CAQH CORE Operating Rules for Prior Authorization &amp; Referrals

Type	Standard / Implementation Specification	Standards Process Maturity	Implementation Maturity	Federally required	Test Tool Availability
Operating Rules	CAQH CORE Prior Authorization & Referrals (278) Data Content Rule Version PA.1.0	Final	Production	No	Yes^$
Operating Rules	CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule Version PA.3.0	Final	Production	No	Yes^$
Operating Rules	CAQH CORE Prior Authorization Web Portal Rule Version PA.1.0	Final	Production	No	Yes^$
Operating Rules	CAQH CORE Attachments Prior Authorization Data Content Rule Version PA.1.0	Final	Production	No	Yes^$
Operating Rules	CAQH CORE Attachments Prior Authorization Infrastructure Rule Version PA.1.0	Final	Production	No	Yes^$

Limitations, Dependencies, and Preconditions for Consideration	Applicable Security Patterns for Consideration
Operating rules for HIPAA standard transactions were added as a requirement of the Patient Protection and Affordable Care Act of 2010, under Section 1104, Administrative Simplification. Operating rules are intended to support and enhance the use of standard transactions. They may include certain requirements to help implement the transaction in a more uniform way between health plans and providers, and to ensure a more complete set of information in the response. The CORE Prior Authorization and Referrals Operating Rules are available for voluntary use by covered entities. In 2022, the CORE Operating Rules for Prior Authorization and Referrals were updated to support the electronic exchange of attachments and medical information. CORE Operating Rules for Eligibility & Benefits further support streamlined prior authorization by requiring health plans and their agents to indicate whether a service requires prior authorization during eligibility verification in real-time, at the point-of-care. Testing or certification with operating rules is voluntary and available through CORE. CORE maintains free tools to support operating rule implementation. Additionally, CORE offers educational webinars on its website.	Feedback requested.

Limitations, Dependencies, and Preconditions for Consideration

Applicable Security Patterns for Consideration

Operating rules for HIPAA standard transactions were added as a requirement of the Patient Protection and Affordable Care Act of 2010, under Section 1104, Administrative Simplification.
Operating rules are intended to support and enhance the use of standard transactions. They may include certain requirements to help implement the transaction in a more uniform way between health plans and providers, and to ensure a more complete set of information in the response.
The CORE Prior Authorization and Referrals Operating Rules are available for voluntary use by covered entities.
In 2022, the CORE Operating Rules for Prior Authorization and Referrals were updated to support the electronic exchange of attachments and medical information.
CORE Operating Rules for Eligibility & Benefits further support streamlined prior authorization by requiring health plans and their agents to indicate whether a service requires prior authorization during eligibility verification in real-time, at the point-of-care.
Testing or certification with operating rules is voluntary and available through CORE. CORE maintains free tools to support operating rule implementation. Additionally, CORE offers educational webinars on its website.

Feedback requested.

Comment

Submitted by mphillips@caqh.org on 2024-08-09

CAQH CORE 2025 ISA Updates

Recommended updates to Operating Rules for Prior Authorizations and Referrals are included on pages 9-10 of the attached document.

CORE Submission_2025 ISA Updates_PriorAuth.pdf

Submitted by mphillips@caqh.org on 2023-10-06

Updates to CORE PA and Referrals Page

CORE recommends several substantive content and clarifying changes to the CAQH CORE Operating Rules for Prior Authorization and Referrals website. The changes are outlined on Page 6-7 of the letter found at this link: CORE Submission for the 2024 ISA Open Comment Period.

Submitted by shellyspiro on 2023-10-02

Pharmacy HIT Collaborative (PHIT) comment

PHIT supports NCPDP’s recommendation of adding NCPDP SCRIPT Standard, Implementation Guide, Version 2022011 to the implementation specification.

Submitted by mphillips@caqh.org on 2022-09-27

CAQH CORE Operating Rules for PA and Referral Updates

Changes to Operating Rules for Prior Authorization and Referrals are on pages 10-11 in the attached document. CAQH CORE proposes an update to change the name of this section from “CAQH CORE Operating Rules for Prior Authorization” to “CAQH CORE Operating Rules for Prior Authorization and Referrals.” Other changes are primarily non-substantive and address consistency, conciseness, and grammar and syntax. Changes are highlighted in gray with proposed deletions shown as strikethrough text.

CAQH CORE ISA Letter 2022_3.pdf

Submitted by pwilson@ncpdp.org on 2021-09-29

NCPDP Comments

Add the following:

Type-Implementation Specification

Standard Implementation/Specification- NCPDP SCRIPT Standard, Implementation Guide, Version 2017071

Standards Process Maturity – Final

Implementation Maturity- Production

Adoption Level – 5

Federally Required – No

Cost – $

Test Tool Availability – Yes

Test Tool Link: https://tools.ncpdp.org/erx/#/home

NCPDP operating rules are in the NCPDP SCRIPT Standard, Implementation Guide Version 2017071

Submitted by doodles531 on 2020-12-12

updated weblink

Submitted by jporras on 2020-11-01

CAQH CORE Comments to ONC ISA - Phase V

Aligning ISA with New Operating Rule Structure: In Spring 2020, CAQH CORE restructured its operating rules from phase-based rule sets to rule sets based on the business processes supported by the rules. No substantive changes were made to existing rule requirements. As a result of the restructuring, CAQH CORE recommends updates to the following sections of the ISA:

Operating Rules for Prior Authorization (Phase V) -- Prior Authorization & Referrals Operating Rules

ISA Comments from CAQH CORE 11.1.20 FINAL_4.pdf