Unlocking Efficiency in Healthcare: CAQH Core's Market-Based Review

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Unlocking Efficiency in Healthcare: CAQH Core's Market-Based Review

Table of Contents

  1. Introduction
  2. Understanding CAQH Core
  3. The Core Code Combinations Maintenance Process
  4. The 2021 Market-Based Adjustment Service
  5. The Mission and Vision of CAQH Core
  6. Writing Operating Rules for HIPAA Mandated Transactions
  7. The Infrastructure and Data Content of EFT and ERA Transactions
  8. The Role of Core Code Combinations in Reporting Adjustments
  9. Conducting the Market-Based Review
  10. How to Submit Adjustments and Enhancements
  11. Frequently Asked Questions

Introduction

Welcome to this training session on the 2021 market-based review presented by CAQH Core. In this session, we will provide an overview of the core code combinations maintenance process and discuss the specifics of the 2021 market-based adjustment service.

Understanding CAQH Core

CAQH Core is a mission and vision-driven company that focuses on developing operating rules to support standards, accelerate interoperability, and Align administrative and clinical activities in the healthcare industry. Led by a board consisting of health plans, providers, vendors, clearinghouses, and government entities, CAQH Core works towards providing solutions that are equitable and efficient for the entire industry.

The Core Code Combinations Maintenance Process

CAQH Core has developed specific requirements for various types of interactions between providers and health plans, known as rule sets. These rule sets include operating rules for eligibility and benefits, claim status, payments and remittance advice, and other mandated transactions. The core code combinations maintenance process ensures that these code combinations are maintained and updated as needed by the industry. The process involves regular meetings and revisions by the code authors and the core code combinations task group.

The 2021 Market-Based Adjustment Service

The market-based adjustment service is a biennial opportunity for the industry to review and update the core code combinations to meet the Current business needs. The survey seeks input from entities that Create, use, or transmit HIPAA-covered transactions. Participants can submit adjustments, including additions, removals, or relocations of code combinations. It is important to support these submissions with evaluation criteria, business case information, and real-world usage data. The submission period for the survey is open for 60 days, and the results will be shared with the industry after review by the task group.

The Mission and Vision of CAQH Core

CAQH Core's main mission is to ensure the use of electronic standards in a manner that is effective and efficient for the healthcare industry. They facilitate collaboration among industry stakeholders to identify and address industry problems. The vision of CAQH Core is to create a more streamlined and automated revenue cycle that reduces costs and improves efficiency.

Writing Operating Rules for HIPAA Mandated Transactions

CAQH Core has written operating rules for various HIPAA-mandated transactions, including eligibility and benefits, claim status, payments and remittance advice, and prior authorization. These operating rules aim to improve the efficiency of these interactions by reducing reliance on manual processes and enabling automation.

The Infrastructure and Data Content of EFT and ERA Transactions

CAQH Core has developed infrastructure and data content rules for electronic funds transfer (EFT) and electronic remittance advice (ERA) transactions. The infrastructure rules include guidelines for connectivity, security requirements, and reassociation of EFT and ERA transactions. The data content rules focus on the uniform use of codes and works to ensure that health plans use specific code combinations to report claim adjustments, denials, and payments.

The Role of Core Code Combinations in Reporting Adjustments

Core code combinations play a crucial role in reporting adjustments to providers. By keeping the code combinations consistent within core-defined business scenarios, providers can easily understand the reasons behind claim adjustments, denials, or payments. The market-based review helps to ensure that the code combinations accurately reflect the business needs of the industry.

Conducting the Market-Based Review

The market-based review occurs every other year and involves collecting feedback from the industry on the core code combinations. Participants can submit adjustments, enhancements, and additional data to support their submissions. The results of the survey are reviewed by the task group to determine whether changes should be made to the code combinations.

How to Submit Adjustments and Enhancements

To participate in the market-based adjustment service, organizations should Gather their team and review their billing and A/R data to identify code combinations that cause confusion or require clarification. Real-world data can be collected to strengthen submissions. The adjustments can be submitted using the online survey tool, providing information on the business Scenario, Type of adjustment, related codes, and supporting evaluation criteria.

Frequently Asked Questions

  1. Where can I see a completed market-based adjustment survey?
  2. Will the CAQH Core code combinations specify if a CARC should be used for denial, payment, or informational purposes?
  3. Has the industry considered including codes such as non-payable allowed amount and payable allowed amount?
  4. Are there any features that allow providers to submit additional documentation after a claim has been submitted and unpaid?
  5. When will the results of the market-based review be shared with the industry?

These are just a few of the frequently asked questions. For more information and assistance, please contact core@caqh.org.

[Additional notes for the content Writer: Please proceed with writing the full article based on the table of contents and guidelines provided.]

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