48 required system benefit types. This information must be provided in real time, taking no longer than 20 seconds round- trip.
The operating rules for health claim status feature infrastructure requirements that improve connectivity. Further, state
trading partners must provide more patient financials, including year-to-date patient accumulators, also within a 20-second,
round-trip response time.
Both operating rules have processes for improving how patient names are stored and retrieved in trading partner systems,
which will reduce misidentifications and mistaken denials. The
rules also require that an acknowledgment of a request is sent
within a set response time.
The rules set expectations to establish reliability in transactions among all trading partners, Lohse says.
HIM professionals who supply clinical information to payers or clearinghouses and other vendors will now have one definitive way to submit that information, Rode says. “They won’t
have to do it differently for every insurance company or health
plan that comes to them requesting data,” he says.
Other departments in hospitals and doctor offices will also
see improvements. In the admitting and registration departments, patient health plan eligibility information requests will
be standardized and received faster due to the operating rules,
since the rules establish the information to be included in the
response, such as co-pay amounts and patient deductibles, and
how quickly the request must be answered.
“Operating rules address things that the standards have not
traditionally addressed that are more business rules, like response times,” Lohse says, adding, “How good is information on
patient eligibility if you get it after the patient has left the office?”
In addition to the real-time eligibility response, the rules establish when trading partners will be available to respond to requests. Setting universal expectations helps provider organizations, many of whom are open around the clock.
In claims processing departments, the operating rules will improve billing functions, because providers will know the proper
co-pay and deductible while the patient is present, not after the
fact when a follow-up bill would be required. Real-time eligibility checks will reduce claim denials, preventing patients from
receiving unexpected bills and helping providers avoid taking
on bad debt.
CAQH studies show provider groups working with health
plans that voluntarily implemented the CORE operating rules
saw a 10 to 12 percent reduction in claim denials and a 20 percent increase in patients verified for eligibility prior to their
visit, according to Robert Bowman, CAQH CORE manager, who
presented on the operating rules during a CAQH-WEDI audio
seminar in December.
“How good is information on
patient eligibility if you get it after
the patient has left the office?”
Simplification at Last?
USE OF THE operating rules accelerates the availably of
eligibility and benefit information, which in turn enables
real-time eligibility verification for providers. Other business
benefits for providers include:
x Improvements in revenue cycle management, such as
the ability to quickly check patient eligibility and ben-
efits prior to a visit.
x Quick online confirmation of patient insurance and
benefit coverage directly from the payer, which leads
to an immediate improvement in the number of denied
claims and write-offs for uncovered services.
x Faster patient registration at the time of the visit.
Voluntary Adoptions Show Results
x Reductions in provider account receivables, which
help organizations gain operational efficiencies and
x Reduction in phone calls. Spending less time on the
phone with payers allows hospital office staff to focus
on more critical administrative tasks.
BlueCross BlueShield of Tennessee (BCBST) is one organization
that has already gained operational efficiencies and administrative cost savings from implementing operating rules. The payer
has been voluntarily using the CORE operating rules for years
and have seen direct benefits, says Susan Langford, an EDI systems analyst at BCBST. The organization began its implementation of the eligibility and claims status operating rules in 2007.
Real-time electronic transactions have greatly increased, allowing the health plan to instantly provide information to providers on patient eligibility for care either before the patient
arrives or while he or she is receiving care. This has reduced
phone calls, because providers get their results instantly, which
has led to a reduction in operating costs for both BCBST and the
providers it works with.
Use of the rules led to an explosion in the number of electronic
transactions BSBST performed each year. When the health plan
first implemented the CORE operating rules in 2008, it handled
600,000 eligibility and benefit requests electronically. By 2011
that number had risen to 12. 6 million transactions.
Use of the operating rules also ensures providers receive additional financial information such as co-insurance amounts,
co-payment, deductible information, and remaining deductible
amounts. This information allows the provider to know exactly
how much to charge patients while they are in the office, reducing open accounts and the need to collect payment later. It is
also done electronically, without the need to pick up the phone
and ask questions.
For Passport Health Communications, a clearinghouse that
was also an early adopter of the CORE operating rules, the rules
led to additional data and support mechanisms that improved
customer service and gave providers better and more consistent