No. This said, as the ACA Administrative Simplification provisions build on and update the provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), ACA Section 1104 requires all HIPAA covered entities to comply with the HIPAA-mandated transaction standards and associated operating rules. Please Note: The HIPAA Administrative Simplification provisions do not require providers to send or receive any of the HIPAA-mandated transaction standards. Providers who submit HIPAA transactions, like claims, electronically are covered.
Frequently Asked Questions - ii. Questions Specific to Non-Health Plans
- My organization is a provider office. Are we Federally required to complete CORE Certification?
- Is CORE Certification available for stakeholder organizations that are not health plans?
- If we are CORE-certified on a set of CAQH CORE Operating Rules, do we stand to lose the certification if we don't also certify on other operating rule sets?
- My organization is not CORE-certified. Which set of CORE Certification is applicable to us?
- Will my organization have to complete the CORE Certification process for each set of CAQH CORE Operating Rules?
- 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?
- What certification testing tasks do providers need to accomplish to become CORE-certified?
- 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?
- 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?
- As an EHNAC accredited clearinghouse, do I qualify for any discounts for CORE Certification?
Yes. CAQH CORE offers CORE Certification on CAQH CORE 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 set of CAQH CORE Operating Rules. A CORE Certification Seal is awarded to an organization or vendor product that successfully completes stakeholder-specific CORE Certification Testing with a CAQH CORE-authorized Testing Vendor.
No. It is up to individual organizations to determine when and if it is feasible to become certified on each set of CAQH CORE Operating Rules. An organization’s CORE Certification is active unless the organization loses or does not renew its CORE Certification Seal and is independent of whether or not the organization chooses to certify on additional operating rule sets.
Loss of a CORE Certification Seal is based upon failure to recertify every three years or findings of nonconformance as outlined in the CAQH CORE Enforcement Policy.
Both an entity’s decision to become CORE-certified and determination on which set of CAQH CORE Operating Rules 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 set of CAQH CORE Operating Rules being considered.
For each set of CAQH CORE Operating Rules, it is up to individual entities to determine when and if it is feasible to become certified on a particular rule set. CORE-certified organizations are encouraged to become CORE-certified on all sets of CAQH CORE Operating Rules applicable to their business.
If your organization becomes CORE-certified it is expected to comply with the applicable CAQH CORE rule requirements for your set 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. Trading partner coordination:
- 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
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, 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.
Any health plan seeking CORE Certification must undergo certification testing for all functions it offers that are covered by the set 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.
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.