National health plans Aetna and Wellpoint are the first to earn certification for electronically exchanging administrative data using the Council for Affordable Quality Healthcare's Committee on Operating Rules for Information Exchange (CORE) Phase II rules.
The CAQH, a nonprofit alliance of health plans and trade associations, said Aetna and Wellpoint are active participants in the ongoing development of CORE rules, which represent an all-payer solution designed to enable electronic provider access to patient insurance information before or at the time of service.
CORE Phase II certification means providers working with these plans can access a richer set of consistent and accurate electronic administrative data such as eligibility, benefits and patient financial information. The Phase II rules also enable improved access to claims status, which was not included in Phase I. More than 20 health plans, large provider groups and technology vendors are seeking Phase II certification.
Officials said Aetna and WellPoint certification represents a turning point in the voluntary, industry-driven effort to advance healthcare interoperability. A CAQH study by IBM Global Business Services issued earlier this year found that industry-wide implementation of the CORE Phase I rules alone could yield $3 billion in healthcare savings, which is expected to increase with Phase II rules.
"The CORE Phase II rules represent a significant milestone in using transparent, consensus-based, national operating rules to streamline electronic administrative transactions among providers, health plans and vendors," said Doug Henley, MD, executive vice president and CEO of the American Academy of Family Physicians. "Health plans that complete CORE Phase II certification can exchange data more effectively, thereby improving efficiency and freeing up time for physicians to focus more on their patients."
"The CORE Phase II rules are advancing the way the healthcare industry communicates," added Ronald A. Williams, CEO of Aetna and CAQH board chairman. "We are investing in an infrastructure that is improving connectivity and operability among healthcare providers and payers, while helping to fulfill the priorities of the national health IT agenda. This ongoing advancement can increase efficiency and quality through more timely access to key healthcare data. We strongly encourage all industry stakeholders to become CORE-certified."
Officials said the CORE rules complement objectives outlined in the American Recovery and Reinvestment Act (ARRA) and its Health Information Technology for Economic and Clinical Health (HITECH) Act. The rules, which are developed by more than 115 participating organizations, aim to foster the development of regional and state data exchanges by pairing robust content with infrastructure requirements that streamline electronic patient data flow through existing information technology systems.
"By using the CORE rules, WellPoint is further promoting the use of electronic data exchange so members and physicians have access to the necessary information to make the best healthcare decisions," said Angela Braly, president and CEO of WellPoint. "Through initiatives like this, which take advantage of lessons learned by other industries, the healthcare industry is working together to find innovative solutions to drive down costs and improve the quality of care for Americans."
CORE participants are now developing Phase III rules, which officials said will focus on improving the electronic exchange of additional administrative transactions such as prior authorization and remittance advice.