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CalOptima Achieves Certification to Strengthen Electronic Transactions

System improvement demonstrates commitment to streamlining health care payments

Orange, California (August 15, 2017)

CalOptima recently achieved a certification for adoption of standardized and enhanced electronic business transactions. The certification is known as CORE (Committee on Operating Rules for Information Exchange), and it is awarded by the Council for Affordable Quality Healthcare. CORE certification is considered the health care industry’s gold standard for administrative data exchange.

“CalOptima providers deliver high quality care to our members, and we want to ensure our electronic transaction capabilities meet high standards as well,” says Len Rosignoli, Chief Information Officer, CalOptima. “Adopting standards and increasing the accuracy of data exchanged with our provider partners are key actions to reduce the overall cost of health care delivery.”

CalOptima implemented Phase I, II and III of the CORE operating rules, and each phase has benefits for the provider community:
Phase I: Real-time automated member eligibility

  • Providers can determine members’ eligibility at the time when they schedule services or have an office visit.

Phase II: Real-time automated claim status

  • Providers can determine the current disposition of a claim sent to CalOptima for payment at any time or correct and resend a claim that did not adjudicate with a resulting payment.

Phase III: Electronic funds transfer (EFT) and electronic remittance advice (ERA)

  • Providers can receive quicker payments because remittance is electronic, thereby eliminating the administrative time and cost of paper checks and remittance advices.

Providers must first register to submit claims under the new CORE standards, and they may do so by calling 714-246-8600 or contacting their CalOptima Provider Representative.

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