CORE Certification Enforcement

CAQH CORE Certification Enforcement

The CORE Certification program is the Industry Gold Standard for demonstrating adherence to the CAQH CORE Operating Rules, enabling organizations and their trading partners to exchange administrative healthcare data efficiently and securely. The program was developed by the industry for the industry with broad, multi-stakeholder representation ensuing requirements for independent third-party testing and neutral program administration. Achievement of CORE Certification provides organizations a means to assure, validate and demonstrate that their systems are operating in conformance with the operating rules and their underlying standards. 

To date, CAQH CORE has awarded more than 300 certifications to organizations in public and private sectors. As the numbers show, there is a growing commitment from health plans, providers, vendors and clearinghouses to share electronic data securely, accurately, efficiently and timely.  As the operating rules become rooted as part of the healthcare system, the need to monitor and enforce adherence becomes vital, as stakeholders rely on the rules to drive business actions that impact care delivery and revenue cycles.

With nearly 65 percent of insured lives in the nation covered by CORE-certified health plans, industry self-monitoring and self-reporting of non-compliance is important. As an industry program, CORE Certification has an enforcement policy in place that enables stakeholders to take part in self-enforcing activities. Enforcing the rules encourages the reporting of non-compliance, which leads to remediation of systems, policies and processes to reach conformance and recertify. An industry-driven enforcement policy strengthens the exchange of administrative data and information sharing across the healthcare system.

 

Why Enforcement Matters

The CAQH CORE Enforcement Policy enables the industry to govern itself to ensure ongoing conformance of the operating rules by CORE-certified organizations. The principle of self-enforcement allows the industry to monitor, regulate, and correct itself enabling preparation or protection from enforcement audits and associated penalties where instances of non-compliance could cost up to $1.5 million.

How does the industry Benefit from CAQH CORE CERFTIFICATION Enforcement?

  • Empowers industry to ensure they are receiving and maximizing benefits afforded via CORE-certified entities, which is critical to providers.
  • Helps industry to prepare for potential external audits/penalties.
  • By industry, for industry approach demonstrates industry’s self-monitoring and self-reporting capability.
  • Fosters industry collaboration through remediation, not penalties.
  • Multi-stakeholder approach allows end-to-end monitoring of conformance across trading partners.

 

Guidelines for CAQH CORE Certification Enforcement:

The CAQH CORE Enforcement Policy applies to all stakeholder entities that can achieve CORE Certification, not just health plans. The enforcement process is a progressive and collaborative approach that attempts to address and resolve issues of non-conformance. A formal enforcement complaint requires documentation (electronic or paper) demonstrating five documented instances of non-conformance by the CORE-certified entity for the specific phase of CORE Certification.

To achieve CORE Certification, organizations must:

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

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, use the CAQH CORE Benefits of Operating Rules Tool to identify gaps.

Navigate HERE to encourage your trading partner to become CORE-certified.

Learn more about the phase(s) of CORE Certification for which your trading partner is certified: Phase I, Phase II, Phase III & Phase IV.

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 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 phase(s) CORE Certification: Phase I, Phase II, Phase III, & Phase IV.

 

 

Filing an Enforcement Complaint

To file a complaint, the Request for Review of Possible Non-Conformance Form should be used in accordance with the appropriate phase(s). The form is divided into four sections that act as progressive steps to evaluate instances of non-conformance to specific transactions. These steps ultimately can lead to the de-certification of a CORE-certified entity if an issue is not remediated:

 

Prerequisites for filing a complaint:

  • Entities filing a complaint must be end-users of the transaction or otherwise be CORE-certified.
  • Two types of entities may file a complaint against a CORE-certified entity:
  • Any healthcare provider that is an end-user of a CORE-certified product/service/health plan.
  • CORE-certified entities impacted by the alleged non-conformance CORE-certified entity; e.g., vendors, health plans, etc.
  • Reasonable steps have already been taken by your company to resolve the issue privately.
  • Entity must file a complaint within 90 days of the most recent conformance violation.

 

Section 1:

  • Complaint Filing:  A minimum of five documented examples of a violations.

Section 2:

  • Complaint Verification:  CAQH CORE verifies/dismisses the complaint under guidance of the enforcement committee.

Section 3:

  • Complaints Not Remedied:  De-certification/removal of the CORE Certified Seal.

Section 4:

  • Re-certification:  A de-certified entity may seek re-certification by remediating areas of non-conformance and re-completing CORE Certification Testing, including payment of recertification fees for a new CORE Certification Seal.

 

A visual approach on filing a complaint.

Enforcement Policy Timeline:

If a CORE-certified entity is found to be in violation, and the violation is not remediated per the required timeline, the entity’s certification is terminated and its name is removed from the public certification listing.

After a complaint is filed, the CAQH CORE Enforcement policy includes a process for review, validation, remediation and resolution of complaint. This process can take up to six months for a complete resolution. Provided below is a timeline of the process starting with the onset of a filed complaint.

 

 

Resources for CAQH CORE Certification Enforcement:

CAQH CORE Operating Rules and Policies

CAQH CORE Enforcement Policy

Non-Compliance Form

Template Letter

FAQs

Phase I Operating Rules and Policies

Phase I

Phase I

Sample Enforcement Template

CAQH CORE Enforcement FAQS

 

Phase II Operating Rules and Policies

Phase II

Phase II

Phase III Operating Rules and Policies

Phase III

Phase III

Phase IV Operating Rules and Polices

Phase IV

Phase IV

 

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