Frequently Asked Questions - i. CORE Certification Testing Overview

All organizations seeking CORE Certification that create, transmit, or use the administrative transactions addressed by the CAQH CORE Operating Rules will have to undergo CORE Certification Testing to obtain a CORE Certification Seal for any applicable CAQH CORE Operating Rule Sets. 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.

CORE Certification testing is required to confirm that entities comply with all of the CAQH CORE Operating Rules for the applicable transaction types 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 transaction(s)-specific CORE Certification Seal.

Recertification testing follows the same process as initial CORE Certification Testing. For recertification, organizations will have to conform to testing requirements as outlined in the CORE Certification Test Suites. However, to help reduce the testing burden for organizations, CAQH CORE has made some of the testing requirements optional for recertification testing:

• Eligibility & Benefits: Testing tasks for operating rule requirements related to batch processing mode, batch acknowledgements and MIME connectivity are optional and not required.
• Claim Status: Testing tasks for operating rule requirements related to batch processing mode, batch acknowledgements and MIME connectivity are optional and not required.
• Payment & Remittance: Testing tasks for operating rule requirements related to MIME connectivity are optional and not required.

For questions related to recertification testing reach out to core@caqh.org to review recertification testing requirements.

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 Test Suite after a rigorous selection process by CAQH CORE, especially the CORE Certification/Testing Subgroup. Alpha and Beta testing of their CORE Certification Testing Platform is checked by CORE Participants to ensure it aligns with the CAQH CORE Master Test Suites, which have test scripts for each rule that are developed and finalized by the CORE Participants.

Edifecs is a CAQH-authorized Testing Vendor that offers a comprehensive testing solution that allows organizations to self-test via a CORE testing platform. Edifecs has provided CORE Certification Testing services since 2006 and has supported more than 375 certifications. About Edifecs: Edifecs is a leading healthcare technology company with the mission to improve healthcare outcomes, reduce costs and accelerate innovation.

NOTE: CORE Certification and certification testing are separate activities. Certification testing is performed by entities seeking CORE Certification and supported by CAQH CORE-authorized testing vendors. CORE Certification is completed by CAQH CORE after an entity has successfully completed 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 entities 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
• Eligibility & Benefits, Claim Status, Payment & Remittance, Prior Authorization & Referrals, Health Care Claims, Benefit Enrollment, & Premium Payment CAQH CORE Operating Rule Sets
•  Eligibility & Benefits, Claim Status, Payment & Remittance, Prior Authorization & Referrals, Health Care Claims, Benefit Enrollment, & Premium Payment CAQH CORE Polices.
• CAQH CORE Certification Test Suites for Eligibility & Benefits, Claim Status, Payment & Remittance, Prior Authorization & Referrals, Health Care Claims, Benefit Enrollment, & Premium Payment CAQH CORE Policies. 
• CAQH CORE Master Test Bed for Eligibility & Benefits and Prior Authorization & Referrals (Note: Master Test Bed Data is not provided for the Claim Status, Payment & Remittance, Health Care Claim, Benefit Enrollment, and Premium Payment CAQH CORE Operating Rule Sets)

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, contact core@caqh.org. 

Certification testing costs are determined by each CAQH CORE-authorized testing vendor and are subject to change. Separately, CAQH CORE charges a one-time fee, per operating rule set, for the CORE Certification Seal. Fees for Recertification will be ½ of the initial CORE Certification fee.

The CORE Certification testing results provided to you by the CAQH CORE-authorized testing vendor are required to apply for a CORE Certification Seal. When your organization has successfully completed CORE Certification testing, submit the results to CAQH CORE, along with other required documentation, when applying for the CORE Certification Seal. Please see the CORE Certification Seal Application Form for more information.

An organization can perform all or specific parts of the CORE Certification testing requirements as many times as needed. 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 Eligibility & Benefits 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 Eligibility & Benefits CORE Certification testing.

CORE Certification is conducted by CORE CAQH CORE-authorized Testing Vendors. The test sites of these authorized testing vendors use a CORE Participant approved set of test script and the site was beta tested by CORE participants.   Currently, there is only one CORE-authorized testing entity: Edifecs. Start here to register for Edifecs CORE Certification Testing on all CAQH CORE Operating Rule sets. 

In the CORE Certification Testing Site, create and submit a rationale statement regarding why the specific testing task does not apply to your organization/line of business. For instructions on how to create and submit an issue, check the CORE Certification Testing Quick Start Guides.

This rationale statement should clearly justify why the testing task or its associated operating rule requirements do not apply to your organization, your line of business, or how your organization conducts the transaction.

The CAQH CORE-authorized Testing Vendor will review the rationale statement with CAQH CORE Staff, and it will be evaluated whether the testing task is applicable to your organization, your line of business, or how your organization conducts the transaction. During review of the issue, more information, documentation, or discussion may be required of your organization; e.g., support that an operating rule requirement is outsourced to a business associate. After completion of the review, CAQH CORE Staff will ultimately communicate its decision to your organization.  

If you need assistance in determining if a testing task is applicable to your organization or its line of business, contact CAQH CORE Staff at core@caqh.org

Note:  Each stakeholder type applying for CORE certification must meet the applicable Operating Rule requirements should the requirement apply to their organization – the purpose of the rationale statement is not to ask for an exception or exemption on applicable requirements.