CORE Phase II Rules

Use of the CORE Phase II rules/policies is voluntary and open to all organizations with an interest in administrative data exchange.

The Phase II rules build on the Phase I rules, with additional rules for patient identifiers, patient accumulators, claims status and connectivity. The Phase II rules also require patient financial responsibility for an increased number of service codes.

Organizations must sign a binding pledge to adopt, implement and comply with CORE Phase II rules. A CORE-authorized testing vendor must certify that systems are CORE compliant within 180 days of signing the pledge.

CORE certification is tailored for providers, health plans, vendors and clearinghouses. Organizations that do not create, send or transmit data can sign the pledge and receive a CORE Endorser seal.

Below are the documents required to complete the CORE Phase II rules certification process. Click the link to view, print, or download the document(s). View the CORE Phase II Glossary (coming soon) for terms related to the CORE Phase II rules.

The Complete Set of CORE Phase II Rules and Policies

CORE Policies (200-205)

200: Guiding Principles

201: Pledge
Goal: Demonstrates public support for CORE and commitment to become certified.

• CORE Seal Application
• HIPAA Attestation Form

202: Certification Policy

203: Exemption Policy

• Health Plan IT Exemption Request Form

204: Testing Policy

• CORE Phase II Master Test Suite

Goal: For each stakeholder type that can receive CORE certification (health plan, vendor, clearinghouse and large provider), Test Suite provides an objective, standardized method to conduct non-exhaustive testing for each Phase II rule.
• CORE Master Test Bed Data - Excel

205: Enforcement Policy

CORE Operating Rules* (250, 258-260, 270)

HIPAA 5010 Requirements: CORE Rule Updates

The CORE Phase II rules have been updated to address HIPAA 5010 requirements. The v5010 updates to the CORE rules are available here.

HIPAA 4010 Requirements:
250: Claims Status Rule
Goal: Promotes increased availability and usage of the claims status transaction through application of Phase I infrastructure rules to the 276/277 claims status transactions, including rules for real-time and batch response times, system availability, connectivity, and acknowledgements.

258: Normalizing Patient Last Name Rule
Goal: Provides enhanced patient matching and better information on why a match did not occur in an eligibility request.

259: AAA Error Code Reporting Rule
Goal: Provides enhanced patient matching and better information on why a match did not occur in an eligibility request.

260: Data Content (270/271) Rule
Goal: Provides reporting of patient liability information (remaining deductible amount, plus static co-pay and co-insurance information) in response to a generic or explicit eligibility inquiry; along with 39 additional service type codes beyond the nine service type codes provided in Phase I.

270: Connectivity Rule
Goal: Provides a comprehensive “Safe Harbor” connectivity rule to facilitate connectivity standardization and interoperability across healthcare information exchange, including message envelope standards and metadata requirements.

• XML Schema Specification (normative)
• Web Services Definition Language (WSDL) Specification (normative)

* Enhancing/expanding upon Phase I rules

HIPAA 5010 Requirements: CORE Rule Updates

The CORE Phase II rules have been updated to address HIPAA 5010 requirements. The v5010 updates to the CORE rules are available here.

For more information about the CORE Phase II Rules, CORE Phase II certification or applying for a CORE seal, please contact CAQH at (202) 861-1492.

Now is the time to begin participating in developing the CORE rules. To join the more than 115 industry stakeholders collaborating on the development of the CORE rules, click here to download a CORE Participant Application Form. For more information, please contact CAQH at (202) 861-1492.