Improvement of Claims Cycle Workflow
The following are results from the National Health Insurer Report Card (NHIRC) years 2008-2013 that address improvement of the claims cycle workflow.
Metric 15 - Committee on Operating Rules for Information Exchange (CORE) certification
Description: Is the payer CAQH CORE certified? Source: CAQH CORE
Metric 16 - Prior-authorization
Description: Is the payer receiving/sending compliant HIPAA X12 278 Services Review Request for Review and Response standard transaction?
Metric 17 - Claims acknowledgement
Description: Is the payer sending a HIPAA X12 277 Unsolicited Claims Status transaction?
NA = Not available
DNR = Payer did not respond
HCSC = Health Care Services Corporation
UHC = UnitedHealthcare
The AMA NHIRC results are based on data pulled from the nationally mandated Health Insurance Portability and Accountability Act of 1996 (HIPAA) electronic standard transactions. The technical references for these transactions are the electronic remittance advice (ERA) (HIPAA ASC X12 835 Health Care Claim Payment/Advice Transaction) submitted to a physician in response to the receipt of an electronic claim submission (HIPAA ASC X12 837 Health Care Claim--professional transactions).