CAQH CORE Certification Enforcement

Because stakeholders rely on operating rules to drive business actions that impact care delivery and revenue cycles, the need to assure adherence with the rules has become essential to support efficient operations and interoperability across the healthcare system. CORE Certification provides a means for industry to validate and verify which organizations have demonstrated successful implementations of operating rules and their underlying standards.

The CORE Certification program was developed by the healthcare industry for the industry and utilizes independent third-party testing and neutral program administration. To date, CAQH CORE has awarded nearly 400 CORE Certifications to public and private sector organizations.

To achieve CORE Certification, organizations must:

  • Abide by CORE Certification Policies
  • Adopt CAQH CORE Operating Rules
  • Pass CORE Certification Testing
  • Attest to HIPAA compliance

 

Guidelines for CAQH CORE Certification Enforcement

The CAQH CORE Enforcement Policy allows the industry to monitor, regulate and correct itself to avoid or prepare for enforcement audits and penalties of up to $1.5 million. The enforcement process is a progressive and collaborative approach. An enforcement complaint requires documentation of five instances of non-conformance.

If you are concerned that a CORE-certified entity is not adhering to the listed elements above, CAQH CORE has developed a toolkit outlining the steps on how and when entities should engage in enforcement conversations with non-compliant trading partners.

 

Enforcement Toolkit: Engage in the CORE Certification Enforcement Process

  • Click HERE to see if your trading partner is CORE-certified.
  • If your trading partner(s) is not CORE-certified, or if you are unsure where to start, contact core@caqh.org to setup a 1:1 call to identify gaps.
  • Navigate HERE to encourage your trading partner to become CORE-certified.
  • Learn more about the rule sets for which your trading partner is CORE-certified HERE.
  • If you already have a CORE-certified trading that is non-conformant with the CORE Operating Rules, first try and privately resolve disputes using the following Enforcement Template Letter.
  • Learn more details about CAQH CORE Certification Enforcement from FAQs HERE.
  • If your CORE-certified trading partner is not cooperating with your request to comply with a CORE CAQH Operating Rule(s), begin to document instances of non-conformance.
  • After five documented instances of non-conformance, complete a Request for Review of Possible Non-Conformance Form for each applicable transaction(s) of CORE Certification.
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Audience
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CAQH Program
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