The Central Hub: A Guide to CAQH Solutions for Healthcare Administration

In the fragmented world of US healthcare, the Council for Affordable Quality Healthcare (CAQH) acts as a central utility. It is a non-profit alliance of health plans and trade associations designed to streamline the business of healthcare.

For providers and practice managers, "doing your CAQH" is often synonymous with credentialing, but the platform offers a suite of solutions that cover the entire administrative lifecycle. This guide breaks down the core CAQH modules and how to use them effectively.

1. CAQH ProView® (The Credentialing Standard)

The industry standard for self-reported provider data.

What it is:
ProView is a centralized database where providers enter their professional and practice information once. Instead of filling out 20 different credentialing applications for Aetna, Cigna, United, and Blue Cross, you fill out one CAQH profile and authorize those payers to access it.

Key Functions:

• Credentialing: Used for initial credentialing and re-credentialing.
• Data Standardization: Collects demographics, education, training, malpractice history, and practice locations in a uniform format.
• Document Repository: Stores digital copies of state licenses, DEA certificates, and liability insurance facesheets.

Best Practices:

• The 120-Day Rule: You must re-attest (confirm your data is accurate) every 120 days. If you don't, payers cannot access your data, and your credentialing/re-credentialing will stall.
• Global Authorization: Ensure you have "Global Authorization" checked so that any participating plan can access your data immediately without you needing to approve them individually.

2. CAQH VeriFide™ (Primary Source Verification)

The engine that validates the data.

What it is:
While ProView is for collecting data, VeriFide is for checking it. It is a Primary Source Verification (PSV) service. Instead of a health plan calling your medical school to verify your degree, they hire CAQH VeriFide to do it.

Key Functions:

• Speed: VeriFide claims to return files with 98% accuracy in roughly 11-14 days, which is significantly faster than manual verification.
• NCQA Compliance: The verification process meets the strict standards of the National Committee for Quality Assurance (NCQA), which health plans require for accreditation.

How it affects you:
You generally don't "log in" to VeriFide. It is a service payers use on the backend. However, if VeriFide finds a discrepancy (e.g., a gap in work history), they will contact you. Respond immediately, or the verification will be closed as "unable to verify."

3. CAQH DirectAssure® (Directory Maintenance)

Solving the "Ghost Network" problem.

What it is:
The "No Surprises Act" and other regulations require health plans to keep their provider directories up to date. DirectAssure works in tandem with ProView to ensure patients can find you at the right location.

Key Functions:

• Data Cleaning: It uses AI and external data sources to flag potential errors in your practice location data (e.g., "This phone number looks like a fax line").
• Reconciliation: It allows you to review the location data that health plans currently have on file for you and correct it within the CAQH portal.

Best Practices:

• When you attest in ProView, pay special attention to the "Practice Location" section. Ensure that the "Accepting New Patients" flag is accurate for each specific location.

4. CAQH COB Smart® (Coordination of Benefits)

Determining who pays first.

What it is:
This is a backend utility for health plans and providers to determine which insurance is primary and which is secondary when a patient has dual coverage.

Key Functions:

• Overlap Detection: It identifies patients with overlapping coverage across different health plans.
• Primacy Determination: It applies standard rules to determine the order of benefits (e.g., "Birthday Rule").

How it affects you:
By using COB Smart, health plans can process claims correctly the first time. This reduces the number of times a provider has to refund a payment because the wrong insurance paid, or deal with a claim denial due to "other insurance coverage."

5. CAQH Endpoint Exchange (Interoperability)

The directory for digital connections.

What it is:
As healthcare moves toward FHIR (Fast Healthcare Interoperability Resources) APIs, payers and providers need to know where to send digital requests. Endpoint Exchange is a directory of valid electronic endpoints.

Key Functions:

• Connection Discovery: It helps payers and third-party apps find the correct digital "address" to request patient records or check prior authorization requirements for a specific provider.

Summary Checklist for Practice Managers

To maximize the value of CAQH for your organization:

1. Designate an Administrator: Have one person manage the CAQH ProView account for all providers in the group.
2. Calendar the Attestations: Set a recurring calendar reminder every 90 days (beating the 120-day deadline) to log in and re-attest all providers.
3. Upload New Documents Immediately: As soon as a provider gets a renewed medical license or DEA certificate, scan it and upload it to ProView. Do not wait for the attestation cycle.
4. Audit Your Directory Data: Once a year, use the DirectAssure features to verify that your phone numbers and addresses are correct to avoid patients being sent to the wrong location.