CORE-certified Organizations (Pending and Current)

CORE-Certified Organizations/Products

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 the CAQH CORE Operating Rules for a specific transaction. 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.

Organization

 

Certified RULE SETS

Certification STatus
Aetna, Inc.
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Prior Authorization & Referrals (Infrastructure Only)
  • Health Care Claims
  • Active
  • Active
  • Active
  • Active
  • Active
Alabama Medicaid Agency Alabama Medicaid A
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Alameda Alliance for Health  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Alaska Department of
Health and Social Services
Alaska Logo
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
All Savers Insurance
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
American Postal Workers Union Health Plan  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Anthem
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Anthem Colorado*
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Anthem Connecticut*
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Anthem Indiana*
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Anthem Kentucky*
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Anthem Maine*
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Anthem Nevada*
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Anthem New Hampshire*
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Anthem Ohio*
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Anthem Virginia*
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
AultCare
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
AvMed Health Plans
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Blue Cross of California*
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Blue Cross Blue Shield of Georgia*
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Blue Cross Blue Shield of Missouri*
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Blue Cross Blue Shield of Nebraska3
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Blue Cross Blue Shield of North Carolina
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
BlueCross BlueShield of Tennessee
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Blue Cross Blue Shield of Wisconsin*
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Boston Medical Center Health Plan       
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
CalOptima  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Centene Corporation5
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Cigna7
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
ConnectiCare
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Contra Costa Health Plan
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
County of Riverside - Exclusive Care
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
DAKOTACARE
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Delta Dental of California  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
^Delta Dental of Delaware  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
^Delta Dental District of Columbia  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
^Delta Dental Insurance Company  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
^Delta Dental of New York  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
^Delta Dental of Pennsylvania  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
^Delta Dental of Puerto Rico  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
^Delta Dental of West Virginia  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Dentegra  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
EmblemHealth
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Empire Blue Cross Blue Shield*
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
 
Excellus Health Plan

  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
First Medical Health Plan
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
 
Florida Division of Medicaid

  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Georgia Department of Community Health
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Gold Coast Health Plan
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Golden Rule Insurance Company
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Government Employees Health Association GEHA Logo
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
 
Harvard Pilgrim Health Care
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Health Plan of San Joaquin  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Health Plan of San Mateo  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
HealthNet
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Healthplex  
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Horizon Blue Cross Blue Shield of New Jersey
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Humana1
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Prior Authorization & Referrals (Infrastructure only)
  • Health Care Claims
  • Benefit Enrollment
  • Premium Payment
  • Active
  • Active
  • Active
  • Active
  • Active
  • Active
  • Active
Inland Empire Health Plan  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Kaiser Permanente Colorado
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Kaiser Permanente Washington
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
MaineCare
 

  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Medical Card Systems  
  • Eligibility & Benefits
  • Active
Medical Mutual of Ohio
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance (Q4 2020)
  • Active
  • Active
  • Pending
MVP Health Care MVP Healthcare
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
National Association of Letter Carriers
Health Benefit Plan
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Nebraska Medicaid
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
New Hampshire Medicaid  
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
North Dakota Department of Human Services  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Oklahoma Healthcare Authority  
  • Eligibility & Benefits (Q4 2020)
  • Claim Status (Q4 2020)
  • Pending
  • Pending
Oklahoma Office of Management and
Enterprise Services: Employees Group
Insurance Division
 
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Partnership Health Plan
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance (Q4 2020)
  • Active
  • Active
  • Pending
Physicians Health Plan
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
PrimeWest Health
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Priority Health  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Providence Health Plan Providence Health Plan Logo
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance (Q4 2020)
  • Active
  • Active
  • Pending
Public Employees Health Plan
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Rocky Mountain Health Plans4
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
San Francisco Health Plan
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Santa Clara Family Health Plan  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Security Health Plan Security Health Plan Logo
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
SummaCare
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Sutter Health Plus Sutter Health Plus
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Texas Medicaid  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Prior Authorization & Referrals (Infrastructure only)
  • Health Care Claims
  • Active
  • Active
  • Active
  • Active
  • Active
Trillium Commmunity Health Plan  
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Triple-S Salud 6
BlueCross BlueShield of Puerto Rico
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
 
Tufts Health Plan
 
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
UnitedHealthcare Life Insurance Compay
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
UnitedHealth Group2
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
University of Pittsburgh Medical Center
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active

Organization

 

CERTIFIED RULE SETS

CERTIFICATION STATUS
Mayo Clinic
  • Eligibility & Benefits
  • Active
Montefiore Medical Center
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Quest Diagnostics  
  • Eligibility & Benefits
  • Active
Summit Medical Group
  • Eligibility & Benefits
  • Active
U.S. Department of Veterans Affairs
  • Eligibility & Benefits
  • Active
Wake Forest University Health Sciences
  • Eligibility & Benefits
  • Active

Organization
Product

 

CERTIFIED RULE SETS

CERTIFICATION STATUS
Ability
CHOICE All-Payer Claims

  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
AdminisTEP, LLC
AdminisTEP Next Generation Clearinghouse including Eligibility and Claim Status
 
  • Eligibility & Benefits
  • Active
ASSERTUS 
ASSERTUS Clearinghouse 
 
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Availity, LLC
Availity Health Information Network
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Prior Authorization & Referrals (Infrastructure only)
  • Health Care Claims
  • Active
  • Active
  • Active
  • Active
  • Active
Avizzor Health Solutions
Clearinghouse
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Capario
Phoenix Processing System
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Cerner/Healthcare Data Exchange
HDX
 
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
 
Change Healthcare
Real Time and Batch Transaction Processing and Data Hosting Service
RelayExchangeTM
Change Healthcare Logo
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Change Healthcare
Remittance and Payment Management
Change Healthcare Logo
  • Payment & Remittance
  • Active
ClaimRemedi
ClaimRemedi by eSolutions
 
ClaimRemedi Logo
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Conduent EDI Solutions, Inc.
Conduent EDI Direct
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Dorado Systems
doradoConnect by eSolutions
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Dorado Systems
doradoVerify
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Eligible
Eligible
Eligible Logo
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
eMEDIX
eMEDIX Clearinghouse Eligibility
  • Eligibility & Benefits
  • Active

eProvider Solutions
eProvider Solutions

eProvider Solutions
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
eServices Group Inc.
Unite
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Experian Health
OneSource
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
GE Healthcare
Centricity EDI Clearinghouse
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
HEALTHeLink
HEALTHeNET
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
HeW
Revenue Cycle Management & EDI Services
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
HealthFusion
HealthFusion® Real-Time
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
HMS
HMS
  • Eligibility & Benefits
  • Active
InstaMed
InstaMed Network
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
MD On-Line, Inc.
ACCE$$ Patient Eligibility Verification
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active

GMG Management Consulting, Inc.
GMG Management Consulting, Inc.

 
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
NaviNet
NaviNet
/sites/default/files/NaviNet%20Logo%20Large.png
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Navicure
Eligibility
 
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Office Ally
Office Ally Clearinghouse
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Optum
Optum360
  • Payment & Remittance
  • Active
OptumInsight
Optum Netwerkes
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
OptumInsight
Optum Transaction Exchange
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Pay Span
PaySpanHealth.com
 
  • Payment & Remittance
  • Active
PNT Data
EDI Services & Clinical Data Services​
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
PokitDok
PokitDok Platform
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Prior Authorization & Referrals (Infrastructure only)
  • Health Care Claims
  • Active
  • Active
  • Active
  • Active
  • Active
Practice Insight
EDIinsight by eSolutions
 
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
RealMed Corporation
RealMed Revenue Cycle Management
 
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Inmediata Health Group Corp.
Inmediata Clearinghouse
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Smart Data Solutions
Smart Data Stream Clearinghouse
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Surescripts
Surescripts Prescription Benefit
  • Eligibility & Benefits
  • Active
TransUnion Healthcare, LLC
Insurance Clearinghouse

  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
The SSI Group, Inc
Access Director V 3.5
SSI Group
  • Prior Authorization & Referrals (Infrastructure only)
  • Active
The SSI Group, Inc
ClickON E-Verify Suite
SSI Group
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
The SSI Group, Inc
ClickON Remittance Module
SSI Group
  • Payment & Remittance
  • Active
TriZetto Provider Solutions
Integrated Eligibility & Integrated Claim Status Inquiry
Trizetto III
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
TriZetto Provider Solutions
CORE III version 2
Trizetto III
  • Payment & Remittance
  • Active
UHIN
uTRANSEND v2.0
 

 

  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Waystar
Claims Management
  • Payment & Remittance
  • Active
WorkCompEDI
Clearinghouse 
  • Payment & Remittance
  • Health Care Claims
  • Active
ZirMed
Eligibility Verification
  • Eligibility & Benefits
  • Active

Organization
Product

 

CERTIFIED RULE SETS

CERTIFICATION STATUS
ABILITY
EligibilityOne
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
athenahealth
athenaCollector
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Automated HealthCare Solutions (AHCS)/ezVerify and Validate
ezVerify
  • Eligibility & Benefits
  • Active
CSC
CSC DirectConnect®
  • Eligibility & Benefits
  • Active

CVS Health
Pharmacy Benefit Management Division

CVS Health Pharmacy Benefit Management Division
  • Payment & Remittance
  • Active
Datavi
P3NET
  • Payment & Remittance
  • Active
SS&C Health
PowerSTEPP
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
ECHO Health, Inc.
National EFT/ERA Simplicity Payment Solution v8.1
  • Payment & Remittance
  • Active
Eldorado, Inc.
HEALTHpac CORE Real-Time Application
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
 
Eldorado, Inc.
Javelina Real-Time
 
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Eligibill
Eligibill II
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
EmergingHealth
TREKS
  • Eligibility & Benefits
  • Active
eServices Group, Inc.
XJ Series Gateway Services
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
EIXSYS
EIXSYS GATEWAY
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
FrontRunnerHC
FrontRunnerHC
FrontRunner Logo
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
GE Healthcare
Centricity Business Version 4.0 and Version 4.3
  • Eligibility & Benefits
  • Active
GE Healthcare
Centricity Business Version 5.0 Eligibility/Benefits
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
GE Healthcare
Financial Risk Manager Version 6.1
 
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
Gi4
Gi4
Gi4 Logo
  • Eligibility & Benefits
  • Active
HealthTrio
Smart Series
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Prior Authorization & Referrals (Infrastructure Only)
  • Health Care Claims
  • Benefit Enrollment
  • Active
  • Active
  • Active
  • Active
  • Active
  • Active
HIPAAsuite
HIPAA Claim Payment Master
  • Payment & Remittance
  • Active
HIPAAsuite
HIPAA RealTime Server
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
 
ikaSystems
ikaClaims version 5.X suite
 

  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Loxogon
Loxogon Alloy™
  • Eligibility & Benefits
  • Active
McKesson/Change Healthcare
RelayPayer Connectivity Services (PCS)
Change Healthcare Logo
  • Eligibility & Benefits
  • Claim Status
  • Payment & Remittance
  • Active
  • Active
  • Active
McKesson/Change Healthcare
RelayClearance™ Plus Version 4.6
Change Healthcare Logo
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Medical Informatics Engineering
WebChart EMR
  • Eligibility & Benefits
  • Active
Medical Present Value, Inc. (MPV)
MPV Eligibility
  • Eligibility & Benefits
  • Active
MEDITECH
EDI Eligibility Validation - Version Client/Server 5.66
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
MEDITECH
Claim Status Inquiry and Response - Version Client/Server 5.66
  • Claim Status
  • Active
MEDITECH
Electronic Claim Submission/Remittance - Version Client/Server 5.66
  • Payment & Remittance
  • Active
NextGen Healthcare
NextGen® Practice Management (Small & Group Practices)
  • Eligibility & Benefits
  • Claim Status
  • Active
NoMoreClipboard.com
NoMoreClipboard.com
  • Eligibility & Benefits
  • Active

NTT DATA Services, LLC
NTT DATA Services

 
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Orbograph
Healthcare Payments Automation Center (HPAC)
Orbograph
  • Payment & Remittance
  • Active
Phreesia 
Phreesia
 
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
PNC 
Remittance Advantage
  • Payment & Remittance
  • Active
Recondo Technology
SurePayHealth
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
The SSI Group Inc
ClickON E-Verify Suite
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Tallan
T-Connect
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active
Ventanex
Provider Pay Application
 
  • Payment & Remittance
  • Active
XIFIN
XIFIN RPM
XIFIN Logo
  • Eligibility & Benefits
  • Claim Status
  • Active
  • Active

Zelis™ Payments
Zelis ACH

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*Indicates an Anthem, Inc. company
^Indicates affiliates to Delta Dental of California

CORE Health Plan IT Exemptions & Out of Scope Designations:

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 exempted system affects no more than 30% of the health plan's membership or total electronic remittance advice plus electronic payment transactions and
  • The remainder of the health plan's IT systems is in conformance with all applicable CAQH CORE Operating Rule requirements.
  • A documented plan is in place for the exempted IT system(s) to be brought into conformance with the CAQH CORE Operating Rules.

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 Payment & Remittance 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 Eligibility & Benefits, Claim Status, and Payment & Remittance 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 & Benefits and 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 & Benefits and 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 Eligibility & Benefits, Claim Status, and Payment & Remittance 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.  
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