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Improvement of Claims Cycle Workflow

The following are results from the National Health Insurer Report Card (NHIRC) years 2008-2012 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 

  Aetna Anthem Cigna HCSC Humana Regence UHC Medicare
Phase 1 Yes Yes Yes No Yes No Yes No
Phase 2 Yes Yes Committed No Committed No Yes No

Metric 16 - Prior-authorization
Description: Is the payer receiving/sending compliant HIPAA X12 278 Services Review Request for Review and Response standard transaction?

Aetna Anthem Cigna HCSC Humana Regence UHC Medicare
Yes DNR Yes DNR Yes DNR Yes  NA

Metric 17 - Claims acknowledgement
Description: Is the payer sending a HIPAA X12 277 Unsolicited Claims Status transaction?

Aetna Anthem Cigna HCSC Humana Regence UHC Medicare
Yes DNR Yes DNR Yes DNR Yes NA

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).