CORE

Delivering Administrative Efficiency and Value to the Healthcare Industry

Formed in 2005, CAQH CORE engages the healthcare industry in standardizing business processes for patients, providers and health plans. More than 130 organizations participate in CAQH CORE, including healthcare providers, health plans, vendors, government entities and standard-setting organizations. Health plans participating in CAQH CORE represent 75 percent or the insured population in the United States.

Collectively, CAQH CORE and participating organizations efforts are focused on:

  • Encouraging greater adoption and awareness of electronic transactions.
  • Maintaining and building upon existing operating rules.
  • Identifying new opportunities to accelerate the industry’s transition to a fully digital business.

CAQH CORE is the leading national operating rule author to improve the efficiency, accuracy and effectiveness of industry-driven business transactions.

The Department of Health and Human Services (HHS) designated CAQH CORE as the author of national operating rules for the HIPAA-covered administrative transactions.

Mission

Drive the creation and adoption of healthcare operating rules that support standards, accelerate interoperability, and align administrative and clinical activities among providers, payers and consumers.

Press Release 08/13/18

State agencies and health plans covering 44 percent of all Medicaid enrollees have achieved some level of CORE Certification. This compares to 78 percent for commercial health plans and 75 percent for Medicare Advantage plans. Medicaid agencies and health plans can save more than $4.8 billion annually by fully adopting CAQH CORE Operating Rules.

Press Release 10/23/18

CAQH announced that April Todd has joined the organization as Senior Vice President of CAQH CORE and Explorations. In this role, she will be responsible for leading industry efforts to develop and adopt operating rules for electronic transactions across the continuum of fee-for-service (FFS) to value-based payment (VBP). She will also direct CAQH Explorations research functions, including the CAQH Index.

Certification

CORE Certification is for organizations that create, use or transmit administrative healthcare data (such as health plans, healthcare providers and vendors)  CORE Certification verifies that an organization or product operates in agreement with the operating rules and the underlying standards, and is doing so with their trading partners. 

CAQH CORE Operating Rules

ACA Section 1104 requires HIPAA covered entities to be in compliance with the remaining ACA-mandated operating rules. 

  • Health claims or equivalent encounter information
  • Health plan enrollment/disenrollment
  • Health plan premium payments
  • Referral certification and authorization
  • Health claims attachments