Aetna, WellPoint earn electronic data exchange certification

Aetna and WellPoint are the first national health plans to earn certification for electronically exchanging administrative data using the Council for Affordable Quality Healthcare (CAQH) Committee on Operating Rules for Information Exchange (CORE) Phase II rules.

The plans are two of the more than 115 organizations - providers, vendors, health plans, the Centers for Medicare and Medicaid Services and other government agencies, associations, regional entities, standard-setting organizations, and other healthcare entities - participating in the ongoing development of the CORE rules. The goal of the voluntary, industry-driven effort is improved electronic provider access to patient insurance information - eligibility, benefits, patient financial information, and claim status information - before or at the time of service.

“We are investing in an infrastructure that is improving connectivity and operability among healthcare providers and payers while helping to fulfill the priorities of the national health information technology agenda,” Ronald A. Williams, CEO of Aetna and CAQH board chairman, said in a prepared statement. “This ongoing advancement can increase efficiency and quality through more timely access to key healthcare data.”

According to CAQH, the CORE rules are intended to complement the national solutions outlined by the American Recovery and Reinvestment Act and its Health Information Technology for Economic and Clinical Health Act and to help foster the development of regional and state data exchanges by pairing content with infrastructure requirements that streamline electronic patient data flow through existing information technology systems. Multi-stakeholder groups in Ohio, Texas, Colorado, and Virginia have recommended that CORE rules be implemented statewide.

More than 20 health plans, large provider groups, and technology vendors have expressed a commitment to completing Phase II certification in the coming months, according to CAQH. CORE participants currently are developing Phase III rules, which focus on improving the electronic exchange of additional administrative transactions, such as prior authorization and remittance advice.

“The CORE Phase II rules represent a significant milestone in using transparent, consensus-based, national operating rules to streamline electronic administrative transactions among providers, health plans, and vendors,” said Doug Henley, MD, FAAFP, executive vice president and CEO of the American Academy of Family Physicians, in the statement from CAQH. “Health plans that complete CORE Phase II certification can exchange data more effectively, thereby improving efficiency and freeing up time for physicians to focus more on their patients.”

A CAQH study by IBM Global Business Services issued in 2009 found that industry-wide implementation of the CORE Phase I rules alone could yield $3 billion in healthcare-related savings. CAQH reportedly expects that widespread adoption of the Phase II rules and subsequent phases of CORE will result in even greater savings for stakeholders across the industry.