CAQH software aids data sharing between providers and insurers

CAQH has developed software to simplify the way data is shared between designated provider groups and health plans.

The software, called CAQH ProView for Groups, replaces a highly manual process. Now, groups no longer need to maintain a separate file for each contracted plan. Rather, they can submit one standardized file through a central portal that automatically checks for errors.

CAQH is a healthcare stakeholder organization that works with providers and payers to improve business processes.

As a result, insurers can receive higher quality provider data and upload it into their systems to support credentialing and provider directories, says Ken Aversa, vice president of provider experience at insurer Anthem. “This solution simplifies and streamlines the process and can be accessed through a provider data platform that most plans and providers already use.”

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CAQH worked with nine health plans and about 35 large organizations to identify pain points and analyze workflows. Provider directories often are inaccurate; as many as half the entries in a directory can be wrong, says Atul Pathiyal, managing director of solutions, product and strategy at CAQH. “For providers of large groups, keeping their data correct is especially challenging.”



Large delivery systems may include hundreds or thousands of healthcare professionals, and that can make communicating with a health plan difficult because it is difficult to know which providers are at which locations on which days, and that’s what makes the CAQH standardized file useful, Atul adds.

Yet obstacles still can remain. For example, providers will send provider directories to insurers, but all the health plans have different file formats for accepting information.

As new doctors join an organization, there may be a delay in health plans making changes on their end to have the provider join the network. Or if a provider is taken off a payer list, providers may not be told that by insurers, which frustrates providers. Further, if a provider gains a new patient but doesn’t alert the insurer that the patient is now being treated in a different practice, the patient may be seen has not having insurance.

“By getting plans to work together and allowing providers to send data to a single one-stop shop in Proview, a group of doctors can send a standard roster and we communicate the information to applicable health plans,” Atul explains. “Providers and plans working for a universal system to administer these groups of rosters will increase data quality and reduce manual work.”