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

ii. Questions Specific to Non-Health Plans

  1. My organization is a provider office. Are we Federally required to complete any Phase of CORE Certification?
  2. Is CORE Certification available for stakeholder organizations that are not health plans?
  3. As a Phase I CORE-certified organization, is my organization required to become Phase II, Phase III, or Phase IV CORE-certified?
  4. If we are CORE-certified on a phase of CAQH CORE Operating Rules, do we stand to lose the certification if we don't also certify on successive CAQH CORE phases?
  5. What version of the CAQH CORE Operating Rules, CORE Test Suite, and CORE Master Test Bed Data should my entity use to achieve CORE Certification?
  6. My organization is not CORE-certified. Which phase of CORE Certification is applicable to us?
  7. Will my organization have to complete the CORE Certification process for each phase of CAQH CORE Operating Rules?
  8. My organization has achieved CORE Certification; however, none of my trading partners are CORE-certified. Do we have to comply with the CAQH CORE Operating Rules?
  9. What certification testing tasks do providers need to accomplish to become CORE-certified?
  10. 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?
  11. 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?
  12. As an EHNAC accredited clearinghouse, do I qualify for any discounts for voluntary CORE Certification?
1. My organization is a provider office. Are we Federally required to complete any Phase of CORE Certification?

No. At this time, there is no Federal mandate that providers - or any organization - complete CORE Certification: All phases of CORE Certification are voluntary.

The Affordable Care Act (ACA) Section 1104 does mandate a certification process for health plans only, but this certification process has not been established in regulation.

All HIPAA covered entities are required to comply with the HIPAA-mandated transaction standards and associated operating rules. However, providers are required to comply with the standards and operating rules for those transactions only if the provider chooses to conduct the transactions electronically.

If a provider chooses to receive eligibility, claim status, claim payment, or remittance information electronically, the provider must implement and comply with the HIPAA-mandated CAQH CORE Operating Rules and standards for each transaction (see CMS FAQ# 1807 and CMS FAQ #6343).

2. Is CORE Certification available for stakeholder organizations that are not health plans?

Yes. CAQH CORE offers CORE Certification on the Phase I, II, III, & IV Operating Rules to healthcare providers, clearinghouses, and vendor products, including Practice Management Systems, that process the X12 v5010 270/271, X12 v5010 276/277, X12 v5010 835, Healthcare EFT Standard,X12 v5010 837, X12 v5010 278, X12 v5010 834, and/or X12 v5010 820 transactions.

CORE Certification offers a mechanism to organizations to test their ability to exchange transaction data with their trading partners in accordance with a specific phase of CAQH CORE Operating Rules. A CORE Certification Seal is awarded to an organization or vendor product that successfully completes stakeholder-specific CAQH CORE Certification Testing with a CAQH CORE-authorized Testing Vendor. 

3. As a Phase I CORE-certified organization, is my organization required to become Phase II, Phase III, or Phase IV CORE-certified?

No. Healthcare providers, clearinghouses, and vendor products that become CORE-certified on earlier phases of CAQH CORE Operating Rules are not required to become certified on successive phases. CORE-certified organizations are encouraged to become certified on successive phases of CAQH CORE Operating Rules as CORE Certification:

  • Provides all organizations across the trading partner network useful, accessible, and relevant guidance in meeting obligations under the CAQH CORE Operating Rules;
  • Encourages trading partners to work together on data flow and content needs;
  • Offers vendors practical means for informing potential and current clients about which health plans are offering operating rules; and
  • Achieves maximum ROI because all organizations in data exchange follow the rules; once CORE-certified, organizations need to follow the rules with all trading partners.

 

 

4. If we are CORE-certified on a phase of CAQH CORE Operating Rules, do we stand to lose the certification if we don't also certify on successive CAQH CORE phases?

 

No. It is up to individual organizations to determine when and if it is feasible to become certified on each phase of CAQH CORE Operating Rules. Healthcare providers, clearinghouses, and vendor products that become CORE-certified on earlier phases of CAQH CORE Operating Rules are not required to become certified on successive phases. An organization’s CORE Certification is active unless the organization loses its CORE Certification Seal and is independent of whether or not the organization chooses to certify on successive CAQH CORE phases.

Loss of a CORE Certification Seal is based upon the CAQH CORE Enforcement Policies (Phase I, Phase II, Phase III, & Phase IV). The CAQH CORE Enforcement Policies dictate that complaints of an organization’s non-conformance with CAQH CORE Operating Rules must be filed against the organization; the complaints must be verified; and the issues must be resolved within a five month period before CORE Certification is lost.

5. What version of the CAQH CORE Operating Rules, CORE Test Suite, and CORE Master Test Bed Data should my entity use to achieve CORE Certification?

Your organization should use the CAQH CORE Test Suite and Master Test Bed Data corresponding to the phase of CAQH CORE Operating Rules for which your organization is pursuing CORE Certification. The most current versions of these documents are available on the CAQH website.

6. My organization is not CORE-certified. Which phase of CORE Certification is applicable to us?

Both an entity’s decision to become CORE-certified and determination on which phase of certification is applicable is an internal business decision. An entity’s decision should be based on a review of its business requirements and system capabilities (and those of its trading partners) as well as the scope and functionality of the phase of CAQH CORE Operating Rules being considered.

NOTES:

  1. Organizations must complete CORE Certification testing in succession (i.e., must be CORE-certified on the earlier phases to become certified on a higher phase of CAQH CORE Operating Rules). An entity may also undergo combined CORE Certification testing for all phases concurrently.
  2. CORE-certified entities must demonstrate conformance with all applicable CAQH CORE Operating Rules of the phase for which they are certifying.
7. Will my organization have to complete the CORE Certification process for each phase of CAQH CORE Operating Rules?

For each phase of CAQH CORE Operating Rules, it is up to individual entities to determine when and if it is feasible to become certified on the phase. Entities that become CORE-certified on earlier phases of CAQH CORE Rules are not required to become certified on successive CAQH CORE phases. However, CORE-certified organizations are encouraged to become CORE-certified on successive phases of CAQH CORE Operating Rules as CORE Certification:

  • Provides all organizations across the trading partner network (e.g., health plans, vendors, clearinghouses, providers) useful, accessible, and relevant guidance in meeting obligations under the CAQH CORE Operating Rules
  • Encourages trading partners to work together on data flow and content needs
  • Offers vendors practical means for informing potential and current clients about which health plans are offering operating rules
  • Achieves maximum ROI because all entities in data exchange follow the rules; once CORE-certified, organizations need to follow the rules with all trading partners

NOTE: To become certified on a higher phase of CAQH CORE Operating Rules an entity must be CORE-certified on the earlier phases. All entities that wish to become certified for a new phase of CAQH CORE Operating Rules will need to complete the CORE Certification testing for that phase and pay all applicable fees. For more information, see the CORE Certification Policy Policies (Phase I, Phase II, & Phase III).

8. My organization has achieved CORE Certification; however, none of my trading partners are CORE-certified. Do we have to comply with the CAQH CORE Operating Rules?

If your organization becomes CORE-certified it is expected to comply with the applicable CAQH CORE Rule requirements for your phase of CORE Certification. In some cases CORE Certification requires an entity to coordinate with trading partners in order to achieve and maintain an entity’s own certification.

9. What certification testing tasks do providers need to accomplish to become CORE-certified?

Providers who wish to become CORE-certified must comply with all of the CAQH CORE Operating Rules that apply to providers and complete the CORE Certification tests for each rule that applies to providers. (See the appropriate CAQH CORE Certification Test Suite, Phase I, Phase II, Phase III & Phase IV, for a list of the provider-specific certification tests). Providers can satisfy the certification requirements by either using a vendor solution or building an in-house solution.

10. 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.

11. 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.

12. As an EHNAC accredited clearinghouse, do I qualify for any discounts for voluntary CORE Certification?

Any clearinghouse/EHN entity actively seeking voluntary CORE Certification as of June 1, 2009 or later that has already achieved EHNAC HNAP-EHN accreditation can take advantage of the partnership program discount. The clearinghouse/EHN must indicate that it holds a current EHNAC HNAP-EHN accreditation when submitting a CAQH CORE Seal Application. (CAQH CORE staff will confirm EHNAC-EHN accreditation status independently). The clearinghouse/EHN can submit its application and apply a 10% discount to the CAQH CORE Certification Fee.


NOTE: If your organization earned a CORE Certification Seal on any CAQH CORE Operating Rules phase prior to June 1, 2009, your organization is not eligible for a retroactive discount for the CAQH CORE Certification Fee.