CAQH [legal name: Council for Affordable Quality Healthcare] is an American non-profit organization established in 2000 and based in Washington, DC. Its mission is to accelerate the transformation of business processes in healthcare through collaboration, innovation and a commitment to ensuring value across stakeholders, including healthcare providers, trade associations, and health plans.
CAQH has created a number of initiatives to streamline the business of healthcare: CAQH CORE®, CAQH Solutions™ and CAQH Explorations™. CAQH Solutions include CAQH ProView™, SanctionsTrack®, EnrollHub® and COB Smart®. CAQH Explorations™, the research arm of CAQH, includes the CAQH Index®.
Established in 2005, CAQH CORE (the Committee on Operating Rules for Information Exchange) is a multi-stakeholder collaboration of more than 140 organizations – providers, health plans, vendors, government agencies and standard-setting bodies – committed to the development and adoption of national operating rules for administrative transactions within the healthcare industry. CAQH CORE participating organizations include health plans representing more than 75% of commercially insured lives, plus Medicare and Medicaid beneficiaries.
The Affordable Care Act (ACA) mandated better standardization of the electronic HIPAA administrative and financial transactions between providers and insurers. In 2012, CAQH CORE was designated by the Department of Health and Human Services (HHS) as an author for ACA-mandated operating rules. Operating rules support a range of existing standards to make electronic data transactions more predictable and consistent, regardless of technology used.
The CAQH CORE process centers on an integrated model consisting of rule development, testing and certification, outreach and tracking measures. In 2012-2013, the organization released operating rules for four transactions now federally mandated for all HIPAA-covered entities: eligibility, claim status, electronic funds transfer and remittance advice (EFT/ERA). In 2015, it announced additional voluntary operating rules for healthcare claims, prior authorization, employee premium payment and employee enrollment and disenrollment.
To drive and track market adoption, CAQH CORE offers a voluntary certification program so organizations can demonstrate that they have adopted and are adhering to the operating rules. Organizations that create, use or transmit administrative healthcare data (such as health plans, healthcare providers and vendors) can earn CORE Certification. In a January 2014 proposed rule, HHS recommended CAQH CORE as the administrator for HHS-required certification of health plans.
CAQH has developed several collaborative Solutions to address the need of the healthcare industry to reduce business costs and inefficiencies.
Launched in 2002 and formerly known as the Universal Provider Datasource®, CAQH ProView is used by more than 1.3 million healthcare providers to self-report professional and demographic information. Health plans, hospitals and provider groups may utilize this information for provider credentialing, network directories and claims payments. Use of CAQH ProView reduces time and resources needed for these processes; it can also minimize manual error and reduce duplicative paperwork and administrative costs.
SanctionsTrack, an add-on feature to CAQH ProView, is an automated, continuous sanctions monitoring solution that reviews multi-state information on provider licensure disciplinary actions. SanctionsTrack helps organizations eliminate redundant data gathering and follow-up research for sanction notices.
Increasing adoption of electronic funds transfer (EFT) and electronic remittance advice (ERA) enrollment continues to challenge healthcare organizations. To simplify this process, CAQH launched EnrollHub in 2013 to offer providers a single enrollment process for EFT and ERA with multiple payers. Providers complete the standardized, electronic enrollment form and select the health plans with which they do business. CAQH notifies the health plans of the enrollment, and the health plan then accesses the provider’s banking information.
Used by health plans and clearinghouses, COB Smart helps identify instances of patients with overlapping insurance coverage. This CAQH Solution determines which individuals have benefits that should be coordinated, as well as which health plans are primary and secondary insurers, so that corresponding claims can be processed correctly the first time. COB Smart launched in 2014.
CAQH Explorations is the research arm of the CAQH. It includes the CAQH Index, which tracks and reports progress by the healthcare industry in its ongoing transition from manual to electronic administrative transactions. The findings of the CAQH Index are based on an analysis of an extensive dataset of administrative transactions between providers and health plans. The 2014 CAQH Index reported that providers and health plans could potentially save $8 billion if they fully adopted electronic transactions.
Members include Aetna, Anthem, America’s Health Insurance Plans, AultCare, the BlueCross BlueShield Association, Blue Cross Blue Shield of Michigan, BlueCross BlueShield of North Carolina, BlueCross BlueShield of Tennessee, CareFirst BlueCross BlueShield, Cigna, Health Net, Horizon Blue Cross Blue Shield of New Jersey, Kaiser Permanente, and UnitedHealth Group.