CAQH CORE Prior Authorization Overview...© 2018 CAQH, All Rights Reserved. April Todd SVP, CAQH...

© 2018 CAQH, All Rights Reserved.

April Todd

SVP, CAQH CORE and

CAQH Explorations

January 31, 2019

CAQH CORE

Prior Authorization

Overview


CAQH CORE Rule DevelopmentCAQH CORE Mission & Vision

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MISSION Drive the creation and adoption of healthcare

operating rules that support standards,

accelerate interoperability and align

administrative and clinical activities among providers, payers and consumers.

VISION An industry-wide facilitator of a

trusted, simple and sustainable

healthcare data exchange that evolves

and aligns with market needs.

DESIGNATION Named by Secretary of HHS to be

national author for operating rules

mandated by Section 1104 of the

Affordable Care Act.

BOARD Multi-stakeholder. Members include health

plans, providers (some of which are appointed

by associations such as the AHA, AMA,

MGMA), vendors, and government entities.

Advisors to the Board include SDOs.


CAQH CORE Rule DevelopmentStreamlining the Administrative Workflow

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Existing CAQH CORE Operating Rules CAQH CORE Operating Rules in Development


Operating Rule Development Process

Identify Opportunities Develop Rules Ballot Participants

Advisory Groups CORE Participants

e.g., Prior Authorization Subgroup,

Claim Status Subgroup, etc.

e.g., Connectivity & Security Subgroup,

Certification/Testing Subgroup, etc.

Subgroups

Rules

Work Group (RWG)

Subgroups

Technical

Work Group (TWG)

e.g., Attachments (Additional

Documentation) Advisory Group.

Advisory Groups research

opportunities for potential rules,

prior to a Subgroup commencing rule

writing. Work Groups vote on draft rules developed by assigned

Subgroup(s). Should the rule have a maintenance component,

the Work Group may convene during maintenance periods to

vote on potential substantive changes to the rule.

Subgroups develop and straw poll draft rules for review by

assigned Work Groups (either RWG or TWG). New Subgroups

form as CAQH CORE rule writing focus changes.

Full CAQH CORE Voting Membership

vote requires for a quorum that 60% of all

Full CORE Voting Member organizations

(i.e., CAQH CORE Participants that create,

transmit, or use transactions) vote on the

proposed rule at this stage with a 66.67%

approval vote.

Once CAQH CORE Participants have

recached quorum, the CAQH CORE Board

will vote for final approval.

CORE Board

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Pilot Testing may occur to evaluate operating rule options and

return on investment (ROI) to address higher impact

opportunities and drive to industry consensus.


CAQH CORE Operating Rule DevelopmentAdopting a Faster Approach

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CAQH CORE Rule DevelopmentProcess for Bringing Rules Forward for Federal Mandatory Adoption

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CAQH CORE Writes

Letter to NCVHSNCVHS Holds Hearing

The NCVHS Subcommittee on

Standards holds hearings on to

gather get industry feedback on the

proposed operating rules.

NCVHS sends a letter to the Secretary

regarding industry feedback given at

the hearing. NCVHS recommends

whether the operating rules should be

mandated.

HHS issues Interim Final Rule (IFR)

to the industry within 90 days of

receiving the NCVHS letter with a 60

day open comment period.

Industry is given 25 months to adopt

the mandated operating rules.

CAQH CORE has been designated by the Secretary of the Department of Health and Human Services (HHS) as the author for federally

mandated operating rules per Section 1104 of the Patient Protection and Affordable Care Act (ACA). Once Operating Rules are approved by the

CORE Board, the following process must occur if the rules are to be mandated.

NCVHS Sends Letter

to Secretary

Expedited Interim Final

Rule MakingFinal Rule Adopted Mandate Implemented

NC

VH

SH

HS

CAQH CORE writes a letter

to NCVHS explaining the

industry need for the

operating rules along with the

CORE Board approved rules.

After the 60 day open comment

period, if no substantial comments

are received, HHS adopts the final

rule and mandates the operating

rule.*

*HHS has the authority to judge whether comments are substantial and whether changes should be made to the final rule.


The Draft Phase V Operating Rules address

needed data content in the prior authorization

transaction and enable greater consistency

across other modes of PA submissions.

CAQH CORE Focus for Prior Authorization

The Phase IV Operating Rule established

foundational infrastructure requirements such

as connectivity, response time, etc. and builds

consistency with other mandated operating

rules required for all HIPAA transactions.

Manual

Partially Automated

Optimized

Entirety of provider and health plan

workflows, including request and

submission, is manual and requires

human intervention, e.g., telephone,

fax, e-mail etc.

Entire prior authorization process is

at its most effective and efficient by

eliminating unnecessary human

intervention and other waste.

Optimized PA process would likely

include automating internal

provider/health plan workflows.

Parts of the prior authorization process

are automated and do not require human

intervention. Typically includes manual

submission on behalf of provider which is

received by health plan via an automated

tool, e.g., health plan portals, IVR, ASC

X12 278 etc.

Au

tom

atio

n S

pectru

m

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Ongoing efforts in 2019 to update the Phase IV

Rule with a timeframe for a completed

response and pilot test rules for a provider to

determine whether an authorization is needed.


Draft Phase V CAQH CORE Prior Authorization Operating Rules

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The Draft Phase V Prior Authorization Rules reduce unnecessary back and forth between providers and health plans.

These efficiencies enable shorter time to final adjudication and more timely delivery of patient care.

Compliance with Data Content Rule

System availability and reporting requirements for a health plan to receive a request, to enable predictability for providers.

Application of standard X12 data field labels to web portals to reduce variation in data elements to ease submission burden

and encourage solutions that minimize the need for providers to submit information to multiple portals.

Confirmation of receipt of a request to reduce manual follow-up for providers.

Consistent patient identification and verification to reduce common errors and associated denials.

Consistent use of diagnosis, procedure and revenue codes to allow for full health plan adjudication.

Consistent use of codes to indicate errors/next steps for the provider, including need for additional documentation.

Detection and display of code descriptions to reduce burden of interpretation.

DR

AF

T

Re

qu

ire

me

nts

DRAFT

RULE

Prior

Authorization

Web Portals

DRAFT

RULE

5010X217 278

Request and

Response

Data Content

DR

AF

T

Re

qu

ire

me

nts


Prior Authorization Process CAQH CORE Operating Rules Address Significant Pain Points in the Prior Authorization Process

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Part B: Provider & Health Plan

Exchange Information

Provider submits PA Request; Health

Plan receives and pends for additional

documentation; Provider resubmits

Part A: Provider Determines if

PA is Required & Info Needed

Provider identifies if PA is required;

Provider collects information required

for PA request

Part C: Health Plan Reviews &

Approves/Denies PA Request

Health Plan reviews PA request and

sends final response; Provider receives

final response

Major Parts of the Prior Authorization Process

Consistent patient identification and

verification Consistent use of diagnosis,

procedure and revenue codes

Consistent use of codes to indicate

errors/next steps for the provider,

including additional documentation

Detection and display of code

descriptions to reduce provider

burden of interpretation

Application of standard X12 data

field labels to web portals

Confirmation of receipt of PA

submission

System availability requirements

Requirement in CAQH CORE Phase V Operating Rule – Nearing Implementation Stage in Q2 2019

Requirement in CAQH CORE Phase IV Operating Rule – Available for Use

Consistent connectivity and security

methods between trading partners

Standard Companion Guide format

Detection and display of code

descriptions to reduce provider

burden of interpretation.

Consistent connectivity and security

methods between trading partners


Pain Point: With the lack

of robust information in the

response, providers

telephone the plan to

determine what is needed,

or resubmit with incorrect/

incomplete information,

resulting in additional

pends or delays in care.

Spotlight on Phase V CAQH CORE Operating Rule Requirement Requesting Additional Documentation for a Pended Response

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* Depicts the most common path for the PA process to follow. Some health plans are able to automate the adjudication process when no additional documentation is needed.

1

2

Pain Point: Not enough

detail included in the

response to know why the

request was pended and

what information is

needed to resolve the

pend.

Easing the burden of

interpretation on the provider

by standardized and uniform

code use and requiring display

of code descriptions. Provider

submits more complete requests,

resulting in fewer pends, iterative

requests for more information,

and denials.

Part B: Provider & Health Plan Exchange Information

The CAQH CORE Prior Authorization (278) Request / Response Data Content Rule targets one of the most significant problem areas in the prior authorization process:

requests for medical services that are pended due to missing or incomplete information. The operating rule reduces the unnecessary and manual back and forth

between providers and health plans by calling for the uniform use of standard codes to streamline communication electronically and reduce time to final

determination and patient care.

When a PA Request is pended

for additional documentation,

rule requires the use of specific

standard codes in conjunction

with detailing the type(s) of

documentation required for

the PA.


Prior Authorization Process Potential Requirements to Pilot

* Depicts the most common path for the PA process to follow.

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Part B: Provider & Health Plan

Exchange Information

Provider submits PA Request; Health

Plan receives and pends for additional

documentation; Provider resubmits

Part A: Provider Determines if

PA is Required & Info Needed

Provider identifies if PA is required;

Provider collects information required

for PA request

Part C: Health Plan Reviews &

Approves/Denies PA Request

Health Plan reviews PA request and

sends final response; Provider receives

final response

Major Parts of the Prior Authorization Process*

Consistent use of codes to indicate

errors/next steps for the provider,

including additional documentation.

Future CAQH CORE Requirements & Potential Pilot Opportunities

Determine whether a particular

service requires a PA.

Timeframe for the health plan to send

back a final determination to the

provider after submission of all

necessary information for a health plan

to adjudicate a PA request.

Determine what additional

documentation is required for the PA

request to be fully adjudicated by the

health plan.

Requirement in CAQH CORE Phase V Operating Rule – Nearing Implementation

Requirement in CAQH CORE Phase IV Operating Rule – Available for Use


Next Steps for Requirements Development & Pilot TestingGet Involved

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Guiding Principle of Pilot: Develop, test, and track impact of requirements that are flexible to support various

connectivity and security methods, and work in concert to add value to existing and emerging standards.

CAQH CORE is engaged in initial discussions with industry partners interested in developing and piloting new and

potential CAQH CORE Operating Rule requirements for prior authorization. Participation in this effort entails:

▪ Scoping and developing the requirements or combination of requirements to test in a pilot.

▪ Identifying primary measures of success for the pilot.

▪ Providing pre and post data on the measures.

▪ Implementing the requirements and providing data during a limited time period for the pilot.

CAQH CORE Prior Authorization Overview...© 2018 CAQH, All Rights Reserved. April Todd SVP, CAQH...

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Transcript of CAQH CORE Prior Authorization Overview...© 2018 CAQH, All Rights Reserved. April Todd SVP, CAQH...