Phase III CAQH CORE Certification for Efficient Electronic Transactions

CAQH CORE Seal Health Plan

IEHP has achieved Phase III certification for CAQH, Council for Affordable Quality Healthcare, and CORE, Committee on Operating Rules for Information Exchange.

In order to streamline provider payment and claim reconciliation, these operating rules establish national expectations for the flow and format of electronic funds transfer (EFT) and electronic remittance advice (ERA). The healthcare industry currently conducts billions of these transactions every year, with many still conducted manually. The operating rules drive the industry changes necessary to make electronic transactions as seamless as possible.  

CAQH CORE Certification confirms that IEHP can exchange electronic healthcare information for EFT and ERA in conformance with the Phase III CAQH CORE Operating Rules. Use of the rules by IEHP will support more accurate and efficient healthcare payment and claims processing. 

“IEHP is a forward-looking organization, and this certification is a testament to that,” said Dr. Bradley Gilbert, IEHP chief executive officer. “It also reflects our latest efforts to integrate new technology and efficiency, especially as it bolsters our collaboration with our providers.” 

The Phase III rules require a standard method of enrolling healthcare providers in EFT and ERA; ensure the re-association between the two transactions; specify the codes that health plans may use when telling a provider why a claim has been adjusted or denied; and detail the system infrastructure requirements to electronically process an ERA quickly and consistently.

IEHP is committed to providing our participating providers with the best possible solutions to support their administrative needs. We provide electronic transactions compliant with the CAQH CORE, Operating Rules for Eligibility and Benefits Request and Response (270/271), Claim Status Request and Response (276/277) as well as Electronic Remittance Advice (ERA). IEHP’s use of secure electronic transactions can result in accurate, time saving solution for our providers.

In an effort to ensure that large amounts of data can be shared electronically across the healthcare system in a fast and efficient way, the Affordable Care Act (ACA) mandated national operating rules for HIPAA administrative transactions. The Department of Health and Human Services (HHS) selected CAQH CORE as the authoring entity to develop these operating rules, which specify the actions needed to ensure uniform, reliable electronic data transmission. 

To drive and track market adoption, CAQH CORE offers a voluntary certification program, widely viewed as the industry “gold standard.” CAQH CORE Certification enables organizations to demonstrate they have adopted and are adhering to the operating rules and their underlying standards. The CAQH CORE Certification seal was awarded after Inland Empire Health Plan successfully completed testing by an independent CORE-certified testing vendor.

According to the Centers for Medicare & Medicaid Services, over ten years the potential net savings to the healthcare system, primarily physician practices, from health plan use of EFT and ERA operating rules ranges from $300 million to $3.3 billion.

“By completing Phase III CORE Certification, Inland Empire Health Plan is supporting national expectations to deliver a connected and clear set of electronic payments and remittances to every health care provider working with them,” said Gwendolyn Lohse, deputy director of CAQH and managing director of CAQH CORE.