EmblemHealth Achieves Phase III CAQH CORE Certification

Demonstrates Commitment to Streamlining Health Care Payments to Providers

NEW YORK, NY (November 5, 2015) — EmblemHealth announced today that it has achieved Phase III CAQH Committee on Operating Rules for Information Exchange (CORE®) Certification, a voluntary certification program widely viewed as the industry "gold standard." In the New York City metro area, EmblemHealth is one of only two health plans — and the only nonprofit plan — to achieve this certification.

In order to streamline provider payment and claim reconciliation, these operating rules establish national expectations for the flow and format of electronic funds transfer (EFT) and electronic remittance advice (ERA) to make electronic transactions as seamless as possible. The health care industry currently conducts an estimated 1.2 billion of these transactions every year, with many still conducted manually.

"This CAQH Core Certification demonstrates that EmblemHealth is on the leading edge of simplifying payment processing, streamlining the accounts receivable process, and improving the accuracy and timeliness of information exchange. Our goal is to simplify administrative processes for our provider partners as we transition together to value-based payments," stated Jennifer Truscott, VP, Claims Operations, EmblemHealth.

To drive and track market adoption, CAQH CORE Certification enables organizations to demonstrate they have adopted and are adhering to the operating rules and their underlying standards.

The CAQH CORE Certification seal was awarded after EmblemHealth successfully completed testing by an independent CORE-certified testing vendor and confirms that they can now exchange electronic health care information with health care providers for EFT and ERA in conformance with the Phase III CAQH CORE Operating Rules. This certification is an example of how EmblemHealth is using technology to improve administrative efficiency across the health care system.

"By completing Phase III CORE Certification, EmblemHealth is supporting national expectations to deliver a connected and clear set of electronic payments and remittances to every health care provider working with them," said Gwendolyn Lohse, deputy director of CAQH and managing director of CAQH CORE.

In an effort to ensure that large amounts of data can be shared electronically across the health care system in a fast and efficient way, the Affordable Care Act (ACA) mandated national operating rules for HIPAA administrative transactions. The Department of Health and Human Services (HHS) selected CAQH CORE as the authoring entity to develop these operating rules, which specify the actions needed to ensure uniform, reliable electronic data transmission.

About EmblemHealth
EmblemHealth, Inc., through its companies Group Health Incorporated (GHI) and HIP Health Plan of New York (HIP), provides quality health care coverage and administrative services to approximately 3.1 million people. Groups and individuals can choose from a variety of PPO, EPO and HMO plans, as well as coverage for prescription drugs and dental and vision care. EmblemHealth offers a choice of networks, including quality doctors and other health care professionals throughout the region, leading acute care hospitals across the tristate area, and physicians and hospitals across all 50 states. For more information, visit www.emblemhealth.com.

CAQH CORE is a multi-stakeholder collaboration of more than 140 participating organizations that work together to develop operating rules. Participants represent health care providers, health plans, vendors, associations, government entities, and the organizations that set standards for health care and data exchange. In addition to the Phase III Operating Rules, CAQH CORE has completed Phase I and II to improve electronic data exchange related to eligibility, benefits and claim status transactions. Most recently, CAQH CORE issued the Phase IV Operating Rules to address electronic transactions for health care claims, prior authorization, enrollment or disenrollment in a health plan and health plan premium payments.


Harris Brandt