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Phase IV CAQH CORE Certification Opens for Prior Authorization and Other Electronic Transactions

Organizations can now become CORE-certified in the Phase IV operating rules for exchanging administrative data electronically. The rules help streamline prior authorization, healthcare claims, employee premium payments, health plan enrollment and disenrollment, and other transactions.

The Phase IV CAQH CORE Operating Rules address key infrastructure challenges related to the transactions, such as connectivity, processing times and system availability. The operating rules are also a critical step in reducing the time-consuming phone and fax communication in the prior authorization process conducted by providers to send information and obtain approvals for procedures. Currently, only 18 percent of prior authorization transactions are conducted fully electronic, according to the 2016 CAQH Index.

Humana, Texas Medicaid and PokitDok are the first to be awarded CORE Certification in the Phase IV rules. These beta testers represent commercial health plans, state Medicaid plans and vendors — key industry segments that depend on these transactions because of their interaction with healthcare providers and employee benefit managers.

CAQH CORE has developed three other phases of operating rules that cover additional healthcare transactions, which have been mandated by the U.S. Department of Health and Human Services for all HIPAA-covered entities. To date, CAQH CORE has awarded 330 certifications for those rules, all of which required verification through a similar testing process.

Read the full press release on Phase IV CAQH CORE Certification.

Register for a webinar to hear from newly certified Phase IV entities on why they became certified and their experiences with the testing process.

To learn more about CORE Certification and the CAQH CORE Operating Rules, visit