Standard business rules have been released by a collaborative organization to facilitate the data exchange process between providers and insurers.
The rules were released last month by the Committee on Operating Rules for Information Exchange, an initiative of the Washington-based Council for Affordable Quality Healthcare.
CAQH, which has been working on the CORE initiative for about two years, said it now will increase efforts to certify healthcare organizations, providers and suppliers as able to meet its standards for exchanging information.
Being able to verify by computer that patients are covered by insurers and eligible for coverage would greatly speed the verification process, which often involves repeated phone calls.
CORE aims to speed the data exchange between business partners in healthcare, reducing the hassle of information exchange and reducing costs for administration and claims management. The CORE rules are built on the ANSI ASC Committee X12, which developed codes for inquiring about patient benefits (270) and for transmitting eligibility and benefit information (271).
Those codes were adopted as standards under the Health Insurance Portability and Accountability Act of 1996. However, variations in the use of the standards have thwarted interoperability between payer and provider systems.
"Interoperability should be at the heart of any long-term solution for improving healthcare administration," said Bob Greczyn, CAQH board chairman and president and CEO of Blue Cross and Blue Shield of North Carolina. "The CORE rules are a foundation and a model for all health plan-provider electronic administrative communication."
The initial phase of the rules intends to speed communication of eligibility and benefits information, said Gwendolyn Lohse, CORE project director.
About 20 organizations are already using the standards, Lohse said. Those voluntarily exchanging patient administrative data include provider organizations such as the Mayo Clinic and Montefiore Medical Center, and payers such as Aetna Inc., Health Net and WellPoint Inc. and its 14 Blue Cross and Blue Shield-licensed subsidiaries. Other major provider and payer organizations are committed to CORE rules compliance this year, Lohse said.
Lohse said the future looks bright for expanded use of CORE standards. For example, the rules were recently included among specifications of the Health Information Technology Standards Panel to develop a national model for populating and maintaining robust patient insurance information in patients' personal health records.
The Phase I testing process for CORE compliance was demonstrated at the Interoperability Showcase earlier at HIMSS07 this year by the Intergrating the Healthcare Enterprise.