Phase I & II CAQH CORE Eligibility & Claim Status Operating Rules

XVI. Resources for Implementing the CAQH CORE Eligibility & Claim Status Operating Rules

1. What resources are available to assist my organization with implementation of the Phase I & II CAQH CORE Eligibility & Claim Status Operating Rules?

CAQH CORE has a number of resources and tools available at no cost to assist entities with implementation of the CAQH CORE Eligibility & Claim Status Operating Rules.

  • CAQH CORE has developed an Analysis & Planning Guide for Adopting the CAQH CORE Eligibility & Claim Status Operating Rules 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 and/or claim status transactions
    • CAQH CORE Systems Inventory & Impact Assessment Worksheet to assess your organization’s external and internal systems that conduct eligibility and/or claim status 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. CAQH CORE also holds free, industry-wide Town Hall calls to update the industry on CAQH CORE activities.
  • CORE Certification also offers a useful resource for entities to ensure successful implementation of applicable CAQH CORE Eligibility & Claim Status 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. Currently, CAQH CORE has issued nearly 230 CORE Certification Seals, with many more entities in the pipeline to achieve CORE Certification this year. CORE Certification testing with a CAQH CORE-authorized testing vendor is available online at no cost to entities.
  • For each phase of CAQH CORE Operating Rules, a CORE Certification Master Test Suite is developed that outlines all of the requirements for entities seeking CORE Certification on the rule phase. These test suites include information about key concepts such as the role of trading partners that also apply for general adoption of the CAQH CORE Eligibility & Claim Status Operating Rules, beyond CORE Certification. The test suites are available online: Phase I, Phase II, Phase III, and Phase IV.