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Aetna Requires CAQH Core Rules Certification for Vendors

Insurance Leader Urges Healthcare Industry to Follow Suit

WASHINGTON, Feb. 13 /PRNewswire-USNewswire/ -- Aetna is the first national healthcare organization to require all of its administrative data-exchange vendors to be certified in compliance with rules created by the Committee on Operating Rules for Information Exchange (CORE), CAQH announced today.

"CORE represents the future of electronic administrative data exchange," said Ronald A. Williams, CAQH chairman of the board and chairman and chief executive officer of Aetna. "We are proud to be the first to take this important step and call on organizations throughout the industry to improve healthcare by requiring CORE certification for their vendors."

According to Aetna, CORE rules generate a robust eligibility transaction that reduces costs and administrative hassles for providers and health plans, and improves healthcare delivery for patients.

CAQH, a nonprofit alliance of health plans and trade associations working to streamline healthcare administration, launched CORE to create an all-payer solution that gives providers access to insurance information before or at the time of service using the electronic system of their choice for any patient or health plan.

The organization has brought together more than 100 industry stakeholders < > to collaborate on a set of uniform business rules to achieve that goal. Built upon national standards, such as HIPAA, the CORE rules make electronic administrative data communications seamless, streamlined and predictable, regardless of the technology -- in many cases eliminating the need for time-consuming phone calls and paperwork.

CORE participants collectively cover more than 130 million lives or more than 75 percent of the commercially insured, plus Medicare and state-based Medicaid beneficiaries.

Findings from a 2006 CAQH study < > showed that providers may reduce labor costs associated with verifying insurance coverage as much as 50 percent by moving from labor-intensive verification methods (web, fax and phone) to automated HIPAA transactions. Health plans also can achieve significant labor savings, as the study showed that average labor costs per phone call are $1.38 versus $0.00 for an automated transaction.

Currently, more than 25 leading national healthcare organizations, including Aetna, are CORE-certified and can exchange select eligibility and benefits information with providers in compliance with the CORE Phase I rules < >. Those organizations cover approximately 65 million or one-third of commercially insured lives in the U.S. Over 20 other healthcare associations, accrediting bodies, networks and businesses have endorsed the rules.

CORE's second set of rules builds on the Phase I rules, with additional guidelines for patient identifiers, patient accumulators, claims status and connectivity. The Phase II rules also require reporting of patient financial responsibility for an increased number of service codes. CAQH expects to announce Phase II certifications beginning at the end of Q3 2008 and into 2009. CORE Phase III will focus on improving the electronic delivery of additional administrative transactions, such as prior authorization.

About CAQH

CAQH is a catalyst for industry collaboration on initiatives that simplify healthcare administration for health plans and providers, resulting in a better care experience for patients and caregivers. CAQH solutions help promote quality interactions between plans, providers, and other stakeholders, reduce costs and frustrations associated with healthcare administration, facilitate administrative healthcare information exchange and encourage administrative and clinical data integration. Visit for more information.

About Aetna

Aetna is one of the nation's leading diversified health care benefits companies, serving approximately 36.7 million people with information and resources to help them make better informed decisions about their health care. Aetna offers a broad range of traditional and consumer-directed health insurance products and related services, including medical, pharmacy, dental, behavioral health, group life and disability plans, and medical management capabilities and health care management services for Medicaid plans. Our customers include employer groups, individuals, college students, part-time and hourly workers, health plans, governmental units, government-sponsored plans, labor groups and expatriates.

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