Healthcare IT Interoperability, EHR interoperability, Hospital Interoperability

Private Payers News

Aetna, Cigna Join 300 Organizations in CAQH CORE Phase III

Two of the country’s largest private payers joined the CAQH CORE collaboration on improving interoperability even with a shaky ACA future.

Aetna and Cigna join CAQH CORE

Source: Thinkstock

- A new press release confirmed that Aetna and Cigna are now certified under CAQH CORE Phase III Operating Rules. Their certification will provide the entire CAQH CORE collaboration interoperable access to two of the largest payers in the US.

Under the Affordable Care Act (ACA), payers, providers, and healthcare vendors are required to operate under CORE standards and share data under a unified electronic system. CAQH CORE, as designated by the Department of Health and Human Services (HHS), created four phase rules that are federally mandated under HIPAA compliance.

While the ACA helped influence CORE standards, many payers opted into the program because of the advantages high quality healthcare interoperability brings to administering large amounts of data. The advantages include moving from manual systems to respond to billions of health plan transactions and reducing administrative costs.

Even with a shaky ACA future, interoperability is still a sought-after goal for many payers.

With having two of the largest payers certified under Phase III before the implementation of Phase IV in the spring of this year, CAQH CORE presents an opportunity to make impactful data sharing systems with required reporting methods and timeframes for data sharing.

"For Aetna, becoming CORE Certified has been a priority," said Lou Ursini, Chair of the CAQH CORE Board and head of IT program delivery and testing for Aetna. "Completing certification Phases I, II and III helps us both push the industry forward and ensure that all of our business partners – especially healthcare providers – receive the benefits of the rules."

The adoption of the two payers adds more streams of data to an already extensive network built upon CAQH CORE’s Phase I and II programs.

According to the CAQH CORE progress report, in the first two phases CORE certified health plans accounted for 76 percent of commercially insured individuals and 46 percent of publicly insured individuals.

“The momentum of CORE Certifications reflects the increased commitment and mounting success of a multitude of players in healthcare to effectively share electronic data in secure and meaningful ways,” the report concluded.

Before the joining of Aetna and Cigna, Phase III coverage only consisted of 27 percent  of commercially insured people and 25 percent of publicly insured individuals. The progress report suggests that there needs to be a more concentrated effort for CORE adoption for both public and private payer/provider adoption.

“However, there is still more work to be done for the healthcare system to obtain the full benefits,” the report stated. “For health plans, the operating rules mean greater efficiency and security. Provider organizations using systems that adhere to the operating rules face fewer IT and administrative hassles and are able to dedicate more resources to patient care.”

More than 300 organizations have joined CAQH CORE because of generally smooth operational procedures. Voluntary methods for testing have helped various healthcare stakeholders such as payers, providers, vendors, and clearinghouses to demonstrate their adherence to the CORE standards and rules for data exchange.

CAQH CORE has been successful in providing the means for healthcare interoperability. The addition of Cigna and Aetna is a positive step towards that goal.

"In a changing healthcare policy environment, CORE Certification is more important than ever," said Gwendolyn Lohse, CAQH CORE Managing Director. "For the business of healthcare to evolve as a working whole – and do so more efficiently than it does today – all parties need to follow the same fundamental rules, and CORE Certification enables everyone to have confidence that this is happening."

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