CORE Certification Progress Report - Updated June 2020

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.

CORE Certification, developed by industry for industry, is the gold standard for driving and tracking market adoption and adherence to the operating rules and their underlying standards. More than 370 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 progress report tracking the reach of CORE Certification into the nation’s healthcare system. The report shares the number of lives covered by health plans that are CORE-certified, including commercial payers, Medicare Advantage and Medicaid. These measures capture the reach, and thus impact, of CORE Operating Rules on the healthcare system. The next stage of the report is in development and focuses on the number of transactions conducted by providers that use CORE-certified vendors and clearinghouses. 

What are the high level findings? (Updated June 2020)

   Foundation Has Been Established:

  • 80% of commercial lives are in health plans that are CORE-certified.
  • 77% of Medicare Advantage lives are in health plans that are CORE-certified.
  • 50% of Medicaid lives are in health plans or state fee-for-service programs that are CORE-certified. There is a large savings opportunity for Medicaid payers.  

   Initial Benefits:

  • Health plans and their trading partners are experiencing the efficiencies from the CAQH CORE Operating Rules enabling them to save time and money.  

   More Plans and Vendors Needed:

  • Still work to be done with health plan market share, especially for use of the Payment & Remittance transactions.
  • Vendor engagement still needed to track and measure provider-facing transactions.  

Health Plans: 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.

  • State agencies and health plans covering 50 percent of all Medicaid enrollees have achieved some level of CORE Certification. This compares to 80 percent for commercial health plans and 77 percent for Medicare Advantage plans.

Large Savings Opportunity for Medicaid—Call to Action

  • There is an opportunity for administrative cost savings for Medicaid of over $4.8B annually by moving to fully electronic transactions covered by the operating rules of CORE Certification. See annual savings numbers by state here.
  • 80% of 74 million enrollees in Medicaid are enrolled in a managed care plan and the administrative cost savings associated electronic transactions certified by CORE can assist a plan in meeting the new Medical Loss Ratio (MLR) requirements of 85% that went into effect in 2017.
  • CORE Certification ensures efficient use of state and federal tax payer money to care for vulnerable populations - transferring limited state resources from administrative costs towards the care of patients.

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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