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

All organizations seeking CORE Certification that create, transmit, or use the administrative transactions addressed by the CAQH CORE Operating Rules will have to undergo CAQH CORE Certification Testing to obtain a CORE Certification Seal for a specific phase of CAQH CORE Operating Rules. All parties essential to the success of the transactions are addressed in the CORE Certification Testing process: providers, health plans, clearinghouses, and vendors. CORE Certification Testing varies by stakeholder type.

Organizations that do not create, transmit, or use administrative data, such as associations and medical societies, are not eligible for CORE Certification. However, such organizations may demonstrate their support for CAQH CORE’s mission and operating rules by signing the CORE Endorser Pledge and applying for and using the CORE Endorser Seal. See “What does it mean to be a CORE Endorser?” for more information on CORE Endorsement.

CORE Certification testing is required to confirm that entities comply with all of the CAQH CORE Operating Rules for the phase for which they are being certified. Successful completion of stakeholder-specific testing, demonstrated through proper documentation from a CAQH CORE-authorized testing vendor, is the prerequisite for obtaining a stakeholder-specific CORE Certification Seal.

CAQH CORE-authorized Testing Vendors are IT companies that have expertise in healthcare transaction testing. They are chosen by CAQH CORE to conduct CORE Certification Testing for all of the CAQH CORE Operating Rules using the CORE-approved Certification Test Suites after a rigorous selection process by CAQH CORE, especially the CORE Certification/Testing Subgroup. The CORE Certification Testing Platform is checked by CORE-certified organizations to ensure it aligns with the CAQH CORE Certification Test Suites, which have test scripts for each rule that is developed and finalized by the CORE Participating Organizations.

NOTE: CORE Certification and CAQH CORE Certification Testing are separate activities. CAQH CORE Certification Testing is performed by organizations seeking CORE Certification and supported by CAQH CORE-authorized Testing Vendors. CORE Certification is completed by CAQH CORE after an organization has successfully completed CAQH CORE Certification Testing with a CAQH CORE-authorized Testing Vendor.

Yes. CAQH CORE conducts a review and selection process with interested organizations prior to approval as a CAQH CORE-authorized Testing Vendor. Interested organizations should contact CORE@caqh.org.

An organization that wishes to achieve the distinction of being a CAQH CORE-authorized Testing Vendor must complete the following four steps:

Step 1.Learn. Develop a thorough understanding of the:

• CORE Certification Step-by-step Process
• Phase I, Phase II, Phase III, & Phase IV CAQH CORE Operating Rules
• Phase I, Phase II, Phase III, & Phase IV CAQH CORE Policies
• CAQH CORE Certification Test Suites for Phase I, Phase II, Phase III, & Phase IV
• CAQH CORE Master Test Bed for Phase I and Phase II (Note: Master Test Bed Data is not provided for Phase III and Phase IV)

Step 2.Build. Develop an on-line testing tool that uses the CAQH CORE Certification Test Suites and the appropriate Master Test Bed Data where applicable. The timeframe for the build is based on the vendor’s resource allocation and commitment to the project.

Step 3.Service. Develop a customer service plan with established staffing and service levels. It is essential that staffing and service levels meet or exceed best market practices.

Step 4.CAQH CORE Review. The functionality of the vendor’s CORE site is tested by both CAQH CORE staff and CORE-certified organizations through a formal testing process which includes Alpha and Beta Testing.
 

For more information on the steps above, as well as additional considerations for organizations seeking to become a CAQH CORE-authorized Testing Vendor, please see HERE or contact core@caqh.org. 

CAQH CORE charges a one-time fee, per phase, for the CORE Certification Seal. See here for a stakeholder-specific fee scale for the cost of the CORE Certification Seal, per each phase.

Separately, there may be fees assessed by the CAQH CORE-authorized Testing Vendors for CAQH CORE Certification Testing. Currently, Edifecs is the only CAQH CORE-authorized Testing Vendor and, currently, Edifecs does not charge fees for CAQH CORE Certification Testing, though this may be subject to change.

When your organization has successfully completed CAQH CORE Certification Testing, the CAQH CORE-authorized Testing Vendor will automatically submit your organization’s CAQH CORE Certification Testing results to CAQH. Your organization may be required to submit additional documentation when applying for a CORE Certification Seal. Please see the CAQH CORE Seal Application for more information.

An organization can perform all or specific parts of the CORE Certification testing requirements as many times as needed. To see the tests required, view the CORE Certification Test Suites. Per the CORE Certification Policy, the number of times each test is undertaken by any entity is confidential information between the entity and the CAQH CORE-authorized testing vendor.

Yes, a provider should have no difficulty substituting currently valid data such as their own provider name, address information, including identifiers into the 270 documents submitted to a CAQH CORE-authorized testing vendor for CORE Certification testing. Some of the Phase I and Phase II CAQH CORE Master Test Bed Data element values can be modified. These modifiable data elements and how they may be modified are specified in the CAQH CORE Master Test Bed Data for both Phase I and Phase II CORE Certification testing.