substantial and whether changes should be made to the final rule.
© 2018 CAQH, All Rights Reserved.
The Draft Phase V Operating Rules address
needed data content in the prior authorization
transaction and enable greater consistency
across other modes of PA submissions.
CAQH CORE Focus for Prior Authorization
The Phase IV Operating Rule established
foundational infrastructure requirements such
as connectivity, response time, etc. and builds
consistency with other mandated operating
rules required for all HIPAA transactions.
Manual
Partially Automated
Optimized
Entirety of provider and health plan
workflows, including request and
submission, is manual and requires
human intervention, e.g., telephone,
fax, e-mail etc.
Entire prior authorization process is
at its most effective and efficient by
eliminating unnecessary human
intervention and other waste.
Optimized PA process would likely
include automating internal
provider/health plan workflows.
Parts of the prior authorization process
are automated and do not require human
intervention. Typically includes manual
submission on behalf of provider which is
received by health plan via an automated
tool, e.g., health plan portals, IVR, ASC
X12 278 etc.
Au
tom
atio
n S
pectru
m
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Ongoing efforts in 2019 to update the Phase IV
Rule with a timeframe for a completed
response and pilot test rules for a provider to
determine whether an authorization is needed.
© 2018 CAQH, All Rights Reserved.
Draft Phase V CAQH CORE Prior Authorization Operating Rules
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The Draft Phase V Prior Authorization Rules reduce unnecessary back and forth between providers and health plans.
These efficiencies enable shorter time to final adjudication and more timely delivery of patient care.
Compliance with Data Content Rule
System availability and reporting requirements for a health plan to receive a request, to enable predictability for providers.
Application of standard X12 data field labels to web portals to reduce variation in data elements to ease submission burden
and encourage solutions that minimize the need for providers to submit information to multiple portals.
Confirmation of receipt of a request to reduce manual follow-up for providers.
Consistent patient identification and verification to reduce common errors and associated denials.
Consistent use of diagnosis, procedure and revenue codes to allow for full health plan adjudication.
Consistent use of codes to indicate errors/next steps for the provider, including need for additional documentation.
Detection and display of code descriptions to reduce burden of interpretation.
DR
AF
T
Re
qu
ire
me
nts
DRAFT
RULE
Prior
Authorization
Web Portals
DRAFT
RULE
5010X217 278
Request and
Response
Data Content
DR
AF
T
Re
qu
ire
me
nts
© 2018 CAQH, All Rights Reserved.
Prior Authorization Process CAQH CORE Operating Rules Address Significant Pain Points in the Prior Authorization Process
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Part B: Provider & Health Plan
Exchange Information
Provider submits PA Request; Health
Plan receives and pends for additional
documentation; Provider resubmits
Part A: Provider Determines if
PA is Required & Info Needed
Provider identifies if PA is required;
Provider collects information required
for PA request
Part C: Health Plan Reviews &
Approves/Denies PA Request
Health Plan reviews PA request and
sends final response; Provider receives
final response
Major Parts of the Prior Authorization Process
Consistent patient identification and
verification Consistent use of diagnosis,
procedure and revenue codes
Consistent use of codes to indicate
errors/next steps for the provider,
including additional documentation
Detection and display of code
descriptions to reduce provider
burden of interpretation
Application of standard X12 data
field labels to web portals
Confirmation of receipt of PA
submission
System availability requirements
Requirement in CAQH CORE Phase V Operating Rule – Nearing Implementation Stage in Q2 2019
Requirement in CAQH CORE Phase IV Operating Rule – Available for Use
Consistent connectivity and security
methods between trading partners
Standard Companion Guide format
Detection and display of code
descriptions to reduce provider
burden of interpretation.
Consistent connectivity and security
methods between trading partners
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Pain Point: With the lack
of robust information in the
response, providers
telephone the plan to
determine what is needed,
or resubmit with incorrect/
incomplete information,
resulting in additional
pends or delays in care.
Spotlight on Phase V CAQH CORE Operating Rule Requirement Requesting Additional Documentation for a Pended Response
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* Depicts the most common path for the PA process to follow. Some health plans are able to automate the adjudication process when no additional documentation is needed.
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Pain Point: Not enough
detail included in the
response to know why the
request was pended and
what information is
needed to resolve the
pend.
Easing the burden of
interpretation on the provider
by standardized and uniform
code use and requiring display
of code descriptions. Provider
submits more complete requests,
resulting in fewer pends, iterative
requests for more information,
and denials.
Part B: Provider & Health Plan Exchange Information
The CAQH CORE Prior Authorization (278) Request / Response Data Content Rule targets one of the most significant problem areas in the prior authorization process:
requests for medical services that are pended due to missing or incomplete information. The operating rule reduces the unnecessary and manual back and forth
between providers and health plans by calling for the uniform use of standard codes to streamline communication electronically and reduce time to final
determination and patient care.
When a PA Request is pended
for additional documentation,
rule requires the use of specific
standard codes in conjunction
with detailing the type(s) of
documentation required for
the PA.
© 2018 CAQH, All Rights Reserved.
Prior Authorization Process Potential Requirements to Pilot
* Depicts the most common path for the PA process to follow.
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Part B: Provider & Health Plan
Exchange Information
Provider submits PA Request; Health
Plan receives and pends for additional
documentation; Provider resubmits
Part A: Provider Determines if
PA is Required & Info Needed
Provider identifies if PA is required;
Provider collects information required
for PA request
Part C: Health Plan Reviews &
Approves/Denies PA Request
Health Plan reviews PA request and
sends final response; Provider receives
final response
Major Parts of the Prior Authorization Process*
Consistent use of codes to indicate
errors/next steps for the provider,
including additional documentation.
Future CAQH CORE Requirements & Potential Pilot Opportunities
Determine whether a particular
service requires a PA.
Timeframe for the health plan to send
back a final determination to the
provider after submission of all
necessary information for a health plan
to adjudicate a PA request.
Determine what additional
documentation is required for the PA
request to be fully adjudicated by the
health plan.
Requirement in CAQH CORE Phase V Operating Rule – Nearing Implementation
Requirement in CAQH CORE Phase IV Operating Rule – Available for Use
© 2018 CAQH, All Rights Reserved.
Next Steps for Requirements Development & Pilot TestingGet Involved
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Guiding Principle of Pilot: Develop, test, and track impact of requirements that are flexible to support various
connectivity and security methods, and work in concert to add value to existing and emerging standards.
CAQH CORE is engaged in initial discussions with industry partners interested in developing and piloting new and
potential CAQH CORE Operating Rule requirements for prior authorization. Participation in this effort entails:
▪ Scoping and developing the requirements or combination of requirements to test in a pilot.
▪ Identifying primary measures of success for the pilot.
▪ Providing pre and post data on the measures.
▪ Implementing the requirements and providing data during a limited time period for the pilot.