Certification: ACA Section 1104 Certification, CORE Certification, Proposed CORE HIPAA Credential, and CORE Endorsement

II. Introduction to CORE Certification

B. CORE Certification: Stakeholder Specific Questions

i. Questions Specific to Health Plans

1. Is completion of Phase III CORE Certification the only proposed option for health plans to meet the requirements for the first ACA-mandated Department of Health and Human Services (HHS) Certification of Compliance program addressing the eligibility, claim status, electronic funds transfer (EFT), and electronic remittance advice (ERA) transactions?

The January 2, 2014, HHS Notice of Proposed Rulemaking (NPRM) proposes two potential options for health plans to meet the HHS certification requirements:

  • Option 1: Obtain a HIPAA Credential: The NPRM proposes that health plans may apply to receive a HIPAA Credential by attesting that they have successfully tested the applicable HIPAA transaction standards and associated operating rules for eligibility, claim status, electronic funds transfers (EFT) and electronic remittance advice (ERA) with trading partners.
  • Option 2: Complete CORE Certification: The NPRM proposes receipt of a Phase III CORE Certification Seal as the second option for health plans to meet the HHS-required certification. Health plans that successfully complete certification testing with a CORE-authorized testing vendor and submit the required documentation will receive a Phase III CORE Certification Seal demonstrating their compliance.

NOTE: According to the Centers for Medicare & Medicaid Services website, “CMS is currently developing a second proposed rule [regarding the ACA-mandated HHS Certification of Compliance program] that would revise the initial proposed provisions in response to public feedback received through the rulemaking process.”

2. The HHS NPRM proposes completion of Phase III CORE Certification as one option for health plans to meet the ACA-mandated certification requirements. My organization is a health plan that is currently not CORE-certified for any Phase(s). If we choose CORE Certification to meet the HHS requirements, are we required to complete Phase I and II CORE Certification in addition to Phase III CORE Certification?

Yes. Per CORE Certification Policy, to achieve Phase III CORE Certification a health plan must be CORE-certified on both the Phase I and Phase II CAQH CORE Operating Rules.

In accordance with this CAQH CORE policy, Section II(A)(3)(b) of the HHS Notice of Proposed Rulemaking (NPRM) on the ACA-mandated HHS Certification of Compliance program specifies that: “A health plan must be awarded a CORE Seal in a previous phase to be eligible for a subsequent phase’s Seal. For example, a health plan must be awarded a CORE Seal for Phase I and II Operating Rules in order to be eligible for a CORE Seal for Phase III Operating Rules.” The NPRM on the ACA-mandated HHS Certification of Compliance program is still only proposed, and a final rule has not been published on the ACA-mandated health plan certification

Please Note: CORE Certification on phases of the CAQH CORE Operating Rules can be completed concurrently or successively. A health plan, or other organization, seeking Phase III CORE Certification may choose to test and become certified for Phase I, then Phase II, and later Phase III or undergo combined CORE Certification testing for all three phases concurrently.

 

3. How will the CORE Certification process be affected for a clearinghouse/vendor and a health plan/provider if the clearinghouse/vendor acts on behalf of the health plan/provider for some CAQH CORE Operating Rules?

Any health plan seeking CORE Certification must undergo certification testing for all functions it offers that are covered by the phase of CAQH CORE Operating Rules for which the health plan is seeking certification. When a health plan outsources some functions to a clearinghouse, both the health plan and the clearinghouse to which the functions are outsourced will need to undergo CORE Certification testing in order for the health plan to become CORE-certified.

In this case, a health plan (and/or provider) can chose the “Not Applicable” option for any certification testing requirement for which it has outsourced the function, provided it uploads a rationale statement explaining why a certain test script is not applicable. For example, if a vendor offers connectivity services for a health plan, the rationale statement would include that Vendor X will be providing this functionality on the health plan’s behalf, so the plan does not need to undergo testing. Vendor X must then undergo CORE Certification testing for this function as a health plan clearinghouse. Both the health plan and the vendor may each test independently using different CAQH CORE-authorized testing vendors.

4. If a health plan outsources some functions to a clearinghouse, will the two entities have to use the same CAQH CORE-authorized testing vendor? If not, can test data or results be exchanged between the two testing vendors?

Organizations that share functions, including the entity that has outsourced some functions, may conduct certification testing with different CAQH CORE-authorized testing vendors when seeking CORE Certification.

When an entity outsources some or all of the capabilities required by the CAQH CORE Operating Rules, it can choose the “Not Applicable” choice for any certification testing requirement, provided the entity uploads a rationale statement explaining why they do not feel a certain test script is applicable. In this case, the entity must indicate which entity is performing that function on its behalf. For example, if a vendor offers connectivity services for a health plan, the rationale statement would include that Vendor X will be providing this functionality on the health plans behalf, so the plan does not need to undergo testing. Vendor X must then undergo certification testing for this function as a health plan clearinghouse. Both the health plan and the vendor may each test independently using different CAQH CORE-authorized testing vendors.