Operating Rules

CAQH CORE: Operating Rules to Drive the Business of Healthcare 

  • Established in 2005, CAQH CORE is a multi-stakeholder collaboration of more than 130 organizations –providers, health plans, vendors, government agencies, and standard-setting bodies – developing operating rules to simplify healthcare administrative transactions. CAQH CORE participating organizations include health plans representing more than 75% of commercially insured lives, plus Medicare and Medicaid beneficiaries.
  • Operating rules support a range of existing standards to make electronic data transactions more predictable and consistent, regardless of the technology. Operating rules facilitate many high-volume transactions that involve multiple parties, such as automated banking transactions and airline ticket bookings.
  • The CORE process centers on an integrated model consisting of: rule development, testing and certification, and measure tracking/outreach.
  • A voluntary CORE Certification program drives value and return on investment for all trading partners by ensuring the rules are used consistently; thereby encouraging broader use of the rules. Health plans, providers, vendor/clearinghouses that create, transmit or use administrative data may become CORE-certified. 
  • CAQH CORE has been designated by the Secretary of the Department of Health and Human Services (HHS) as the author for federally mandated operating rules per Section 1104 of the Patient Protection and Affordable Care Act (ACA).
CAQH Program: