CORE-Certified Organizations/Products
Organization |
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Certified RULE SETS |
Certification STatus |
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Aetna, Inc. | ![]() |
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Alabama Medicaid Agency | ![]() |
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Alameda Alliance for Health |
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Alaska Department of
Health and Social Services
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All Savers Insurance | ![]() |
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American Postal Workers Union Health Plan |
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Anthem | ![]() |
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Anthem Colorado* | ![]() |
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Anthem Connecticut* | ![]() |
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Anthem Indiana* | ![]() |
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Anthem Kentucky* | ![]() |
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Anthem Maine* | ![]() |
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Anthem Nevada* | ![]() |
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Anthem New Hampshire* | ![]() |
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Anthem Ohio* | ![]() |
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Anthem Virginia* | ![]() |
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AultCare | ![]() |
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AvMed Health Plans | ![]() |
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Blue Cross of California* | ![]() |
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Blue Cross Blue Shield of Georgia* | ![]() |
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Blue Cross Blue Shield of Missouri* | ![]() |
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Blue Cross Blue Shield of Nebraska3 |
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Blue Cross Blue Shield of North Carolina | ![]() |
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BlueCross BlueShield of Tennessee | ![]() |
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Blue Cross Blue Shield of Wisconsin* | ![]() |
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Boston Medical Center Health Plan | ![]() |
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CalOptima |
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Centene Corporation5 | ![]() |
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Cigna7 |
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ConnectiCare | ![]() |
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Contra Costa Health Plan | ![]() |
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County of Riverside - Exclusive Care | ![]() |
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DAKOTACARE | ![]() |
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Delta Dental of California |
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^Delta Dental of Delaware |
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^Delta Dental District of Columbia |
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^Delta Dental Insurance Company |
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^Delta Dental of New York |
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^Delta Dental of Pennsylvania |
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^Delta Dental of Puerto Rico |
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^Delta Dental of West Virginia |
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Dentegra |
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EmblemHealth | ![]() |
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Empire Blue Cross Blue Shield* | ![]() |
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Excellus Health Plan
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First Medical Health Plan | ![]() |
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Florida Division of Medicaid
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Georgia Department of Community Health | ![]() |
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Gold Coast Health Plan | ![]() |
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Golden Rule Insurance Company | ![]() |
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Government Employees Health Association | ![]() |
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Harvard Pilgrim Health Care
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Health Plan of San Joaquin |
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Health Plan of San Mateo |
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HealthNet | ![]() |
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Healthplex |
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Horizon Blue Cross Blue Shield of New Jersey | ![]() |
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Humana1 | ![]() |
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Inland Empire Health Plan |
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Kaiser Permanente Colorado | ![]() |
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Kaiser Permanente Washington | ![]() |
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MaineCare
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Medical Card Systems |
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Medical Mutual of Ohio | ![]() |
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MVP Health Care | ![]() |
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National Association of Letter Carriers
Health Benefit Plan
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Nebraska Medicaid | ![]() |
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New Hampshire Medicaid |
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North Dakota Department of Human Services |
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Oklahoma Healthcare Authority |
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Oklahoma Office of Management and
Enterprise Services: Employees Group
Insurance Division
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Partnership Health Plan | ![]() |
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Physicians Health Plan | ![]() |
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PrimeWest Health | ![]() |
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Priority Health |
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Providence Health Plan | ![]() |
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Public Employees Health Plan | ![]() |
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Rocky Mountain Health Plans4 | ![]() |
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San Francisco Health Plan | ![]() |
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Santa Clara Family Health Plan |
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Security Health Plan |
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SummaCare | ![]() |
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Sutter Health Plus | ![]() |
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Texas Medicaid |
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Trillium Commmunity Health Plan |
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Triple-S Salud 6
BlueCross BlueShield of Puerto Rico
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Tufts Health Plan
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UnitedHealthcare Life Insurance Compay | ![]() |
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UnitedHealth Group2 | ![]() |
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University of Pittsburgh Medical Center | ![]() |
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Organization |
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CERTIFIED RULE SETS |
CERTIFICATION STATUS |
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Mayo Clinic | ![]() |
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Montefiore Medical Center | ![]() |
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Quest Diagnostics |
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Summit Medical Group | ![]() |
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U.S. Department of Veterans Affairs | ![]() |
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Wake Forest University Health Sciences | ![]() |
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Organization |
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CERTIFIED RULE SETS |
CERTIFICATION STATUS |
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Ability
CHOICE All-Payer Claims
|
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AdminisTEP, LLC
AdminisTEP Next Generation Clearinghouse including Eligibility and Claim Status
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ASSERTUS
ASSERTUS Clearinghouse
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Availity, LLC Availity Health Information Network |
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Avizzor Health Solutions Clearinghouse |
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Capario Phoenix Processing System |
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Cerner/Healthcare Data Exchange HDX |
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Change Healthcare
Real Time and Batch Transaction Processing and Data Hosting Service RelayExchangeTM
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Change Healthcare
Remittance and Payment Management
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ClaimRemedi
ClaimRemedi by eSolutions |
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Conduent EDI Solutions, Inc. Conduent EDI Direct |
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Dorado Systems doradoConnect by eSolutions |
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Dorado Systems doradoVerify |
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Eligible Eligible |
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eMEDIX eMEDIX Clearinghouse Eligibility |
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eProvider Solutions |
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eServices Group Inc. Unite |
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Experian Health OneSource |
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GE Healthcare Centricity EDI Clearinghouse |
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HEALTHeLink HEALTHeNET |
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HeW Revenue Cycle Management & EDI Services |
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HealthFusion HealthFusion® Real-Time |
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HMS HMS |
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InstaMed InstaMed Network |
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MD On-Line, Inc. ACCE$$ Patient Eligibility Verification |
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GMG Management Consulting, Inc. |
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NaviNet NaviNet |
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Navicure Eligibility |
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Office Ally Office Ally Clearinghouse |
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Optum Optum360 |
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OptumInsight Optum Netwerkes |
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OptumInsight Optum Transaction Exchange |
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Pay Span
PaySpanHealth.com
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PNT Data EDI Services & Clinical Data Services |
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PokitDok PokitDok Platform |
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Practice Insight
EDIinsight by eSolutions |
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RealMed Corporation
RealMed Revenue Cycle Management |
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Inmediata Health Group Corp.
Inmediata Clearinghouse |
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Smart Data Solutions Smart Data Stream Clearinghouse |
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Surescripts Surescripts Prescription Benefit |
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TransUnion Healthcare, LLC Insurance Clearinghouse |
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The SSI Group, Inc Access Director V 3.5 |
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The SSI Group, Inc ClickON E-Verify Suite |
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The SSI Group, Inc ClickON Remittance Module |
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TriZetto Provider Solutions Integrated Eligibility & Integrated Claim Status Inquiry |
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TriZetto Provider Solutions CORE III version 2 |
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UHIN
uTRANSEND v2.0
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Waystar Claims Management |
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WorkCompEDI
Clearinghouse
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ZirMed Eligibility Verification |
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Organization |
|
CERTIFIED RULE SETS |
CERTIFICATION STATUS |
---|---|---|---|
ABILITY EligibilityOne |
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athenahealth athenaCollector |
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Automated HealthCare Solutions (AHCS)/ezVerify and Validate ezVerify |
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CSC CSC DirectConnect® |
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CVS Health |
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Datavi P3NET |
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SS&C Health PowerSTEPP |
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ECHO Health, Inc. National EFT/ERA Simplicity Payment Solution v8.1 |
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Eldorado, Inc. HEALTHpac CORE Real-Time Application |
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Eldorado, Inc.
Javelina Real-Time
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Eligibill Eligibill II |
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EmergingHealth TREKS |
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eServices Group, Inc. XJ Series Gateway Services |
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EIXSYS EIXSYS GATEWAY |
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FrontRunnerHC FrontRunnerHC |
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GE Healthcare Centricity Business Version 4.0 and Version 4.3 |
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GE Healthcare Centricity Business Version 5.0 Eligibility/Benefits |
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GE Healthcare Financial Risk Manager Version 6.1 |
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Gi4 Gi4 |
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HealthTrio Smart Series |
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HIPAAsuite HIPAA Claim Payment Master |
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HIPAAsuite HIPAA RealTime Server |
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ikaSystems
ikaClaims version 5.X suite
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Loxogon Loxogon Alloy™ |
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McKesson/Change Healthcare RelayPayer Connectivity Services (PCS) |
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McKesson/Change Healthcare RelayClearance™ Plus Version 4.6 |
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Medical Informatics Engineering WebChart EMR |
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Medical Present Value, Inc. (MPV) MPV Eligibility |
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MEDITECH
EDI Eligibility Validation - Version Client/Server 5.66
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MEDITECH
Claim Status Inquiry and Response - Version Client/Server 5.66
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MEDITECH
Electronic Claim Submission/Remittance - Version Client/Server 5.66
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NextGen Healthcare NextGen® Practice Management (Small & Group Practices) |
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NoMoreClipboard.com NoMoreClipboard.com |
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NTT DATA Services, LLC |
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Orbograph
Healthcare Payments Automation Center (HPAC)
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Phreesia Phreesia |
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PNC Remittance Advantage |
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Recondo Technology SurePayHealth |
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The SSI Group Inc ClickON E-Verify Suite |
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Tallan T-Connect |
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Ventanex Provider Pay Application |
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XIFIN XIFIN RPM |
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Zelis™ Payments |
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*Indicates an Anthem, Inc. company
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
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.