CAQH CORE Creates New Rules for Prior Authorization Automation

May 17, 2019 - CAQH’s Committee on Operating Rules for Information Exchange (CORE) recently released Phase V operating rules to move the healthcare industry toward full prior authorization automation.

The new operating rules are the result of a collaborative multi-stakeholder effort to address the burdensome prior authorization process. Approved by nearly 90 percent of voting CAQH CORE participating organizations, including providers and health plans, the rules specifically address prior authorization data content and web portal use.

“Not only do the operating rules announced today represent a foundational step forward in improving the prior authorization process,” Tim Kaja, COO of UnitedHealth Networks and CAQH CORE board vice chair, states in the announcement. “They also signal broad industry commitment to adopting tangible solutions to reduce administrative burdens.”

Prior authorizations are a key utilization management strategy. Health plans use prior authorizations to prevent potentially unnecessary, inappropriate, and unsafe healthcare services.

However, the prior authorization process has created significant administrative burdens, according to providers. The American Medical Association’s 2018 AMA Prior Authorization Physician Survey found that 86 percent of providers say prior authorization burdens are high or extremely high, and the majority of providers (88 percent) feel the burdens have increased over the last five years.

Additionally, 28 percent of providers said the prior authorization process affected care delivery and led to a serious adverse event.

The bulk of prior authorization issues stem from manual processes, CAQH CORE explains. Currently, 88 percent of prior authorizations are either partially or entirely manual, the group reports.

Providers are still using the phone or fax to reply to plan requests for prior authorizations and clinical information, which is taking hours, days, and sometimes weeks for the health plan to respond.

Furthermore, a lack of uniform prior authorization rules adds to provider burdens. Health plans have their own unique rules for submitting prior authorizations and additional clinical information for the requests.

Through Phase V operating rules for prior authorization automation, CAQH CORE intends to “enhance and standardize the data shared between plans and providers, eliminating unnecessary back-and-forth, accelerating adjudication timeframes, and freeing staff resources spent on manual follow-up.”

Specifically, Phase V operating rules will tackle the exchange of clinical information and how providers submit prior authorizations across all plans.

The first rule – “Phase V CAQH CORE Prior Authorization (278) Request / Response Data Content Rule” – focuses on requests for medical services that are pending due to missing or incomplete information. The rule aims to standardize the data related to clinical information sharing so providers and health plans do not need to go back and forth with clinical information requests.

Under the second rule titled “Phase V CAQH CORE Prior Authorization Web Portal Rule,” CAQH CORE addresses the lack of uniformity for data field labels in the prior authorization process. The rule requires the use of the 5010X217 278 Request and Response TR3 implementation names for the web portal data field labels for prior authorizations and referrals.

By standardizing data fields used in web portals, CAQH CORE hopes to reduce the variation in data element names to alleviate the burdens of prior authorization burdens and support technology solutions that reduce the need for providers to submit information to multiple web portals.

Phase V operating rules are a first step for CAQH CORE. The new operating rules provide the foundation on which the group will continue to improve prior authorization automation to reduce provider burden, states Susan Turney, MD, MS, FACMPE, FACP, president and CEO of Marshfield Clinic Health System and CAQH CORE board chair.

“These rules are an important step in addressing the challenges regarding prior authorization, however more work needs to be done to reduce delays in patient care,” she says in the announcement. “CAQH CORE is also working to reduce the timeframe for a prior authorization decision, help providers determine whether a prior authorization is needed, and improve the way attachments and medical documentation are exchanged.”