CORE Certification Process

CORE Certification: A Step-By-Step Process

Overview

CAQH CORE certifies and awards CORE Certification Seals to entities and products/services that create, transmit or use the administrative transactions addressed by the CAQH CORE Operating Rules. A CORE Certification Seal means an entity has demonstrated that its IT system or product is operating in conformance with CAQH CORE Operating Rules for specific transaction(s). CORE Certification is available for providers, health plans, clearinghouses, and vendor products. See a list of organizations that are currently undergoing or have completed CORE Certification HERE.

Are you an organization that wants to demonstrate its support for operating rules, but you do not create, transmit, or use administrative healthcare transactions? Find out how to become a CAQH CORE Endorser HERE.

CORE Certification on specific CAQH CORE Operating Rule transactions can be completed concurrently or successively. 

The CORE Certification process has five components:

Each of the components has multiple steps which must be completed prior to moving on to the next component. The CORE documents required to complete each component step are indicated and accessible through the included links to the CAQH website.

Questions: Contact CAQH CORE at core@caqh.org

 

Component 1: Pre-certification Planning and Systems Evaluation

​Gauge your organization’s ability to adopt and become compliant with the CORE Operating Rules by identifying systems/software and business process gaps. The following documents will help you create a project plan to eliminate any gaps found between CAQH CORE rule requirements and your organization’s current capabilities: All gaps should be closed prior to the start of CORE certification testing.  Additionally, consider requesting a call with CAQH CORE Staff, who can provide guidance to help with your remediation project.
 

Name of Document

Description

Eligibility & Benefits

Claim Status

Payment & Remittance

PA & Referrals

Health Care Claims

Benefit Enrollment

Premium Payment

CAQH CORE Operating Rules

Lists and explains the transaction-specific operating rules regarding Certification and Certification testing

Eligibility & Benefits

Claim Status

Payment & Remittance

PA & Referrals

Health Care Claims

Benefit Enrollment

Premium Payment

CAQH CORE Analysis and Planning Guides

Help entities identify system/software gaps and create a project plan to complete any necessary system remediation

Eligibility & Benefits Analysis & Planning Guide

Claim Status Analysis & Planning Guide

Payment & Remittance
Analysis & Planning Guide

PA & Referrals
Analysis & Planning Guide

Health Care Claims
Analysis & Planning Guide

Benefit Enrollment
Analysis & Planning Guide

Premium Payment
Analysis & Planning Guide

CAQH CORE Master Test Suites

Transaction-specific documents that specify the test scripts that must be met in Certification Testing

Eligibility & Benefits Master Test Suite

Claim Status Master Test Suite

Payment & Remittance Master Test Suite

PA & Referral Master Test Suite

Health Care Claims Master Test Suite

Benefit Enrollment Master Test Suite

Premium Payment Master Test Suite

Master Test Bed Data

Dummy data that must be used in Certification Testing

Eligibility & Benefits Master Test Bed Data

Not
Applicable

Not
Applicable

PA & Referral Master Test Bed Data

Not Applicable

Not Applicable

Not Applicable
CORE Certification Policy Outlines principles and polices that guide the CORE Certification Program.                                                       CORE Certification Policy  

CAQH CORE FAQs

Frequently asked questions and answers serve as helpful resources to organizations, aiding to answer both general and technical questions about CORE Certification and CAQH CORE Operating Rules

FAQS

 

 

 

Component 2: Sign and Submit the CORE Pledge

  1. Sign and submit the CORE Pledge: The first form to submit is the CORE Pledge. The CORE Pledge must be signed by an authorized executive level employee.
     
  2. Submit the signed CORE Pledge for each of the CAQH CORE Operating Rule transactions that you are pursuing via email, fax, or mail.

    Email, Fax, or Postal Service Submission:
    Organizations may submit the CORE Pledge via email (CORE@caqh.org), fax: (202) 517-0397 or mail: 

    CORE, c/o CAQH
    2020 K Street, NW
    Suite 900
    Washington, DC 20006

    Your organization may download and/or print the CORE Pledge Forms for the following transaction by clicking the accoiated links: Eligibility & BenefitsClaim StatusPayment & RemittancePA & Referral, Health Care Claims, Benefit Enrollment and/or Premium Payment.
 

Component 3: CORE Certification Testing

CORE Certification requires successful Certification Testing by a third-party CAQH CORE-authorized Testing Vendor. CAQH CORE-authorized Testing Vendors are chosen to conduct CORE Certification Testing for all of the CAQH CORE Operating Rules after a rigorous selection and approval process by CAQH CORE.

Edifecs is currently the only CAQH CORE-authorized Testing Vendor; however, any organization that meets the requirements and completes review and approval by CAQH CORE is eligible to become a CAQH CORE-authorized Testing Vendor. 

Steps for CORE Certification Testing:

  1. Register with Edifecs, a CAQH CORE-authorized Testing Vendor.
  2. Complete CORE Certification Testing within the 180-day pledge window.
  3. Contact the CAQH CORE-authorized Testing Vendor with any questions or concerns related to any part of the CORE Certification Testing process.
  4. Upon successful completion of the CORE Certification Testing, the CAQH CORE-authorized Testing Vendor will provide you with documentation that demonstrates the successful completion of your organization’s CORE Certification Testing. The CAQH CORE-authorized Testing Vendor will also provide a copy of your organization’s CORE Certification Testing to CAQH CORE. 

NOTE:

Any fee/cost imposed by the CAQH CORE-authorized Testing Vendor will be independent and separate from the fee charged by CAQH CORE for your organization to obtain the CORE Certification Seal.

Complaints regarding CAQH CORE-authorized Testing Vendors: In the event an entity seeking CORE Certification is dissatisfied with its testing results, it may file an appeal with CAQH CORE. See the CORE Certification Testing Policy.

 

Component 4: Applying For the CORE Seal

After successful completion of CORE Certification Testing, your next step is to apply for the CORE Certification Seal. Applying for the CORE Certification Seal requires you to notify CAQH CORE that certification testing is complete and to submit a CAQH CORE Seal Application, a CAQH CORE HIPAA Attestation, and CAQH CORE Certification Fee for each CAQH CORE Operating Rule transaction you are seeking to become CORE-certified.

  1. Notify CAQH CORE that CORE Certification Testing with the CAQH CORE-authorized Testing Vendor has been completed. 
     
  2. Submit the CAQH CORE HIPAA Attestation and the CAQH CORE Seal Application for each CAQH CORE Operating Rule transaction that you are pursuing via email (CORE@caqh.org) or mail:

    CORE, c/o CAQH
    2020 K Street, NW
    Suite 900
    Washington, DC 20006 

    Your organization may download and/or print the forms via the following links:

    CORE Certification Seal Application

    CAQH CORE HIPAA Attestation: Eligibility & BenefitsClaim StatusPayment & RemittancePA & Referrals, Health Care Claims, Benefit Enrollment or Premium Payment
     
  3. Determine your CORE Seal fee by reviewing the fee scale below.

    The fee for the CORE Seal is based upon a stakeholder-specific fee scale. This fee is a one-time cost for each transaction of CORE certification, unless an entity becomes de-certified. For more information about certification and decertification, see the CORE Certification Policy

    Organizations pursuing more than one certification at a time are eligible for a discount. For more information on this savings opportunity, please email core@caqh.org
CORE SEAL FEE* SCALE  
Health Plans  
Below $75 million in net annual revenue: $6,000 fee
$75 million and above in net annual revenue: $9,000 fee
   
Clearinghouses  
Below $75 million in net annual revenue: $6,000 fee
     EHNAC HNAP-EHN accredited - apply 10% ($600) discount
$75 million and above in net annual revenue: $9,000 fee
     EHNAC HNAP-EHN accredited - apply 10% ($900) discount
   
Vendors  
Below $75 million in net annual revenue: $6,000 fee
$75 million and above in net annual revenue: $9,000 fee
   
Providers  
Up to $1 billion in net annual revenue: $750 fee
$1 billion and above in net annual revenue: $2,250 fee
   
Government  
Federal or State Government Entities No Fee



Payment Options:

  • TO PAY BY ACH, contact CAQH CORE for an invoice. Send your CORE Seal Application form and HIPAA Attestation form to the address below. 
  • TO PAY BY PAPER CHECK, make your check payable to CAQH and send with your completed CORE Seal Application form and HIPAA Attestation form to:

CORE, c/o CAQH
2020 K Street, NW
Suite 900
Washington, DC 20006

  1. Upon receiving the CAQH CORE HIPAA Attestation and the CAQH CORE Seal Application, CAQH CORE conducts a robust, multi-level review of the application materials and the Certification Testing results. CAQH CORE will have a maximum of 20 business days to complete its assessment of the application and respond to the applicant with a clear response of approval or need for clarification.
     
  2. A final decision about the CAQH CORE Seal Application is made by CAQH CORE within 30 business days of receiving a complete application, unless there are extenuating circumstances. If so, CAQH CORE will notify the applicant about the reason for an extension to the review.
     
  3. After receiving a CORE Certification Seal:
  • The certified entity may market itself as being CORE-certified.
  • CAQH CORE will report on its website:
         - CORE-certified entities and endorser
         - The number of CORE Pledges it has received by stakeholder type​

Component 5: Recertification

Recertification ensures ongoing conformance of operating rules by CORE-certified organizations over time supporting market needs, evolving technology, mergers/acquisitions and system upgrades. 

Guidelines for Recertification:

  • Recertification is required every three years for an entity to remain CORE-certified. Recertification renewals may occur anytime during the calendar year, based off initial year of certification. 
  • After communicating intent to recertify, recertification testing must be completed within 180 days.
  • CORE-certified entities will become decertified if there is a 180-day lapse in renewing certification.
  • CORE-certified organizations must implement versions of the CAQH CORE Operating Rules that have been published 24 months prior to the CORE Certification Seal renewal date. 

Recertification - Step by Step Process:

  1. Recertification Planning and Systems Evaluation
  • Your organization will need to evaluate for any changes or updates to operating rules, as most recent versions will have to be implemented. Execute any necessary system changes/updates as part of recertification.
  1. Apply for Recertification (CORE Recertification Application Form - Available Q2 2020)
  • Communicate intent to recertify and maintain certification status by completing the CORE Recertification Application Form.
  • Submit payment for recertification. (Note: Fees for Recertification are ½ of the initial CORE Certification fee)
  1. Recertification Testing
  • An entity undergoing recertification will need to work with a CORE-authorized testing vendor to perform certification testing based upon criteria outlined in the CAQH CORE Certification Test Suites. (Note: Recertification testing will have a reduced number of test cases and provide opportunitiy to recertify across multiple rule sets at once.)
  1. CORE Seal Renewal
  • CAQH CORE will grant renewal of the CORE Certification Seal after an entity completes recertification testing and submits all documentation required. For more information about recertification, see the CAQH CORE Recertification Fact Sheet.

CORE Certification Terms and Conditions

An entity’s CORE Certification Seal remains valid unless a certified entity’s seal is revoked as a result of a validated complaint of nonconformance. For more information on enforcement see the CAQH CORE Enforcement Policy.

After remedying the issue which led to the validated complaint of noncompliance, the decertified entity is free to seek recertification at any time. Decertified entities will need to complete the entire certification process and pay all applicable fees to achieve CORE certification.

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