Mandates in the health reform law to adopt "operating rules" for a series of existing and new HIPAA transactions between 2013 and 2016 should be achievable, says the leader of the initiative that has been creating such rules during the past five years. The rules are designed to make electronic claims and related transactions far more uniform than they are today.

"We have experience in how long it takes to write rules and implement them," notes Gwendolyn Lohse, managing director of the initiative, called the Committee for Operating Rules (CORE), which operates under the umbrella of CAQH, a Washington-based alliance of health plans and trade associations. "The timelines are achievable as the industry comes around to this concept."

In five years, CORE has gotten more than 120 stakeholder organizations at the table. Insurers represent 75 percent of the commercially insured market, covering 130 million lives, and some Medicare and Medicaid plans also participate, Lohse says. To date, the group of providers, insurers, regulators, clearinghouses and software vendors have created operating rules for the eligibility/benefit determination and claim status transactions, and this year will complete initial rules on prior authorization and remittance transactions, plus more tightening of the claim status transaction.

The reform law does not designate CORE as the organization to spearhead the operating rules, but the required characteristics of the organization fits the CORE initiative, which is the only entity that has been developing operating rules for HIPAA transactions. CORE will apply to be the designated entity, Lohse says, and other organizations may apply as well.

--Joseph Goedert


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