CAQH CORE certifies and awards CORE Certification Seals to entities that create, transmit or use the administrative transactions addressed by the CAQH CORE Operating Rules. CORE Certification means an entity has demonstrated that its IT system or product is operating in conformance with a specific phase(s) of the CAQH CORE Operating Rules. Voluntary CORE Certification is available for providers, health plans, clearinghouses, and product vendors.

 

Organizations that do not create, transmit, or use administrative healthcare transactions, and therefore cannot implement the CAQH CORE Operating Rules, can demonstrate their support for the CORE mission and vision and operating rules by applying for and using the CORE Endorser Seal. View endorser organizations by visiting the CORE Endorsers page.

Exemptions: The CAQH CORE Exemption Policy allows a health plan seeking voluntary CORE Certification to request that a scheduled migration of an existing IT system(s) or recent mergers at the time of CORE Certification be exempt from CAQH CORE Conformance. Health plan exemptions will be granted only if:

The CAQH CORE Exemption Policy requires that within 12 months of the health plan's CORE Certification all exempt systems must be remediated to operate in conformance with the applicable CAQH CORE Operating Rules.

Out of Scope Designations: Out of Scope Designations are applied when claims are fully owned and processed by another organization and, therefore, the CAQH CORE Operating Rules cannot be applied by the certifying health plan (i.e., member data for the product is wholly owned by the external organization). If a health plan touches the administrative data but outsources some processing to a Business Associate(s), an Out of Scope Designation does not apply.

  Exemptions & Out of Scope Designations for CORE-certified Health Plans   System Exemptions: ⁷Cigna: System migrations are underway to ensure the following Cigna products run over Phase III CORE-certified platforms: Qualcare and Qualcare Delivery System Alliances. These products cover less that 1% of Cigna's membership.   Out of Scope Designations:
¹ Humana: Humana Military Healthcare Services (HMHS) and Humana Puerto Rico, covering approximately 30% of Humana's membership, are out of scope for the Phase I, II, and III CAQH CORE Operating Rules. HMHS claims are owned and processed by PGBA of South Carolina and, as a non-US product, Humana Puerto Rico is not covered by the CAQH CORE Operating Rules.

² UnitedHealth Group: OptumRx (formerly Prescription Solutions, Inc.) is out of scope for the CAQH CORE Eligibility & Claim Status Operating Rules; claims are wholly owned and processed by OptumRx.

³ Blue Cross Blue Shield of Nebraska (BCBS NE): BCBS NE's Medicare Advantage and Vision products, covering less than 10% of BCBS NE's membership, are out of scope for the CAQH CORE Operating Rules. Claims for these products are owned and processed by ClearStone Solutions (for Medicare Advantage) and VSP and Davis Vision (for Vision product).

⁴ Rocky Mountain Health Plans (RMHP): RMHP's non-medical Dental and Vision products, covering less than 10% of RMHP's membership, are out of scope for the CAQH CORE Eligibility & Claim Status Operating Rules. Claims for these products are owned and processed by Delta Dental (for Dental product) and VSP (for Vision product).

⁵ Centene Corporation: Centene's vision, pharmacy, and hybrid specialty products are out of scope for Phase I, II, & III CORE Certification. Claims for these products are wholly owned and processed by OptiCare Managed Vision, US Script, and Celtic Insurance Company respectively. As of June 2014, Centene is working to migrate claim processing for its vision and pharmacy products into its CORE-certified system. Centene will notify CAQH CORE when this migration has been completed. Centene's hybrid specialty product, for which claims are wholly owned and processed by Celtic Insurance Company, will remain out of scope.   ⁶ Triple-S Salud: Triple-S Salud's previously offered Medicare Advantage product is out of scope for the CAQH CORE Operating Rules. As of December 31, 2013, all claims for BCBS PR Medicare Advantage are owned and processed by Triple-S Advantage, which is a separate legal entity from Triple-S Salud.