1. health and fitness

HIPAA Collaborative of Wisconsin
2015 Spring Conference
Oconomowoc, Wisconsin April 10, 2015
© 2015 CAQH. All rights reserved.
•
ACA Mandate Scope and Updates
•
Third Set of Draft CAQH CORE Operating Rules
•
Draft Phase IV Connectivity Rule Overview
•
Q&A
© 2015 CAQH. All rights reserved.
ACA Mandated and HHS Health
Plan Certification
Scope and Updates
1
About
CAQH CORE
Vision
Mission
4
CAQH CORE is an industry-wide stakeholder collaboration committed to the
development and adoption of national operating rules for administrative
transactions. The more than 140 CORE Participants represent all key
stakeholders including providers, health plans, vendors, clearinghouses,
government agencies, Medicaid agencies, banks and standard development
organizations.
An industry-wide facilitator of a trusted, simple and sustainable
healthcare data exchange that evolves and aligns with market needs.
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.
© 2015 CAQH. All rights reserved.
CAQH CORE
in Process of
drafting rules
HHS NPRM and
deadline
adjustment
issued 12/31/13
Mandated Requirements
available and should be
in use in market
Compliance in
Effect as of
January 1, 2013
5
• Eligibility for health plan
• Claim status transactions
HIPAA covered entities conduct these transactions
using the CAQH CORE Operating Rules
Compliance in
Effect as of
January 1, 2014
• Electronic funds transfer (EFT)
• Health care payment and remittance advice (ERA)
Proposes an
adjusted
Implementation:
December 2015
Proposes health plans certify via either CORE
certification or HIPAA Credential; applies to Eligibility/
Claim Status/EFT/ERA operating rules and underlying
standards
Implement by
January 1, 2016
(Draft Rules available in Late 2014)
HIPAA covered entities conduct these transactions
using the CAQH CORE Operating Rules
Applies only to health plans and includes potential penalties for incomplete certification;
existing voluntary CORE Certification is for vendors/PMS/large providers, and health plans
•
•
•
•
•
Health claims or equivalent encounter information
Enrollment/disenrollment in a health plan
Health plan premium payments
Referral, certification and authorization
Health claims attachments (HHS Standard not yet
mandated)
© 2015 CAQH. All rights reserved.
•
ACA Section 1104 mandates that all HIPAA covered entities comply with healthcare operating
rules; additional guidance on HIPAA covered entity designations may be found HERE
•
HIPAA Administrative Simplification standards, requirements and
implementation specifications apply to2:
–
Healthcare Providers: Any person or organization who furnishes, bills, or is paid for healthcare in the
normal course of business3
•
•
1
Examples include but are not limited to: Doctors, Clinics, Psychologists, Dentists,
Chiropractors, Nursing Homes, and Pharmacies
Covered ONLY if they transmit any health information electronically (directly or through a business
associate) in connection with a transaction for which HHS has adopted a standard2
–
Health Plans (including Self-insured and Group Health Plans, Long-term
Care, Medicare, Medicaid, etc.)
–
Healthcare Clearinghouses
Covered Entity Charts
Administrative Simplification: 45 CFR §§ 160.102,
HIPAA Administrative Simplification: 45 CFR § 160.103
2 HIPAA
3
6
© 2015 CAQH. All rights reserved.
2

ACA § 1104
Requires HHS to adopt
and update operating rules
for HIPAA transactions
HHS
CAQH CORE
Sept. 2012: HHS designates
CAQH CORE as the
operating rule authoring entity
for remaining transactions:
2013-2015: CAQH CORE
develops and submits the set
of Phase IV CAQH CORE
Operating Rules approved by
the CORE Participants via the
CORE Voting Process to
HHS/NCVHS as appropriate
1. Health claims or equivalent
encounter information
2. Health plan
enrollment/disenrollment
3. Health plan premium payments
4. Referral certification and
authorization
5. Health claims attachments*
* NOTE: HHS has not adopted a standard for health claims attachments or indicated what standard(s) it might consider for the transaction, and an effective date
for these operating rules is not included in the ACA. Thus, the immediate focus of CAQH CORE will not include attachments.
7
© 2015 CAQH. All rights reserved.
• Health claims or equivalent encounter information
• Referral, certification, and authorization
• *Enrollment and disenrollment in a health plan
• *Health plan premium payments
=================================
• Health claims attachments
Goal: Have draft rules in early 2015 and begin formal CORE voting process
•
•
Rules are infrastructure-focused (vs. content) and apply across transactions; built
on existing rules.
*These two transactions are being used in the Insurance Exchanges (HIXs)
–
•
8
CORE rules will apply to HIPAA covered entities only, yet use in HIX environment is informative.
Research conducted on behalf of CAQH CORE by a Firm with Federal and State HIX experience
summarized lessons learned in HIX market. Report was shared with the Benefit Enrollment &
Maintenance/Premium Payment Subgroup, which verified findings regarding HIX and traditional HIPAA
use of these transactions.
Attachment standard(s) not adopted; CAQH CORE has developed potential vision
–
Held a series of CORE-only calls to review and verify CORE findings on current volumes, attachment formats,
future plans and related ROI, knowledge levels, etc.
–
Research indicates industry neutral standards, e.g., PDF, may have significant benefit and that industry
education will be key given current level of knowledge of key standards such as HL7 C-CDA
–
Pursuing pilot to inform rule writing, which will be started when standard(s) adopted by CMS
© 2015 CAQH. All rights reserved.
TBD – Rule Development for Attachments
(Pilot being done separate from CORE)
Q1
Q2
Q3
Q4
• CORE Technical and Rules Workgroups Meet
• Draft Phase IV Rules Open for Full CORE Membership Vote Draft
• Phase IV Rules Open for CORE Board Vote
• CAQH CORE will create Tools and Resources to aid in the understanding and
implementation of the Phase IV Operating Rules
• Full set of FINAL Phase IV Operating Rules Released
Rule development for Attachments TBD (pilot conducted separately from CORE)
NOTE: CAQH CORE as authoring entity must update NCVHS on CORE rules; as advisor to HHS Secretary, NCHVS will make a recommendation to HHS
regarding the CORE rules and actions they suggest CORE take.
11
© 2015 CAQH. All rights reserved.
3
Development of Phase IV CAQH CORE Operating Rules
Estimated 2015 Timeline
The CAQH CORE Board’s normal voting procedures would
apply. If the Board does not approve any proposed
Operating Rule, the Board will issue a memorandum setting
forth the reasons it did not approve the proposed Operating
Rule and will ask the CORE Subgroups and Work Groups to
revisit the proposed Operating Rule
Work Groups require a quorum of 60%
of all participants that are voting
members. Simple majority vote
(greater than 50%) by this quorum is
needed to approve a rule.
Technical/Rules Work Group Review &
Balloting
Q1 2015
CORE Board
Q2 2015
Q3 2015
Full CAQH CORE Voting
Member Ballot
Full CORE Voting Membership vote requires for a quorum
that 60% of all Full CORE Voting Member organizations
(i.e., CORE Participants that create, transmit, or use
transactions) vote on the proposed rule at this stage. With
a quorum, a 66.67% approval vote is needed to approve a
rule.
NOTE: CAQH CORE as authoring entity must update NCVHS on CORE rules; as advisor to HHS Secretary, NCHVS will make a
recommendation to HHS regarding the CORE rules and actions they suggest CORE take.
10
© 2015 CAQH. All rights reserved.
Draft Phase IV CAQH CORE Operating Rules are publically available for download from the CAQH
CORE website by clicking HERE.
Draft Phase IV CAQH CORE 450 Health Care Claim (837) Infrastructure Rule v4.0.0
•
Draft Phase IV CAQH CORE 452 Health Care Services Review – Request for Review and
Response (278) Infrastructure Rule v4.0.0
•
Draft Phase IV CAQH CORE 454 Benefit Enrollment & Maintenance (834) Infrastructure Rule
v4.0.0 *
•
Draft Phase IV CAQH CORE 456 Payroll Deducted and Other Group Premium Payment for
Insurance Products (820) Infrastructure Rule v4.0.0 *
•
Draft Phase IV CAQH CORE 470 Connectivity Rule v4.0.0
•
•
•
•
XML Schema Specification (normative)
Web Services Definition Language (WSDL) Specification (normative)
Draft Phase IV CAQH CORE Required Processing Mode and Payload Type Tables v4.0.0
*Draft Rules will be posted to the CAQH CORE website once the draft rules are approved for Rules Work Group review.
21
© 2015 CAQH. All rights reserved.
Infrastructure
Requirement
Prior
Authorization1
Claims1
Enrollment2
Premium
Payment2
Batch OR Real Time
Required
Batch Required;
Real Time Optional
Batch Required;
Real Time Optional
Batch Required;
Real Time Optional
Batch Processing Mode
Response Time
If Batch Offered
X
X
X
Batch
Acknowledgements
If Batch Offered
X
X
X
Real Time Processing
Mode Response Time
If Real Time Offered
If Real Time Offered
If Real Time Offered
If Real Time Offered
Real Time
Acknowledgements
Processing Mode
If Real Time Offered
If Real Time Offered
If Real Time Offered
If Real Time Offered
Safe Harbor Connectivity
and Security3
X
X
X
X
System Availability
X
X
X
X
Companion Guide
Template
X
X
X
X
N/A
Include guidance for COB in
companion guide
Timeframe requirements to
process data after successful
receipt and verification of
transaction
Timeframe requirements to
process data after successful
receipt and verification of
transaction
Other
X = Required
1. Draft Rules approved by Claims/Prior Authorization Subgroup under Rules Work Group review.
2: Draft Rules being straw polled by Benefit Enrollment & Maintenance/Premium Payment Subgroup.
3: Draft Connectivity Rule approved by Connectivity & Security Subgroup under Technical Work Group review.
12
© 2015 CAQH. All rights reserved.
4
Batch Processing Mode Response Time requirements specify the overall length of elapsed
time from when a transaction is sent to a health plan and when the acknowledgement(s) or
response to the transaction is available for pick up (retrieval) by the provider/health plan
purchaser (sender).
1 Sent by 9 pm ET on a business day

Health Plan

Sender
2 Available by 7 am ET within second or third business day depending on transaction
Applicability of Requirements
13
Infrastructure
X12N v5010
X12N v5010
X12N v5010
X12N v5010
Requirement
837
278
834
820
Batch Processing
Mode
Response Time
X
X
X
X
© 2015 CAQH. All rights reserved.


837/278/834/820
Sender
Health Plan

999/277CA
•
Requirements for 837
-
•
W hen any Functional Group of an ASC X12N v5010 837 Claim Transaction Set is accepted, accepted with errors, or rejected, an
entity must return a ASC X12C v5010 999.
A health plan must acknowledge each claim received in any institutional, professional, or dental ASC X12N v5010 837
Transaction Set using the ASC X12N v5010 277CA unless previous processing resulted in a rejection of the Interchange or a
Transaction Set in a Functional Group.
Requirements for 278, 834 & 820
-
W hen any Functional Group of these transaction is accepted, accepted with errors, or rejected, an entity must return an ASC
X12C v5010 999.
Applicability of Requirements
Infrastructure
Requirement
Batch
Acknowledgement
14
X12N v5010
837
X12N v5010
278
X
X12N v5010
834
X
X12N v5010
820
X
X
© 2015 CAQH. All rights reserved.
Real Time Processing Mode Response Time requirements specify the overall length of elapsed time from
when a provider/health plan purchaser (sender) sends a transaction to a health plan and the related
response transaction is received by the sender.

20 Seconds
Round Trip Max Response Time
Sender
Health Plan
Applicability of Requirements
Infrastructure
Requirement
Real Time
Processing Mode
Response Time
X12N v5010
X12N v5010
X12N v5010
X12N v5010
837
278
834
820
If Real Time
Used
If Real Time
Used
If Real Time
Used
If Real Time
Used
15
5

837/278/834/820
Sender
Health Plan

999/277CA
•
Requirements for 837 (NOTE: RTA is not in scope for this draft Phase IV rule)
-
W hen any Functional Group of an ASC X12N v5010 837 Claim Transaction Set is accepted, accepted with errors, or rejected,
an entity must return a ASC X12C v5010 999.
A health plan must acknowledge each claim received in any institutional, professional, or dental ASC X12N v5010 837
Transaction Set using the ASC X12N v5010 277CA unless previous processing resulted in a rejection of the Interchange or a
Transaction Set in a Functional Group.
•
Requirements for 278
•
Requirements for 834 & 820
-
-
A receiver must return one response to an ASC X12N v5010 278 request: either an ASC X12C v5010 999 rejection or an ASC
X12N v5010 278 response.
A health plan must return an ASC X12C v5010 999 for any Functional Group of any ASC X12N v5010 transaction to indicate if
the Functional Group is accepted, accepted with errors, or rejected.
Applicability of Requirements
Infrastructure
X12N v5010
Requirement
837
278
834
820
Real Time
Acknowledgement
If Real Time
Used
X12N v5010
If Real Time
Used
X12N v5010
If Real Time
Used
X12N v5010
If Real Time
Used
16
The System Availability requirements establish the amount of time a system must be
available to process the specified transactions:



Minimum of 86 percent
system availability (per
calendar week)

Publish regularly
scheduled downtime
Provide one week
advance notice on nonroutine downtime
Provide information
within one hour of
emergency downtime
Applicability of Requirements
20
Infrastructure
X12N
X12N
X12N
X12N
Requirement
v5010 837
v5010 278
v5010 834
v5010 820
System
Availability
X
X
X
X
© 2015 CAQH. All rights reserved.
When an entity publishes a Companion Guide the CAQH CORE Companion Guide requirements
establish the format and flow of Companion Guides.


CORE v5010 Master
Companion Guide Template
Companion Guides
Format & Flow Specified in Template
•
•
•
•
•
Introduction
Getting Started
Testing with the Payer
Connectivity with Payer/Communications
Contact Information
•
•
•
•
•
Control Segment/Envelopes
Payer Specific Business Rules and Limitations
Acknowledgements and/or Reports
Trading Partner Agreements
Transaction Specific Information
For Companion Guides addressing the X12N v5010 837 Claim, entities are also required to include
their requirements for coordination of benefits in specified Sections.
Applicability of Requirements
18
Infrastructure
Requirement
X12N
v5010 837
X12N
v5010 278
X12N
v5010 834
X12N
v5010 820
Companion
Guide
X
X
X
X
© 2015 CAQH. All rights reserved.
6
It is anticipated that the regulatory process for adoption of the ACA-mandated Phase IV Operating Rules
will be similar to the process for EFT & ERA and include opportunities for public comment. That process
includes the following key steps:
=Public Comment Opportunity
Step Five:
Step One:
Once comments have been
reviewed, HHS will publish a
Final Rule that may or may
not include adjustments
based on the public
comments
CAQH CORE will update
NCVHS on the status of the
draft Phase IV Operating
Rules at its next 2015
meeting
19
Step Two:
Step Three:
As appropriate, NCVHS will
make an adoption
recommendation to the HHS
Secretary or ask for CORE
to return to NCVHS later in
2015 before NCVHS makes
its recommendation
HHS will publish a regulation
in the Federal Register once
it receives a final set of rules
from CORE and determines
what is appropriate for
Federal mandate
© 2015 CAQH. All rights reserved.
Step Four:
A public comment period
(60 days or more) will follow
publication of the regulation
whereby entities can submit
comments on the regulation
to CMS/HHS
NOTE: In February 2015, CAQH will release the 2014 Index report. This report provides
an aggregated analysis of the adoption and cost of eight claims transactions based on
blinded claims data from nearly half of the country’s commercially insured..
CAQH CORE will help organizations understand and implement the Phase IV Operating Rules by developing
a suite of tools and resources similar to those available for Phases I, II and III, such as:
Analysis and Planning
Guide
Informational Webinars
with downloadable recording
and presentations
20

Dedicated Phase IV
Webpage
If you have any
suggestions for Tools
and/or Resources that will
help you better understand
or more easily implement
the rules, please let us
know at CORE@caqh.org
FAQs
Staff Experts are always
available to answer your
questions
© 2015 CAQH. All rights reserved.
Non-CORE Participants should continue to follow the Phase IV CAQH CORE Rule
Development Process by:
◦ Checking the Phase IV CAQH CORE Operating Rule Website for updates and links to the
Draft Phase IV CAQH CORE Operating Rules
◦ Attending upcoming CAQH CORE Education Sessions on the Phase IV Rules
◦ Following the regulatory process via HHS including the upcoming NCVHS

HIPAA covered entities, e.g. health plans, providers, and clearing houses along with
their business associates should also begin to familiarize themselves with the draft
rule requirements and schedule preliminary, internal discussions to begin
implementation planning
© 2015 CAQH. All rights reserved.
7
•
CAQH CORE Work Groups and Subgroups
–
Open to all individuals from CORE Participating entities
–
Each Subgroup/Work Group is chaired by two or more experts representing different
stakeholders from CORE Participating entities who facilitate meetings
–
CAQH CORE staff support CORE activities, Work Groups, and Subgroups
•
•
•
CAQH CORE retains consultants to provide technical and other expertise
CAQH CORE meeting frequency (during rule-writing or if key maintenance needed)
–
Rule-development Subgroup meetings are held via conference call weekly or bi-weekly; calls
are typically 1.5 hours
–
Work Group conference calls are held bi-weekly or monthly
–
Call schedule is developed and communicated by CAQH CORE and Co-Chairs
Meeting materials
–
Are available on the CAQH CORE Member Calendar
–
CAQH CORE staff/consultants assist Co-chairs with drafting meeting materials and
ensure they are made available on the calendar 24 hours prior to the call
–
Meeting summaries are created after each call/meeting and approved by the Work
Group/Subgroup
22
© 2015 CAQH. All rights reserved.
Draft Phase IV CAQH CORE 470
Connectivity Rule Version 4.0.0
Rule Scope, Requirements & Relationship to Prior
Connectivity Rules
23
© 2015 CAQH. All rights reserved.
Conduct Environmental Scan (Market and Business Analysis)
1
Agree on Phase IV Business and Technical Evaluation Criteria
2
Identify Phase IV Rule Opportunities using Market and Business Analysis
3
Evaluate Candidate Rule Opportunities using Business and Technical
Evaluation Criteria
4
Prioritize Rule Opportunities using Criteria, and Identify Set of Phase IV High
Priority Rule Opportunities
5
Agree to Rule Option(s) to Address High Priority Rule Opportunities
6
7
Agree to Technical Rule Requirements for Selected Rule Option(s)
© 2015 CAQH. All rights reserved.
8
Legislative and National Initiatives Movement
towards increased adoption of Standards
Market Movement towards increased
Connectivity, new Business Needs
Legislative Movement
Market Movement
HIPAA covered entities are implementing
Market movement from paper based
to Internet based electronic
transactions.
CAQH CORE Connectivity for ACA Section
1104 compliance
Efficiencies of scale gained as more
Meaningful Use Stage 2 has transport
trading partners support electronic
transactions
requirements for Providers/EHR systems
such as use of ONC DIRECT
Improved efficiency as more
HITECH Act added security breach
electronic transactions become
standards based
reporting requirements and increased
penalties for security violations.
Interoperability Initiatives
Technical Impact of Direct Connectivity
CAQH CORE
eHealth Exchange (formerly NwHIN)
ONC S&I esMD has adopted CAQH CORE
Need to support standards in new areas
such as attachments
Need
for reliability and security in
support of the new business transactions
Connectivity
Trust policy frameworks developed by
DirectTrust, white papers by ONC S&I esMD
Author of Record
Government PKI Infrastructures
Federal Bridge is built and operational
supporting cross-certification of trusted PKIs
© 2015 CAQH. All rights reserved.
Many prominent public and private industry initiatives in healthcare connectivity and security were reviewed to identify industry
trends and opportunities for CORE Connectivity Rule Improvement
ONC S&I Electronic
Submission of Medical
Documents (esMD) and
Electronic
Determination of
Coverage (eDoc)
HealtheWay eHealth Exchange
(formerly NwHIN
Exchange)
(included in
Meaningful Use-2)
Industry
Initiatives
ONC DIRECT
(included in
Meaningful Use-2)
NCPDP
Connectivity
Guide
(Retail Pharmacy
based on CORE
Connectivity)
Health Level 7
(HL7)
DirectTrust
(See Appendix Slide
19 for Details on
Initiatives)
PHASE IV Connectivity Subgroup Review Processes
Key Industry
Trends
(See Appendix Slide 26
for a full list of Trends)
Use of SOAP
Envelope
Standard for
Healthcare
Data
Exchange
Use of
X.509
Digital
Certificates
Increased
Emphasis
on Security
Use of
SSLv3 with
movement to
TLS 1.1 and
Higher
© 2015 CAQH. All rights reserved.
Improved Security
(Authentication,
Transport)
Better Interoperability (Single Message
Envelope Standard)
Processing Mode
Definitions for 3rd Set of
ACA Mandated
Transactions
Draft Phase IV CAQH CORE 470
Connectivity Rule v4.0.0
Easier Maintenance using
Companion Payload and
Processing Mode Document
Key Features
Improved Support for
Business Workflows
(Push / Pull)
Improved Rule Language Clarity
based on Implementer Feedback
© 2015 CAQH. All rights reserved.
9
Key Decisions Made By Phase IV
CAQH CORE Connectivity &
Security Subgroup
© 2015 CAQH. All rights reserved.
27
Background:
The Phase II CAQH CORE 270 Connectivity Rule v2.2.0 has two message envelope standards
(SOAP+WSDL and HTTP+MIME). This rule identified convergence to single envelope standard as a
vision for future phases of connectivity based on greater industry experience with implementing the
two message envelope standards specified in the rule.
Subgroup Decision and Rationale:
After extensive analysis CAQH CORE determined that converging on the use of SOAP+WSDL as the
single message envelope standard in this Draft Phase IV CAQH CORE 470 Connectivity Rule v4.0.0
includes these benefits
• relatively simple rule change
• simplicity of rule requirements
• reduction of implementation cost and complexity by having fewer options
• XML based and therefore extensible
• good tooling support for SOAP in most platforms
• alignment with clinical initiatives and industry trends
• significant ROI through improvements in interoperability
• limits variations in use of SOAP for real time and batch processing modes by requiring the
use of MTOM for both processing modes
© 2015 CAQH. All rights reserved.
Background:
The Phase II CAQH CORE 270 Connectivity Rule defined message interactions for conducting Real Time and Batch
interactions. Phase IV preserves the Real Time and Batch interactions while adding some message interactions that could be
used as generic building blocks for supporting current or future transactions. The following interactions were added or fully
specified in this phase:
Generic
Push
Client
Batch Payload
-Transactions
Client submits or “pushes” a Batch Payload to
a Server, then Retrieves
The associated acknowledgment or error
Generic Pull
Client
Subgroup Decision and Rationale:
•
•
Server
Batch Payload –
Transactions
Client retrieves or “pulls” a Batch Payload from
a Server, then submits
The associated acknowledgment or error
Server
ASC X12N 820 and ASC X12 834 transactions need both Generic Push and Generic Pull Batch Interactions to be supported by
the rule.
Provides flexibility to support common industry message interaction patterns for ASC X12N 820 and ASC X12 834, where:
•
Health Plan Sponsor (Client), can “Push” a Batch to a Health Plan (Server)
•
Health Plan (Client) can “Pull” a Batch from Health Plan Sponsor (Server)
© 2015 CAQH. All rights reserved.
10
Technical Requirements of Draft Phase IV CAQH CORE 470 Connectivity Rule
Version 4.0.0 and the Relationship to Requirements of Previous Phases
Connectivity Rule Area
CORE Phase I
Connectivity
Rule
Requirements
CORE Phase II & III
Connectivity Rule Requirements
CORE Phase IV
Connectivity Rule Requirements
Network
Internet
Internet
Internet
Transport
HTTP
HTTP
HTTP
Transport Security
SSL
SSL 3.0 with optional use of TLS 1.x
SSL 3.0, and optionally TLS 1.1 or higher. TLS
1.1 or higher can be used in lieu of SSL 3.0.
Submitter (Originating System
or Client) Authentication
Name/Password
Name/Password or X.509 Certificate
(subject to conformance requirements)
X.509 Certificate based authentication over
SSL/TLS
Envelope and Attachment
Standards
Unspecified
SOAP 1.2 + W SDL and MTOM (for Batch)
or
HTTP+MIME (subject to conformance
requirements)
SOAP 1.2 + WSDL and MTOM (for both Real
Time and Batch)
Envelope Metadata
Unspecified
Metadata defined (Field names, values)
(e.g., PayloadType, Processing Mode,
Sender ID, Receiver ID)
• Metadata defined (Field names, values) (e.g.,
PayloadType, Processing Mode, Sender ID,
Receiver ID)
• FIPS 140-2 compliant implementations can
use SHA-2 for checksum.
Message Interactions/
Routing
Real-time
Batch (Optional if
used)
Real-time
Batch (Optional if used)
• Batch and Real-Time processing
requirements defined for each transaction
• Push and Pull messaging support for 820/834
Payload level Security
Unspecified
Considered and deferred
Considered and deferred
Acknowledgements, Errors
Specified
Enhanced Phase I, with additional
specificity on error codes
Errors updated based on Implementer feedback
Basic Conformance
Requirements for Client and
Server Roles
Minimally specified
Well specified
Considered and deferred to Infrastructure Rules
Response Time
Specified
Maintained Phase I requirements
Companion Implementation
Specified
Enhanced Phase I, with additional
specificity
3G4uidCeORE Technical Workgroup Call
CAQH CORE Connectivity Rule Versions
Graphical View and Comparison
Phase II CORE Connectivity Rule
Maintained Phase I requirements
d.Enhanced Phase I, with additional specificity
Draft
Phase IV CORE Connectivity Rule
to be adopted under the ACA
Mandated under the ACA
Payload(s)
X12 Administrative Transactions
NCPDP, HL7 V2.x or V3 Messages
Other
X12 Administrative Transactions
NCPDP, HL7 V2.x or V3 Messages
Other
Submitter
(Client)
Authentication
Username/Password (WS-Security Token)
X.509 Digital Certificate
X.509 Digital Certificate over SSL/TLS
Processing
Mode/Message
Interactions
Required: Real Time
Optional: Batch
Required: Batch, Generic Push and Pull
Optional: Real Time
Message
Envelope
Metadata
CORE Specified Message Envelope Metadata
CORE Specified Message Envelope Metadata
Message
Envelope(s)
MIME Multipart
SOAP+WSDL (MTOM for Batch only)
Communications
Channel Security
Secure Sockets Layer - (SSLv3 required with optional
use of TLS1.0 or higher)
Transport
HTTP over TCP
Network
Public Internet
SOAP+WSDL
(MTOM for both Real Time and Batch)
Secure Sockets Layer
(SSLv3.0 with optional use of TLS1.1 or higher. Entities
needing higher security can use TLS1.1 in lieu of SSLv3.0)
HTTP over TCP
Public Internet
=Revised from the previous phase

Background:
• Phase II CAQH CORE 270 Connectivity Rule v2.2.0 had the Payload Type Table and
Processing Modes defined as part of the rule document.
• Addressing set of ACA-mandated transactions identified for third set of operating rule
development could benefit from expanding the Payload Type enumeration.
• Change management of the Payload Types Table and Processing Modes would
benefit from de-coupling these from the rule version.

Subgroup Decision and Rationale:
• Use a companion document for the PayloadType table and Processing Modes and
update for the new ACA mandated transactions or other content/transactions.
• The PayloadType table can be updated without updating the entire CORE
Connectivity Rule, making it easier to maintain the rule to address future business
needs. This option increases flexibility by making it easier to add more PayloadType
values.
• Attachment standard(s) has/have not been selected for Federal mandate at this point;
preliminary work in this area may need to be revisited after attachment standards are
selected.
© 2015 CAQH. All rights reserved.
11
Background:
 Addressing set of ACA-mandated transactions identified for third set of operating rule
development requires defining the processing mode requirements for each
transaction
Subgroup Decision and Rationale:
 Subgroup considered several processing mode requirements, and after extensive
discussion and straw polling, subgroup decided on the Processing Mode
requirements listed below:
Transaction
Processing Modes
ASC X12N v5010 837I
Batch Mode Required, Real Time Optional
ASC X12N v5010 837P
Batch Mode Required, Real Time Optional
ASC X12N v5010 837D
Batch Mode Required, Real Time Optional
ASC X12N v5010 278 Request and
Response
Either Real Time or Batch Mode; both modes may be implemented, at
least one mode must be implemented
ASC X12N v5010 820
Batch Mode Required, Real Time Optional
ASC X12N v5010 834
Batch Mode Required, Real Time Optional
© 2015 CAQH. All rights reserved.
Scope: Draft Phase IV CAQH CORE 470 Connectivity Rule
What the Rule Applies To –
•
•
•
•
Layered View
Message Envelope is outside the Message Payload (content), and inside the Transport Protocol envelope
Transport Protocol Envelope corresponds to OSI Model Layer 3 and 4
Message Envelope corresponds to OSI Model Layers 5 and 6
Message Payload (content) corresponds to OSI Model Layer 7
Communications (T ransport) Protocol
Netw ork
Message E nvelope +
Message Metadata
= Public Internet (TCP /IP) - established in
CAQ H CORE Phase I Connectivity
Message Payload (Content)
= HTTP over SSL 3.0, or optionally TLS 1.1 or higher. (HIPAA
covered entities that wish to use stronger security or m ust
also be FIPS 140-2 com pliant m ay im plem ent
TLS 1.1 or higher in lieu of SSL 3.0)
= Message Envelope & Message Metadata
(SOAP + MTOM) – CA QH CORE Phase IV
Connectivity
= HIPAA Adm inistrative Transactions (X12)
HL7 Clinical Messages
Zipped Files
Personal Health Record
Other Content
© 2015 CAQH. All rights reserved.
Rule Applicability to Transactions
Draft Phase IV CAQH CORE
470 Connectivity Rule v4.0.0
Claims
Prior Authorizations
Benefit Enrollments
Premium Payments
HIPAA Covered
Entity
HIPAA Covered
Entity
Phase II CAQH CORE 270
Connectivity Rule v2.2.0
Eligibility Inquiry
Claim Status Inquiry
Electronic Remittance Advice
Phase I/II/III Rules Mandated under ACA
© 2015 CAQH. All rights reserved.
12
Connectivity
Safe Harbor
HTTP 1.1



Health Plan
Other key rule requirements:
•
•
•
•
•
•
•
•
•
•
37
Rule applicable to HIPAA mandated ASC X12N
v5010 837, 278, 834, 820 transactions
Transport Layer Security (SSL minimum/TLS instead
of SSL when required by HIPAA covered entity’s
security policy)
Single Message Envelope Standard (SOAP v1.2)
Single Submitter Authentication Method (X.509)
Normative Message Envelope Metadata
Standard CORE-specified Schema (.xsd)
Standard CORE-specified Web Services Description
Language (.wsdl)
Transaction Specific Required/Optional Processing
Modes
Standard Payload Type Identifiers for each
transaction for each processing mode
Process for maintaining Processing Mode and
Payload Type Identifiers

Provider
Enables trading partners to use different
communications and security methods than
what is specified in rule:
•
HIPAA covered entities must support CORE rule
requirements for real time and batch processing
modes (if that mode is required by the CORE rules)
•
Can offer other communications and security
methods
•
Does not require trading partners to deimplement
any existing connectivity methods not compliant with
CORE rule
© 2015 CAQH. All rights reserved.
© 2015 CAQH. All rights reserved.
Appendix
CAQH CORE Operating Rules
Industry Adoption Update
© 2015 CAQH. All rights reserved.
13
At present, the industry overall is facing several challenges that are critical to consider:


Health Plan
Certification
HIPAA-covered health
plans must be in
compliance with
HIPAA-mandated
transaction standards
and operating rules by
December 31, 2015

ICD-10
Delay
ICD-10 has been delayed to
October 1, 2015, which may
pose a challenge to entities
working to meet the previous
deadline



Lagging
Implementation
CAQH CORE polling
data indicates that a
minority of entities are
still in the process of
implementing the CAQH
CORE EFT & ERA
Operating Rules
The current burden on the industry demonstrates the limited bandwidth entities have to develop and implement
operating rules for remaining transactions. This emphasizes the feasibility of implementing infrastructure rules.
40
© 2015 CAQH. All rights reserved.
•
Voluntary CORE Certification
–
Phase I and II Eligibility and Claims Status CORE Certifications
–
Phase III EFT & ERA CORE Certifications
•
•
•
Polling data from Q1, Q2 and Q3 2014 education sessions shows steady EFT & ERA Operating Rule
implementation progress across all stakeholder group
•
Polling and registration information is always BLINDED and is taken in aggregate to protect personal information
of registrants/attendees
NACHA EFT transaction volume
–
41
A number of entities have completed Phase III CORE certifications with many more in the pipeline. Recent
examples include Centene Corp, Excellus Blue Cross Blue Shield, Horizon Blue Cross Blue Shield of New
Jersey, AultCare, Ventanex, etc.
CORE education session polling on industry status
–
•
Recent certifications include Meditech, Florida Medicaid, MaineCare, Oklahoma Office of Management and
Enterprise Services, etc.
Unlike for other HIPAA transactions, use of the ACH network for CCD+ enables tracking of this
transaction (if entities use trace number)
© 2015 CAQH. All rights reserved.
•
These numbers reflect EFT payments that are clearly identified as healthcare payments by the use of the
specific identifier “HCCLAIMPMT”* in the CCD+ transaction
•
There has been steady growth in the use of CCD+ for healthcare EFT payments with roughly a 200% net
increase in CCD+ volume from the beginning of Q4 2013 to the beginning of Q4 2014
Source: NACHA
2
*NOTE: Some providers are receiving EFT payments without the HCCLAIMPMT identifiers in the CCD+. To identify an EFT payment as a healthcare EFT,
originators of the transaction (i.e. Health Plans/Payers) need to include the HCCLAIMPMT identifier in the CCD+Addendum
**November saw a drop in the total healthcare EFT volumes due to a limited number of processing days (18). The average number of credit transactions
per day, however, was actually higher than October.
10
© 2015 CAQH. All rights reserved.
14
Pre-registration questions were used to identify implementation status and challenges
• All stakeholder types have made great strides in their implementation with more than 50% of all stakeholder types having
either completed implementation or are well on their way towards completion
o Health Plans have had the biggest increase in completed implementations between Q1 and Q3 (+17%).
o PMS/Vendors have increased in all categories from W ell Underway through Completion between Q1 and Q3 (+23% total).
o Clearinghouses still are highest in the key categories of W ell Underway, Nearing Completion or Complete (89% for Q3)
• Resource constraint remains the main challenge to implementation
Not Started
N=925
Planning & Analysis
N=607
Well Underway
N=326
29%
36%
+17
%
15%
-6%
12%
19%
+2
%
21%
26%
Q3 2014
Health Plan/TPA/Payer
Nearing Completion
N=165
48%
51%
+2
%
16%
+13
%
31%
25%
13%
15%
12%
34%
21%
Q1 2014
Complete
N=122
+1
%
18%
13%
Q1 2014
38%
+9
%
53%
18%
N=201
Q3 2014
PMS/Vendor
Q1 2014
+5
%
17%
4%
21%
3%
12%
8%
Q3 2014
Clearinghouse
11
© 2015 CAQH. All rights reserved.
15