CORE Certification Progress Report - as of February 2017

CORE Certification Progress Report: Measuring Market Reach

The CAQH CORE Operating Rules promote seamless, electronic sharing of large quantities of administrative data across our nation’s healthcare system quickly, cost effectively and accurately. Widespread adoption of the operating rules not only offers the promise of impressive cost savings — it also can help providers and patients worry less about “paperwork,” and focus more on care.

Developed by industry for industry, CORE Certification is the gold standard for driving and tracking market adoption and adherence to the operating rules and their underlying standards. More than 300 certifications have been awarded across the private and public sectors.

Why does measuring reach by both health plans and providers matter?   

In late 2016, CAQH CORE published its first ever progress report tracking the reach of CORE Certification into the nation’s healthcare system. The report shares findings from a study of the two main sides of the equation: the number of lives covered by health plans and the number of transactions conducted by CORE-certified entities serving providers. These measures capture the reach, and thus impact, of CORE Operating Rules on both sides of the healthcare system—payers and providers. Without both sides, full impact doesn’t occur given many providers work with vendors to send inquiries and responses to health plans. 

What are the high level findings?


Part One - Health Plans:  CALCULATED Number of Covered Lives Benefiting from CORE Certification

To view a list of
organizations that
have achieved
CORE Certification
or pledged to become
click here.

Part One focused on the number of insured lives covered by CORE-certified health plans. Data from public reports—including the AIS Directory of Health Plans, the Census Bureau, and the Kaiser Family Foundation—was analyzed to determine the number of insured lives in the U.S. in the commercial and public health plan markets.

The study found that for its first two phases, CORE-certified health plans cover approximately 64% of totally US insured lives. Specifically, for Phase I and Phase II, 76% of the commercially insured and 44% of the publicly insured are covered by CORE-certified health plans. For Phase III, adoption is growing but not as strong—27% of the commercially insured and 25% of the publicly insured are covered by certified plans.


Part Two - Providers: IN PROGRESS Volume of Data Exchange Benefiting from CORE Certification

Part Two of the study focuses on the number of industry transactions conducted by providers that benefit from CORE Certification. As data on provider market share isn’t publicly available, CAQH CORE is surveying CORE-certified vendors and clearinghouses that support providers to exchange the transactions addressed in CORE Phases I, II and III. As with health plans, the industry needs a denominator of total available transactions, and numerator for status to reach that total. For the numerator, the certified provider-facing vendor products/clearinghouses are asked to provide the total number of transactions they conducted for the year 2015, by transaction type. For the denominator, CAQH CORE is using the CAQH Index as a benchmark to estimate the total volume of electronic transactions conducted annually in the U.S. It is expected that the Part Two results will be shared in Q2 2017.

Contribute to Healthcare Efficiency—Commit to CORE Certification

The momentum of CORE Certifications reflects the increased commitment and mounting success of a multitude of players in healthcare to effectively share electronic data in secure and meaningful ways. However, there is still more work to be done for the healthcare system to obtain the full benefits. For health plans, the operating rules mean greater efficiency and security. Provider organizations using systems that adhere to the operating rules face fewer IT and administrative hassles and are able to dedicate more resources to patient care. For consumers, if both plans and vendors follow them, the operating rules hold the promise of a healthcare system with fewer frustrating paperwork errors, more secure information and lower costs.


Learn how your organization can become CORE-certified or how to encourage others to pursue certification. Contact us here.





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