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Certification: HHS Proposed Program and CORE
Thank you for your interest in CORE Certification. CAQH certifies and awards CORE Certification Seals to entities that create, transmit, or use the healthcare administrative and financial transactions addressed by the CAQH CORE Operating Rules. CORE Certification means an entity has demonstrated that its IT system, or product, is operating in conformance with applicable requirements of a specific phase(s) of the CAQH CORE Operating Rules.
If you are a health plan, provider, clearinghouse, or vendor interested in information related to the CORE Certification please click HERE.
If you are a HIPAA covered health plan interested in learning more about the mandatory HHS health plan certification or compliance process please continue reading below.
NOTE: Organizations that do not create, transmit, or use healthcare administrative and financial transactions, and therefore are ineligible for CORE Certification, can demonstrate their support for the CAQH CORE mission and Operating Rules by applying for and using the CORE Endorser Seal. Please refer to the CORE Endorser Seal: Application Process page for further information.
ACA Section 1104 Mandated Certification Process
Section 1104 of the Patient Protection and Affordable Care Act (ACA) mandates a certification process for health plans only. Per the ACA, health plans must file a statement with HHS, in such form as the Secretary may require, certifying that their data and information systems are in compliance with any applicable transaction standards and associated operating rules.
On December 31, 2013, HHS issued a Notice of Proposed Rulemaking (NPRM) on the ACA-mandated health plan certification. HHS accepted public comments on the NPRM through April 3, 2014 (previously March 3, 2014). Comments submitted to HHS may be viewed on www.regulations.gov.
The NPRM includes health plan certification requirements for the eligibility, claim status, electronic funds transfers (EFT), and electronic remittance advice (ERA) transactions. It defines two potential certification options for health plans to meet HHS compliance requirements:
Option 1: HIPAA Credential: Under the HIPAA Credential Program it is proposed that health plans will attest to compliance with the HIPAA-mandated transaction standards and operating rules. Once HHS issues the Final Rule later in 2014, CAQH CORE, as the proposed administrator, would offer the ability to complete the necessary HIPAA Credential documentation. Draft versions of the HIPAA Credential documentation, as outlined in the NPRM, are currently available on the CAQH CORE website. For more information on Option 1 click HERE.
Option 2: CORE Certification: The NPRM proposes to adopt the existing CORE Certification Program, authored and administered by CAQH CORE. Health plans that successfully complete certification testing with a CORE-authorized testing vendor and submit the required documentation will receive a Phase III CORE Certification Seal demonstrating their compliance. CORE Certification is available now. For more information on Option 2 click HERE.
The January 2, 2014 NPRM proposed a December 31, 2015 deadline by which CHPs were required to certify compliance. However, the proposed rule, including the December 31, 2015 deadline, was not mandated in a final regulation before December 31, 2015.
According to the Centers for Medicare & Medicaid Services website, “CMS is currently developing a second proposed rule [regarding the ACA-mandated HHS Certification of Compliance program] that would revise the initial proposed provisions in response to public feedback received through the rulemaking process.”