Frequently Asked Questions - I. Overview of CAQH CORE Eligibility & Benefits Operating Rules

What resources are available to assist my organization with implementation of the CAQH CORE Eligibility & Benefits Operating Rules?

Submitted by dasteriadis@caqh.org on Wed, 07/28/2021 - 12:59
What resources are available to assist my organization with implementation of the CAQH CORE Eligibility & Benefits Operating Rules?

CAQH CORE has several resources and tools available at no cost to assist entities with implementation of the CAQH CORE Eligibility & Benefits Operating Rules, including:

  • CAQH CORE has developed an Eligibility & Benefits Analysis & Planning Guide to assist entities with determining with which CAQH CORE Rule requirements their organization will need to comply, which CAQH CORE Rule requirements are outsourced, and with identifying the remediation necessary to ensure conformance of outsourced functions. The Analysis & Planning Guide includes three tools:
    • CAQH CORE Stakeholder & Business Type Evaluation to determine your organization’s stakeholder type(s) and understand the role of your intermediaries that conduct the eligibility transactions
    • CAQH CORE Systems Inventory & Impact Assessment Worksheet to assess your organization’s external and internal systems that conduct eligibility transactions and are impacted by the CAQH CORE Operating Rules
    • CAQH CORE Gap Analysis Worksheet to determine the level of system(s) remediation necessary for your organization to adopt the business requirements of the CAQH CORE Operating Rules
  • CAQH CORE holds frequent education sessions with various industry partners on implementation of the CAQH CORE Operating Rules. Information on upcoming sessions and materials (both slides & audio) from past sessions is available on the CAQH website.
  • CORE Certification also offers a useful resource for entities to ensure successful implementation of applicable CAQH CORE Eligibility & Benefits Rule requirements. CORE Certification has been embraced by many entities given its value in assisting with CAQH CORE Operating Rule adoption and ensuring the greatest ROI is achieved with trading partners. CORE Certification testing with a CAQH CORE-authorized testing vendor is available online at no cost to entities.
  • For every CAQH CORE Operating Rule for a particular transaction, a CORE Certification Master Test Suite is developed that outlines all the requirements for entities seeking CORE Certification. These test suites include information about key concepts such as the role of trading partners that also apply to the general adoption of the CAQH CORE Eligibility & Benefits Operating Rules, beyond CORE Certification. See Eligibility & Benefits Master Test Suite to learn more.
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