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CAQH Initiative Creates First-Time National Provider Access to Consistent Patient Deductible Data, Moves Industry Closer to Electronic Connectivity Standard

September 15, 2008

WASHINGTON, Sept. 15 /PRNewswire/ — CAQH announced today that for the first-time providers will be able to receive consistent electronic information about patient deductible balances from potentially any health plan at the point of care.

This achievement is the result of voluntary business rules developed during the second phase of activities conducted by the CAQH Committee on Operating Rules for Information Exchange (CORE), a collaborative healthcare industry initiative.

CAQH, a nonprofit alliance of health plans and trade associations working to streamline healthcare administration, launched the multi-phase program in 2005. CORE is focused on improving provider access to electronic patient administrative and payer information before or at the time of service using any technology they choose. The CORE rules build upon national standards, such as HIPAA. Each phase expands the pool of available data and augments the functional requirements to exchange it electronically.

“Today’s announcement further demonstrates that CORE is transforming the way our industry communicates,” said Ronald A. Williams, CAQH chairman of the board and chairman and CEO of Aetna. “With the Phase II rules now in place and work begun on Phase III, CORE is effectively achieving its mission to create an all-payer approach to streamlined administrative data exchange.”

Through CORE, CAQH has brought together more than 100 healthcare industry stakeholders as partners in rules development. Health plans participating on the committee cover more than 130 million lives or more than 75 percent of the commercially insured plus Medicare and state-based Medicaid beneficiaries.

The Phase II rules also cover requirements for electronic connectivity, patient identification, claims status and reporting of patient financial responsibility for an increased number of service codes included in the HIPAA standards. CORE’s second set of rules builds on the rules created by the initiative during its Phase I efforts, completed in 2006. Both phases are advancing health plan-provider system interoperability.

“CAQH CORE standards reduce costs and enhance efficiency by connecting payers, providers and patients with the data they need to support the administration of healthcare,” said John Halamka, Healthcare Information Technology Standards Panel (HITSP) Chairman, and Chief Information Officer, Harvard Medical School and Beth Israel Deaconess Medical Center.

CAQH also announced that more than 25 leading health plans, large provider groups and technology vendors are committed to completing Phase II rules certification testing by the end of 2009. These stakeholders — currently certified as complying with the CORE Phase I rules — include: Aetna Inc.; AultCare Corporation; WellPoint, Inc. and its 14 BCBS-licensed subsidiaries; Mayo Clinic; Montefiore Medical Center; Affiliated Computer Services, Inc.; Availity, LLC; Emdeon Business Services; HMS; MedAvant Healthcare Solutions; MedData; NaviMedix, Inc.; Passport Health Communications; Post-N-Track; RelayHealth; Siemens Medical Solutions; athenahealth, Inc.; CSC Consulting, Inc.; Emerging Health Information Technology; GE Healthcare; Medical Informatics Engineering, Inc.; NoMoreClipboard.com; The SSI Group, Inc.; and VisionShare, Inc.

Harvard Pilgrim Health Care and Ingenix have committed to achieve CORE Phase I and II rules certification by the end of next year.

BlueCross BlueShield of Tennessee; Health Net, Inc.; Humana Inc. and SureScripts-RxHub will become CORE Phase II rules certified by the end of the first quarter in 2010.

Entities must complete a testing process to confirm that their systems and/or products comply with the CORE rules. Phase I certification is required prior to completing Phase II certification. The CORE rules now allow for entities to complete Phase I and II certification testing during a single, integrated process.

More than 20 healthcare associations, accrediting bodies, networks and businesses have committed to endorsing the CORE Phase II rules.

The Blue Cross and Blue Shield Association expressed its support for the initiative with the following statement: “BCBSA is pleased to participate in CAQH CORE’s efforts to streamline electronic eligibility. Simplifying provider access to patient insurance coverage information is critical and the Blues believe that CORE is a key initiative to bring the industry together for collaboration and consensus building.”

CORE is currently determining the scope of issues it will create rules for during its third phase. Issues under consideration include determining in- or out-of-network status of a provider, alternative search requirements for eligibility transactions when some member ID information is missing, coordination of benefits, claims attachments and harmonizing CORE with other industry standardization efforts.

About CAQH

CAQH serves as a catalyst for industry collaboration on initiatives that simplify healthcare administration for health plans and providers, resulting in a better care experience for patients and caregivers. CAQH solutions help promote quality interactions between plans, providers and other stakeholders, reduce costs and frustrations associated with healthcare administration, facilitate administrative healthcare information exchange and encourage administrative and clinical data integration. Visit http://www.caqh.org/ for more information.

CAQH

CONTACT: Chris McNamara of CAQH, +1-202-778-3271

Web site: http://www.caqh.org/




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