Harvard Pilgrim Hits CORE Milestone

Harvard Pilgrim Health Care Inc. is the first health plan to become certified in both the Phase I and Phase II rules of the CORE initiative to standardize administrative transactions.

CORE is the Committee on Operating Rules for Information Exchange within CAQH, a Washington-based payer advocacy organization. The initiative seeks to build industry consensus on voluntary tightening of the HIPAA standards to make health care financial/administrative transactions as easy as a bank ATM transaction.

CORE initially created a Phase I standard for the basic eligibility and benefit determination transaction. Phase II expanded the initial work by adding requirements for patient identification, claim status, patient deductible balances and electronic connectivity information in the transaction. This will enable more information to be given to providers in an eligibility response transaction.

More than 30 organizations are certified for the Phase I rules. Many of these organizations are committed to Phase II certification by early 2010. Wellesley, Mass.-based Harvard Pilgrim completed testing for both sets of rules during a single integrated process. The insurer covers more than one million members through a network of 135 hospitals and 28,000 physicians and other clinicians.

CORE participants have started developing Phase III rules to further standardize additional transactions, such as prior authorization and electronic remittance advice.