Coalition works on third set of standards for claims processing

Health plans are moving to the next phase of standardizing the way they report eligibility and pay claims, continuing a process begun in 2005.

The Committee on Operating Rules for Information Exchange (CORE) initiative is a project of the Washington, D.C.-based Council for Affordable Quality Healthcare, a coalition of health plans. The group is developing Phase III of its standards for health plans.

Six health plans are currently certified as complying with Phase I, and CAQH expects to offer certification for Phase II in 2009, spokesman Chris McNamara said.

Aetna, AultCare, BlueCross BlueShield of North Carolina, BlueCross BlueShield of Tennessee, Health Net and WellPoint are Phase I certified, he said.

The American Medical Association in October 2008 announced its support of the CORE initiative, noting that the process complements the AMA's Heal the Claims campaign launched last year.

The American Academy of Family Physicians and the American College of Physicians also endorsed the CORE process.

The AMA in December 2008 submitted a list of recommendations for Phase III of the CORE rules that echoed the goals of the Heal the Claims campaign.

The AMA recommended that:

• Information such as the fee schedule, patient responsibility for deductible or co-payment and the entity responsible for paying for a service all be included in the response to an eligibility check.
• The allowed amount, "class of contract" and date of claim receipt be included in every payment or remittance advice.
• Current standards be expanded to improve the clarity of payments and remittance notices and consistency between payers remittance codes.

The Heal the Claims campaign began at the AMA's 2008 Annual Meeting with the release of a scorecard that found enormous waste created by confusing, redundant and slow claims payment processes.