CORE Certification Process

CORE Certification: A Step-By-Step Process For Phases I-IV

NOTE: CORE Certification Testing on the Phase IV CAQH CORE Operating Rules is now open for public beta testing.  Follow the link to access the Phase IV CORE Certification Test Site. Pease contact CORE@caqh.org if your organization is interested in becoming an early adopter of this rule set.

Overview

Thank you for your interest in voluntary CORE Certification. CAQH CORE certifies and awards CORE Certification Seals to entities and products/services that create, transmit or use the administrative transactions addressed by the CAQH CORE Operating Rules. A CORE Certification Seal means an entity has demonstrated that its IT system or product is operating in conformance with a specific phase(s) of the CAQH CORE Operating Rules. Voluntary CORE Certification is available for providers, health plans, clearinghouses, and vendor products. See a list of organizations that are currently undergoing or have completed CORE Certification HERE.

Are you an organization that wants to demonstrate its support for operating rules, but you do not create, transmit, or use administrative healthcare transactions? Find out how to become a CAQH CORE Endorser HERE.

Voluntary CORE Certification on specific phases of the CAQH CORE Operating Rules can be completed concurrently or successively. 

The CORE Certification process has four components:

Each of the components has multiple steps which must be completed prior to moving on to the next component. The CORE documents required to complete each component step are indicated and accessible through the included links to the CAQH website.

Questions: Contact CAQH CORE at core@caqh.org.

August 30, 2016

Use this learning module to learn about the four components of voluntary CORE Certification.

 

Component 1: Pre-certification Planning and Systems Evaluation

​Gauge your organization’s ability to adopt and become compliant with the CORE Operating Rules by identifying systems/software and business process gaps. The following documents will help you create a project plan to eliminate any gaps found between CAQH CORE rule requirements and your organization’s current capabilities: All gaps should be closed prior to the start of CORE certification testing.  Additionally, consider requesting a call with CAQH CORE Staff, who can provide guidance to help with your remediation project.
 

Name of Document

Description

Phase I

Phase II

Phase III

Phase IV

CAQH CORE Operating Rules and Policies

Lists and explains the phase-specific operating rules, and the policies regarding Certification and Certification testing.

Version 1.1.0

Version 2.1.0

Version
3.0.0

Version 
4.0.0

CAQH CORE Analysis and Planning Guides

Help entities identify system/software gaps and create a project plan to complete any necessary system remediation.

 Phase I & II
Analysis & Planning Guide

Phase III
Analysis & Planning Guide

Phase IV Analysis & Planning Guide

CAQH CORE Master Test Suites

Phase-specific documents that specify the test scripts that must be met in Certification Testing

Version 1.1.0

Version 2.1.0

Version
3.0.0

Version
4.0.0

Master Test Bed Data

Dummy data that must be used in Certification Testing

Version 1.2.0

Version 2.2.0

Not Applicable

Not Applicable

CAQH CORE FAQs

Frequently asked questions and answers serve as helpful resources to organizations, aiding to answer both general and technical questions about CORE Certification and CAQH CORE Operating Rules

FAQS

 

NOTE: Are you planning a migration of a component of your system that is currently non-conformant with the operating rules? Or have you acquired a new system that needs to be remediated? You may be eligible for the CAQH CORE Health Plan IT System Exemption. Review the CAQH CORE Health Plan IT System Policy from the appropriate phase here: Phase IPhase II,  Phase III, or Phase IV.  

 

Component 2: Sign and Submit the CORE Pledge

  1. Sign and submit the CORE Pledge:  The first form to submit is the CORE Pledge. The CORE Pledge must be signed by an authorized executive level employee.
     
  2. Submit the signed CORE Pledge for each of the CAQH CORE Operating Rule Phases that you are pursuing through via online through the CORE Certification Application Portaor send to CAQH via email, fax, or mail.

    Online Submission:

    Organizations may sign and submit the CORE Pledge online. First, your organization will have to register and create an account for the CORE Certification Application Portal. The CORE Certification Application Portal allows your organization to submit, complete, sign, and track all required CORE Certification forms online.

    - Click HERE to view a User Guide on how to navigate through the CORE Certification Application Portal.
    - Click HERE to register and create an account for the CORE Certification Application Portal.
    - Click HERE to access and log into the CORE Certification Application Portal.

    Email, Fax, or Postal Service Submission:
    Alternatively, organizations may submit the CORE Pledge via email (CORE@caqh.org), fax: (202) 517-0397 or mail: 

    CORE, c/o CAQH
    1900 K Street, NW
    Suite 650
    Washington, DC 20006

    Your organization may download and/or print the Phase IPhase IIPhase III, and/or Phase IV CORE Pledge forms by clicking the associated links.

Component 3: CORE Certification Testing

Voluntary CORE Certification requires successful Certification Testing by a third-party CAQH CORE-authorized Testing Vendor. CAQH CORE-authorized Testing Vendors are chosen to conduct CORE Certification Testing for all of the CAQH CORE Operating Rules after a rigorous selection and approval process by CAQH CORE.

Edifecs is currently the only CAQH CORE-authorized Testing Vendor; however, any organization that meets the requirements and completes review and approval by CAQH CORE is eligible to become a CAQH CORE-authorized testing vendor. More information on the process and requirements for entities to become a CAQH CORE-authorized Testing Vendor is available via the How to Become a CAQH CORE-authorized Testing Vendor Fact Sheet HERE.

Steps for Voluntary CORE Certification Testing:

  1. Register with Edifecs, a CAQH CORE-authorized Testing Vendor, on the appropriate landing page below. You must register separately for Phases I/IIPhase III and Phase IV. Note: The Phase IV CORE Certification Test is open for public beta testing.
     
  2. Complete CORE Certification Testing within the 180-day pledge window.
     
  3. Contact the CAQH CORE-authorized Testing Vendor with any questions or concerns related to any part of the CORE Certification Testing process.
     
  4. Upon successful completion of the CORE Certification Testing, the CAQH CORE-authorized Testing Vendor will provide you with documentation that demonstrates the successful completion of your organization’s CORE Certification Testing. The CAQH CORE-authorized Testing Vendor will also provide a copy of your organization’s CORE Certification Testing to CAQH CORE. 

NOTE:

Any fee/cost imposed by the CAQH CORE-authorized Testing Vendor will be independent and separate from the fee charged by CAQH CORE for your organization to obtain the CORE Certification Seal.

Complaints regarding CAQH CORE-authorized Testing Vendors: In the event an entity seeking voluntary CORE certification is dissatisfied with its testing results, it may file an appeal with CAQH CORE. See the CAQH CORE Testing Policy from the appropriate phase here: Phase IPhase IIPhase III, and Phase IV.
 

Component 4: Applying For the CORE Seal

After successful completion of CORE Certification Testing, your next step is to apply for the CORE Certification Seal. Applying for the CORE Certification Seal requires you to notify CAQH CORE that certification testing is complete and to submit a CAQH CORE Seal Application, a CAQH CORE HIPAA Attestation, and CAQH CORE Certification Fee for each Phase(s) of the CAQH CORE Operating Rules you are seeking to become CORE-certified.

  1. Notify CAQH CORE that CORE Certification Testing with the CAQH CORE-authorized Testing Vendor has been completed. 
     
  2. Submit the CAQH CORE HIPAA Attestation and the CAQH CORE Seal Application for each Phase that you are pursuing via the CORE Certification Application Portal, email (CORE@caqh.org), fax (202) 517-0397, or mail:

    CORE, c/o CAQH
    1900 K Street, NW
    Suite 650
    Washington, DC 20006 

    Your organization may download and/or print the forms via the following links:

    CAQH CORE HIPAA Attestation: Phase IPhase IIPhase III, or Phase IV
    CAQH CORE Seal Application: Phase IPhase IIPhase III, or Phase IV
     
  3. Determine your CORE Seal fee by reviewing the fee scale below or on the CORE Seal Application form (Phase IPhase IIPhase III, or Phase IV).

    The fee for the CORE Seal is based upon a stakeholder-specific fee scale. This fee is a one-time cost for each phase of CORE certification, unless an entity becomes de-certified. For more information about certification and decertification, see the appropriate CORE Certification Policy (Phase IPhase II,  Phase III, or Phase IV).
CORE SEAL FEE* SCALE  
Health Plans  
Below $75 million in net annual revenue: $4,000 fee
$75 million and above in net annual revenue: $6,000 fee
   
Clearinghouses  
Below $75 million in net annual revenue: $4,000 fee
     EHNAC HNAP-EHN accredited - apply 10% ($400) discount
$75 million and above in net annual revenue: $6,000 fee
     EHNAC HNAP-EHN accredited - apply 10% ($600) discount
   
Vendors  
Below $75 million in net annual revenue: $4,000 fee
$75 million and above in net annual revenue: $6,000 fee
   
Providers  
Up to $1 billion in net annual revenue: $500 fee
$1 billion and above in net annual revenue: $1,500 fee
   
Federal or State Government Entities No Fee

*Fees are a one-time cost for each Phase of certification

Payment Options:

  •  TO PAY BY CREDIT CARD, CLICK HERE.  NOTE:  There is an additional convenience fee when you pay by credit card or e-check.  Send your completed CORE Seal Application form and HIPAA Attestation form to the address below.
  • TO PAY BY PAPER CHECK, make your check payable to CAQH and send with your completed CORE Seal Application form and HIPAA Attestation form to:

CORE, c/o CAQH
1900 K Street, NW
Suite 650
Washington, DC 20006

  1. Upon receiving the CAQH CORE HIPAA Attestation and the CAQH CORE Seal Application, CAQH CORE conducts a robust, multi-level review of the application materials and the Certification Testing results. CAQH CORE will have a maximum of 20 business days to complete its assessment of the application and respond to the applicant with a clear response of approval or need for clarification.
     
  2. A final decision about the CAQH CORE Seal Application is made by CAQH CORE within 30 business days of receiving a complete application, unless there are extenuating circumstances. If so, CAQH CORE will notify the applicant about the reason for an extension to the review.
     
  3. After receiving a CORE Certification Seal:
  • The certified entity may market itself as being CORE-certified.
  • CAQH CORE will report on its website:
         -  CORE-certified entities and endorser
         - The number of CORE Pledges it has received by stakeholder type​
     

CORE Certification Terms and Conditions

An entity’s CORE Certification Seal remains valid unless a certified entity’s seal is revoked as a result of a validated complaint of nonconformance. For more information on the Enforcement Policy, see the CAQH CORE Enforcement Policy from the appropriate phase here: Phase I, Phase II, Phase III, or Phase IV.

After remedying the issue which led to the validated complaint of noncompliance, the decertified entity is free to seek recertification at any time. Decertified entities will need to complete the entire certification process and pay all applicable fees to achieve CORE certification.

NOTE: CORE rules may be substantially modified one time during the first year of each relevant phase if agreed to by a vote of the entire CORE membership. If that substantial modification takes place, all entities (certified for the relevant Phase, or not) will need to complete the entire CORE certification process and pay all applicable fees to achieve CORE certification for the modified set of the relevant Phase rules.
 

Forms required for CORE Certification:

 

Phase I

Phase II

Phase III

Phase IV

CORE Pledge

Phase I CORE Pledge

Phase II CORE Pledge

Phase III CORE Pledge

Phase IV CORE Pledge

CAQH CORE Seal Application

Phase I CAQH CORE Seal Application

Phase II CAQH CORE Seal Application

Phase III CAQH CORE Seal Application

Phase IV CAQH CORE Seal Application

CAQH CORE HIPAA Attestation

Phase I CAQH CORE HIPAA Attestation

Phase II CAQH CORE HIPAA Attestation

Phase III CAQH CORE HIPAA Attestation

Phase IV CAQH CORE HIPAA Attestation

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