Provider-Owned Health Plans Seek CAQH CORE Certification

Rapidly growing segment of the healthcare economy turns to CORE Certification to improve electronic data sharing

WASHINGTON, DC - 4/25/17

The CAQH Committee on Operating Rules for Information Exchange® (CORE®) today announced that provider-owned health plans are seeking CAQH CORE Certification to go above and beyond regulatory requirements and improve electronic information sharing. To date, Boston Medical Center Health Plan, Providence Health Plan and UPMC Health Plan have completed testing and have been awarded certifications.“As a provider-owned health plan, we have a unique understanding of how critical it is for data to flow seamlessly and securely between payers, hospitals and other partners,” said Kim Sinclair, Chief Information Officer of Boston Medical Center Health Plan, part of the Boston Medical Center Health System.  Boston Medical Center is the primary teaching affiliate for Boston University School of Medicine and is the largest safety net hospital in New England. “The CORE seal demonstrates to all of our partners our commitment to efficient data exchange and it enables us to identify partners that we can count on to do business efficiently, so we can focus on coordinating the care of our members.”

Provider-owned health plans are a rapidly growing part of the new healthcare economy. According to a report by McKinsey & Company, today more than 15 million people are covered by provider-owned insurance plans in 39 states, and growing. These plans combine both medical claims and clinical data enabling them to achieve economies of scale, manage risk and improve population health. CORE Certification supports these goals by ensuring they exchange administrative data securely, accurately and efficiently.

CORE Certification demonstrates that not only are organizations following business rules and underlying standards to promote data interoperability, but are also adopting voluntary national data exchange rules created by the industry. The rules apply to electronic checks of patient eligibility and claims status, electronic funds transfers and remittance advices and a variety of other HIPAA claims-related transactions. The CORE seal gives trading partners confidence that all parties are adhering to the rules when conducting these transactions—an important sign that sharing information will be secure and efficient. 

To date, more than 300 CORE Certifications have been awarded to public and private entities, including health plans, hospital systems, clearinghouses and vendors. 

Click here for a complete list of CORE-certified organizations.

Click here to learn how to become CORE certified.


CAQH CORE was formed in 2005 to drive the creation and adoption of healthcare operating rules that support standards, accelerate interoperability and align administrative activities among providers, payers and consumers. Today, more than 130 organizations participate in CAQH CORE, including healthcare providers, health plans representing 75 percent of insured Americans, vendors, government entities and standard setting organizations. Four phases of CAQH CORE Operating Rules have been issued to date, and CORE Certification is currently available for Phases I, II and III Operating Rules. For more information, visit

About Boston Medical Center Health Plan, Inc.
Boston Medical Center founded Boston Medical Center Health Plan, Inc. in 1997 as a not-for-profit managed care organization doing business in Massachusetts as Boston Medical Center (BMC) HealthNet Plan. Outside Massachusetts the business name is Well Sense Health Plan. BMC HealthNet Plan has received a rating of 4.5 out of 5 for its Massachusetts Medicaid product in the National Committee for Quality Assurance (NCQA) 2016-2017 Health Insurance Plan Ratings. This rating gives BMC HealthNet Plan the distinction of being one of the highest rated Medicaid health plans in the nation. Its Medicaid HMO has achieved Excellent Accreditation status from the National Committee for Quality Assurance (NCQA) based on the results from its most recent submissions of HEDIS® and CAHPS® data to NCQA. Excellent Accreditation is the highest status awarded by NCQA. In addition, BMC HealthNet Plan has maintained Accredited status for its Qualified Health Plan coverage. Accredited is the highest status currently available for Qualified Health Plans. For more information, go to For more information about BMC HealthNet Plan Senior Care Options, go to


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