Electronic Claims Submission Billing Certification (Recommendation)

History

Per the Preliminary ARRA 2011 Interoperability Test Guide, to document compliance we must provide proof of CAQH CORE, EDIFECS, CLAREDI or equivalent 3rd party certification of standards compliance as well as demonstrate the ability to submit claims electronically to public and private payers. We must also have the ability to report % claims submitted electronically to all payers. Quote from the new IFR.pdf document - “As a supporting implementation specification for the eligibility for health plan transactions HIPAA transaction standard we have also adopted the requirements of Phase 1 of the Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE). We request public comment on the HIT industry’s experience using CAQH CORE Phase 1 with adopted HIPAA transactions standards.” It may behoove us to seek at least CORE Phase I certification, more details below on all three parties listed in the Preliminary ARRA 2011 Interoperability Test Guide.

CORE Overview

CAQH launched the Committee on Operating Rules for Information Exchange (CORE) with the vision of giving providers access to eligibility and benefits information before or at the time of service using the electronic system of their choice for any patient or health plan. CORE is more than 115 industry stakeholders – health plans, providers, vendors, CMS and other government agencies, associations, regional entities, standard-setting organizations and other healthcare entities. CORE participants maintain eligibility and benefits data for more than 130 million commercially insured lives plus Medicare and Medicaid beneficiaries. Working in collaboration they are building consensus on a set of operating rules that will: 1. Enhance interoperability between providers and payers 2. Streamline eligibility, benefits, and claim data transactions 3. Reduce the amount of time and resources providers spend on administrative functions – time better spent with patients.

EDIFECS Overview – CORE Phase I and Phase II Testing

Edifecs has been selected as an approved CORE testing vendor by CAQH. The Edifecs CORE testing service will allow entities interested in becoming CORE-certified to perform the requirements necessary to show implementation of all applicable CORE Rules. CAQHs Step-by-step CORE Certification Process page provides detail as to how to become certified with CORE. The Edifecs CORE Testing suite has been setup to allow stakeholders to perform the compliance steps for all of the rules and test scripts required by CORE. Edifecs is providing CORE testing at no cost to CORE stakeholders.

CLAREDI Overview – CORE Phase I Testing

The Claredi CORE site allows you to conduct a comprehensive test of your eligibility system to make sure you meet the equirements specified by CORE. Claredi has created a process that takes you step by step through the CORE requirements. This process is designed to help you obtain the CORE certification and uncover any potential problems and differences between your eligibility system and the CORE requirements. At the end of the certification process you will be ready to submit your CORE Seal application with all appropriate documentation, included testing results, to CORE as the final step in seeking CORE certification. This web site will guide you, step by step, in meeting each of the certification criteria.

• CORE Phase I Certification Testing User Manual