Frequently Asked Questions - ii. CORE Certification Policies

How long does my CORE Certification remain active?

Submitted by caqh_admin on Wed, 01/06/2021 - 10:53
How long does my CORE Certification remain active?

Once certified, CORE-certified entities must remain conformant with applicable CAQH CORE Operating Rules throughout any system upgrades. An entity’s CORE Certification Seal will remain valid for three years, based off the year the certification was awarded. After three years, entities are required to complete the recertification process to renew its CORE Certification Seal.

Further, A CORE-certified entity may become de-certified and have their CORE Certification Seal revoked if instances of non-conformance are found and not remedied or if there is a 180-day lapse in renewing certification.

In instances of mergers, acquisitions, or deployment of new systems:

  • If a CORE-certified entity is acquired by an entity that is not CORE-certified, the newly merged company will only be allowed to be CORE-certified if the acquired company is the only business that is applicable to the CAQH CORE Operating Rules. If this is not the case, then the newly merged company will be required to seek certification.
  • If a CORE-certified entity acquires or develops new system(s) that are not CORE-certified, the CORE-certified entity will have 12 months to certify the new system(s); if the CORE-certified entity does not certify the new system(s), it will lose its CORE Certification Seal.
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What are the processes, expected timelines, and requirements for recertification?

Submitted by caqh_admin on Wed, 01/06/2021 - 10:54
What are the processes, expected timelines, and requirements for recertification?
  1. Recertification is required every three years for an entity to remain CORE-certified.
  2. Recertification renewals may occur anytime during the calendar year, based off initial year of certification.
  3. At a minimum, entities must implement versions of CAQH CORE Operating Rules that were

published 24 months prior to the CORE Certification Seal renewal date.

  1. Entities seeking to maintain their certification status must complete the CAQH CORE Recertification Application Form within the recertification renewal year. After the CAQH CORE Recertification Form is completed, an entity must complete recertification testing within 180 days. The CAQH CORE Recertification Application Form communicates an entity’s intent to pursue recertification, collects contact information and identifies payment information for renewal of the CORE Certification Seal.
  2. CORE-certified entities renewing their CORE Certification Seals will be charged a fee for recertification (Recertification Fee) as determined by CAQH CORE.
  3. Recertification requires demonstration of successful testing with a CAQH CORE-authorized Testing Vendor.
  4. CAQH CORE will grant renewal of the CORE Certification Seal after an entity submits all documentation required: CAQH CORE Recertification Application Form, CORE Recertification Fee, recertification testing results, CAQH CORE HIPAA Attestation and any other supplemental materials requested by CAQH CORE.
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My company is seeking CORE Certification but has many subsidiaries. Do they all have to be conformant with the CAQH CORE Operating Rules?

Submitted by caqh_admin on Wed, 01/06/2021 - 10:55
My company is seeking CORE Certification but has many subsidiaries. Do they all have to be conformant with the CAQH CORE Operating Rules?

Per the CAQH CORE policies on certification, a parent corporation seeking CORE Certification will not be certified unless all subsidiaries of the corporation are in conformance with the CAQH CORE Operating Rules. Otherwise, each subsidiary of the parent must individually seek certification and thus would receive its own CORE Certification Seal for the appropriate set of CAQH CORE Operating Rules.

Vendors must complete the CORE Certification process and pay the required fee for each product they want to be CORE-certified. For vendors, CORE Certification will apply only to vendor products rather than to corporate entities.

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What happens if an entity that is not CORE-certified buys a CORE-certified entity?

Submitted by caqh_admin on Wed, 01/06/2021 - 10:56
What happens if an entity that is not CORE-certified buys a CORE-certified entity?

Per the CAQH CORE policies on certification, if a CORE-certified entity is acquired by an entity that is not CORE-certified, the acquiring company will only be allowed to be CORE-certified if the acquired company is the only business that is applicable to the CAQH CORE Operating Rules. Or, if the acquired company continues to operate as a separate subsidiary, it may retain its CORE Certification. If this is not the case, then the newly merged company will be required to seek certification. 

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Who can file a complaint of non-conformance with the CAQH CORE Operating Rules against a CORE-certified organization?

Submitted by caqh_admin on Wed, 01/06/2021 - 10:58
Who can file a complaint of non-conformance with the CAQH CORE Operating Rules against a CORE-certified organization?

Under the CORE Certification program, two types of organizations may file a complaint of non-conformance with CAQH CORE against a CORE-certified organization:

  • Any healthcare provider that is an end-user of a CORE-certified product/service may lodge a complaint against a CORE-certified organization if the provider believes the CORE-certified organization is not conforming to the CAQH CORE Operating Rules. The complaint must be made by submitting a CAQH CORE Request for Review of Possible Non-Compliance Form to CAQH CORE. See the CAQH CORE Enforcement Policy for more information.
  • Beyond provider end-users, CORE-certified organizations involved in the alleged non-conformant transactions may file a complaint, e.g., vendors, health plans, etc.
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What happens if a CORE-certified organization believes that a CORE-certified trading partner is not conforming to the CAQH CORE Operating Rules?

Submitted by caqh_admin on Wed, 01/06/2021 - 10:59
What happens if a CORE-certified organization believes that a CORE-certified trading partner is not conforming to the CAQH CORE Operating Rules?

Under the CAQH CORE Enforcement Policy, CORE-certified organizations are encouraged to privately resolve disputes before submitting a formal complaint of possible non-conformance to CAQH CORE. CAQH CORE enforcement is a complaint-driven process that requires documentation (electronic or paper) demonstrating multiple instances of non-conformance with the CAQH CORE Operating Rules at the specific rule set of CORE Certification. Please see the CAQH CORE Enforcement Policy for further details.

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What happens if an organization becomes de-certified?

Submitted by caqh_admin on Wed, 01/06/2021 - 11:00
What happens if an organization becomes de-certified?

If a CORE-certified entity is found to be in actual violation of a CAQH CORE Operating Rule(s) and the violation is not remedied per the CAQH CORE enforcement timeline, the entity’s certification will be terminated and its name removed from the CAQH CORE website. De-certified organizations are entitled to seek re-certification by re-completing the CORE Certification process and paying all required fees again. De-certified entities can no longer use the CORE Certification Seal and the entity’s name will be removed from all CAQH CORE listing of CORE-certified entities.

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Is the CAQH CORE complaint process for CORE-certified entities confidential?

Submitted by caqh_admin on Wed, 01/06/2021 - 11:01
Is the CAQH CORE complaint process for CORE-certified entities confidential?

Per the CAQH CORE Enforcement Policy, the details of specific complaints against non-conforming CORE-certified entities remain confidential. Names or other identifying information will not be publicly released by CAQH CORE. This information will only be used and disclosed by CAQH CORE for its non-conformance review by the CAQH CORE Enforcement Committee.

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What is the CAQH CORE Enforcement Committee?

Submitted by caqh_admin on Wed, 01/06/2021 - 11:01
What is the CAQH CORE Enforcement Committee?

The CAQH CORE Enforcement Committee, composed of a diverse group of CORE-certified entities, reviews verified complaints of non-conformance against CORE-certified entities and is responsible for providing any extension to the grace period to remediate an issue. Enforcement Committee members will be appointed by the CAQH CORE Board.

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What is the CAQH CORE Health Plan IT System Exemption Policy?

Submitted by caqh_admin on Wed, 01/06/2021 - 11:03
What is the CAQH CORE Health Plan IT System Exemption Policy?

The CAQH CORE Health Plan IT System Exemption Policy allows a health plan seeking CORE Certification to request that a scheduled migration of an existing IT system(s) that represents less than 30 percent of a payer’s market share be exempt from being CORE conformance only if the remainder of the health plan’s IT systems are CORE conformant. The policy requires the new IT system to be CORE conformant by the end of the exemption period, which lasts for 12 months.

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What criteria must be met for a health plan to be eligible for an exemption under the CAQH CORE Health Plan IT System Exemption Policy?

Submitted by jporras on Wed, 01/06/2021 - 11:05
What criteria must be met for a health plan to be eligible for an exemption under the CAQH CORE Health Plan IT System Exemption Policy?

Any health plan seeking an exemption under the CAQH CORE Health Plan IT System Exemption Policy must meet the following criteria:

  • No more than 30 percent of a health plan’s total membership can be processed by the IT system(s) to be covered by the exemption.
  • Migration must be scheduled for completion no later than 12 months from the date of when the health plan is granted CORE Certification.

See the CAQH CORE Health Plan IT System Exemption Policy and CAQH CORE Health Plan IT Exemption Request Form for more information.

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