Health Plan Business Partners Find Value in CAQH CORE Certification

August 2016

Health plan business partners increasingly recognize that, by becoming CORE-certified, they can help their clients meet requirements under the Affordable Care Act (ACA) to conduct secure and efficient administrative data exchange. Business partners may include vendors, clearinghouses, third party administrators (TPAs) and other entities that help health plans and healthcare providers process transactions more efficiently.

CORE Certification is the gold standard for demonstrating that an organization or product operates in agreement with the operating rules and the underlying standards mandated by the ACA, and is doing so with their business partners.

Organizations rely on their business partners to follow the operating rules to ensure more predictable and consistent healthcare administrative transactions. Working with a CORE-certified business partner contributes to the widespread adoption of trusted, simple and sustainable healthcare data exchange while meeting the ACA mandate.

Nearly half of the almost 300 awarded CORE Certifications to date have been to business partners that facilitate efficient electronic transactions for health plans.

“By becoming CORE-certified, we are helping our clients meet—and exceed—an important regulatory mandate, while contributing to a more efficient healthcare system for everyone,” Cate McConnell, Director of Product Management, Payer Services, McKesson/Relay Health, said in a recent press release.

To enhance data sharing and support the seamless flow of billions of administrative transactions across the healthcare system, the ACA mandated the creation of Federal operating rules. HIPAA-covered entities such as health plans are required to comply with those rules. The ACA also directed the Department of Health and Human Services (HHS) to create a certification program to verify health plan compliance with the rules and underlying standards. In 2014, HHS proposed designating CAQH CORE as the certifying entity for the Federal program, although final rulemaking is still pending.

More Resources:

  • Learn more about CORE Certification.
     
  • Read how the ACA has influenced CORE Certification in a recent interview with CAQH Deputy Director Gwen Lohse in Health Payer Intelligence.
     
  • Register for an upcoming CAQH CORE Webinar to hear why Post-N-Track, a healthcare clearinghouse, decided to implement the operating rules and become CORE-certified.
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