InstaMed Blog

Recently, we posted a list of five things that payers can do now to prepare for upcoming reform mandates (click here to read the post). This post emphasizes the importance of collaborating with other organizations like clearinghouses, trading partners and vendors, in order to achieve compliance with the mandated CAQH CORE Operating Rules. These relationships are crucial regardless of the approach payers take to achieve compliance.

Below is an outline of the three main models payers can use to meet the upcoming regulations, including how payer responsibilities differ for each and the relationships that will be most important.

Overview of Upcoming Mandated Operating Rules:

Operating Rules: Eligibility and Claim Status

Effective Date: January 1, 2013

Scope of Requirements: More robust eligibility verification and financials, enhanced error reporting and patient identification, companion guides, system availability, response times, and connectivity/security.

Operating Rules: Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA)

Effective Date: January 1, 2014

Scope of Requirements: Uniform use of claim adjustment reason codes (CARCs) and remittance advice remark codes (RARCs), EFT/ERA enrollment standards, EFT/ERA association standards, and claim payment/remittance infrastructure standards.

3 Relationship Models to Achieve Compliance

Note: All graphics are illustrative.

1. Direct

In this model, the payer takes the initiative to meet the Operating Rules on its own and sends compliant data to its trading partners and providers. This model requires the payer to have the necessary IT resources in-house to build the capability to meet requirements.

2. Payer-Hosted Data

In this model, the payer relies on a clearinghouse to maintain compliance, but the data is still hosted by the payer. While the clearinghouse is responsible for managing trading partner relationships and performing translation to meet regulations, the payer still needs to provide the necessary information to the clearinghouse. This model requires the payer and clearinghouse to work closely together.

3. Clearinghouse-Hosted Data

In this model, the payer gives all data files to a compliant clearinghouse and allows the clearinghouse to host the data on its behalf. On the payer side, one of the most important things is making sure that the data sent to the clearinghouse is up to date. Commonly, this model works best for smaller payers.

Leveraging any of these three models will enable payers to achieve compliance with the upcoming mandated Operating Rules. Additionally, compliance gives payers an opportunity to significantly reduce administrative costs through more efficient operations and reduced provider call volume.

For tips and strategies for payers of all sizes to implement Operating Rules, view the presentation from the latest CAQH and InstaMed Webinar Series: click here.

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