CAQH CORE Releases EFT and Remittance Advice Transactions, Public Comment Period Opens

Instant Information For Hospitals, Doctors, Patients, and Health Plans

“Imagine an American healthcare system where doctors and hospitals can instantly verify patient insurance information before or at the time of care.  From any health plan.  With any electronic system…”  These words are the vision of the CORE (“The Committee on Operating Rules for Information Exchange”) which is backed by several health plans, providers, agenncies, and vendors.  Among its initiatives are a Universal Provider Datasource (UPD), real-time electronic funds transfer for claims, real-time status, real-time eligibility at the point of care.

Banks HIPAA status  – Beginning the Convergence of Banking and Healthcare

Prior postings to the Federal Register dating back to first quarter of 2012 have noted that banks will be involved in the data interchange between plans and providers as they begin to support EFT.  This makes the bank in effect a clearing house, subject to HIPAA regulations regarding privacy and security.

Standards such as this will start to integrate electronic funds and protected patient data requiring new standards and consideration of new issues.

From the CAQH letter to HHS:

“Some financial institutions will continue to translate nonstandard payment/processing information received from health plans into the CCD format… become de facto health care clearinghouses as defined by HIPAA. To the extent, however, those entities engage in activities of a financial institution, … they will be exempt from having to comply with these HIPAA standards with respect to these activities.”

CAQH Releases CORE IFR for EFT and Remittance

CAQH CORE announced that the Centers for Medicare and  Medicaid Services (CMS)  issued an Interim Final Rule (IFR) with comment period – Administrative Simplification: Adoption of Operating Rules for Health Care Electronic Funds Transfers (EFT) and Remittance Advice Transactions.

Health plans Backing CORE

Aetna, Cigna, several state Blue Cross Blue Shield plans (Blue Cross Blue Shield of Michigan, CareFirst BlueCross BlueShield, Excellus Blue Cross Blue Shield, Independence Blue Cross Healthcare Service Corporation and Wellpoint, which own several Blue plans), United Health.

Providers Backing CORE

Leading providers who back CORE include Adventist,  Dignity Health, Cedars-Cinai, Healthcare Partners, Mobility Medical, New York Presbyterian, North Shore Health System, Physician Healthcare Network, Spectrum LaboratyrNetwork, and University Physicians.

Standards Groups and Associations Backing Core

AHIP, ASC X12, Blue Cross and Blue Shield Association (BCBSA), Delta Dental PLans, HL7, Healthcare Association of New York State, Healthcare Billing and Management Association, LINXUS, National Committee for Qualty Assurance (NCQA), National Council for Prescription Drug Programs (NCPDP), JN Shore (WEDI Affiliate) Private Sector Technology Group, Utah Health Information Network (UHIN).

Government Agencies Backing Core

Louisiana Medicaid – Unisys, Michigan Department of Community Health, Minnesota Department of Human Services, Oregon Department of Human Resources.

Vendors Backing CORE

CareMedica Systems, Electronic Data Systems (EDS), Electronic Network Systems (ENS, owned by Optum), First Data, Gateway EDI, Healthare Adminstration Technolgies, IBM, Optum, InstaMed, mPay Gateway, National Account Service Comany (NASCO), NetGen Healthcare Information Systems, Payerpath (Misys), Recondo, Secure EDI Health Group, and TriZetto.

Realizing Benefits of Core Require Updated Healthcare IT Infrastructure

CORE will have the effect of reducing lengthy waiting periods for patients who wish to know if they are eligible, what the status of a claim is, and what their out of pocket reimbursement will be and when it will be received.  It will force health plans and providers to replace decades old mainframes that use ‘batch’ oriented mechanisms to answer these and other questions with near real-time capabilities.   In the future, CORE will help move healthcare to more of a retail experience for the consumer, “…at the point of care.”

The IFR adopts the Phase III CORE EFT & ERA Operating Rule Set, including:

  • EFT Enrollment Data Rule
  • ERA Enrollment Data Rule
  • EFT & ERA Reassociation (CCD+/835) Rule
  • Uniform Use of CARCs and RARCs (835) Rule, with the CORE-required Code Combinations for CORE-defined Business Scenarios
  • Health Care Claim Payment/Advice (835) Infrastructure Rule (except for the batch acknowledgement requirements)

The Catch – Will Health Plans and Other Healthcare Organizations be Able to Support CORE any time Soon?

Third parties who provide clearing house services and claims settlement for out of network, in-network and pharmacy claims are proving they can deliver faster claims processing and daily if not real-time claims status.  Would they be in a better position to provide these services?  Similarly there are near real-time eligibility companies who have sprung up to solve these problems for their clients.  New more innovative companies may be in the best position to realize the dream of CORE and provide it as a service to some of the health plans and providers who back this initiative.

Public comment may be submitted at until October 9, 2012.  The direct link to the published document is here:!documentDetail;D=HHS_FRDOC_0001-0461

Michael F. Arrigo

Michael is Managing Partner & CEO of No World Borders, a leading healthcare management and IT consulting firm. He serves as an expert witness in Federal and State Court and was recently ruled as an expert by a 9th Circuit Federal Judge. He serves as a patent expert witness on intellectual property disputes, both as a Technical Expert and a Damages expert. His vision for the firm is to continue acquisition of skills and technology that support the intersection of clinical data and administrative health data where the eligibility for medically necessary care is determined. He leads a team that provides litigation consulting as well as advisory regarding medical coding, medical billing, medical bill review and HIPAA Privacy and Security best practices for healthcare clients, Meaningful Use of Electronic Health Records. He advises legal teams as an expert witness in HIPAA Privacy and Security, medical coding and billing and usual and customary cost of care, the Affordable Care Act and benefits enrollment, white collar crime, False Claims Act, Anti-Kickback, Stark Law, physician compensation, Insurance bad faith, payor-provider disputes, ERISA plan-third-party administrator disputes, third-party liability, and the Medicare Secondary Payer Act (MSPA) MMSEA Section 111 reporting. He uses these skills in disputes regarding the valuation of pharmaceuticals and drug costs and in the review and audit of pain management and opioid prescribers under state Standards and the Controlled Substances Act. He consults to venture capital and private equity firms on mHealth, Cloud Computing in Healthcare, and Software as a Service. He advises ERISA self-insured employers on cost of care and regulations. Arrigo was recently retained by the U.S. Department of Justice (DOJ) regarding a significant false claims act investigation. He has provided opinions on over $1 billion in health care claims and due diligence on over $8 billion in healthcare mergers and acquisitions. Education: UC Irvine - Economics and Computer Science, University of Southern California - Business, studies at Stanford Medical School - Biomedical Informatics, studies at Harvard Medical School - Bioethics. Trained in over 10 medical specialties in medical billing and coding. Trained by U.S. Patent and Trademark Office (USPTO) and PTAB Judges on patent statutes, rules and case law (as a non-attorney to better advise clients on Technical and Damages aspects of patent construction and claims). Mr. Arrigo has been interviewed quoted in the Wall Street Journal, New York Times, and National Public Radio, Fortune, KNX 1070 Radio, Kaiser Health News, NBC Television News, The Capitol Forum and other media outlets. See and for more about the company.

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