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

II. Introduction to CORE Certification

C. CORE Certification: Testing

ii. Phase I CORE Certification Testing

  1. What is the purpose of the Phase I CAQH CORE Certification Master Test Suite?
  2. Does the Phase I CAQH CORE Certification Master Test Suite have to be used for certification on all Phase I CAQH CORE Operating Rules?
  3. Do the test scripts in the Phase I CAQH CORE Certification Master Test Suite address all of the Phase I CAQH CORE Operating Rules?
  4. What is the purpose of the Phase I CAQH CORE Master Test Bed Data?
  5. Can my organization use internal health plan test data for CORE Certification testing purposes?
  6. Can the CAQH CORE Master Test Bed Data be modified (length/format/datatype) in order to load into my organization’s internal system? 
  7. Where can my organization obtain the test data required for Phase I CORE Certification?
  8. I am a health plan. The group number used in the CAQH CORE Master Test Bed Data does not align with my organization’s eligibility system requirements for format requirements (length/format/datatype).
  9. I am a health plan. The Member ID (MID) in the CAQH CORE Master Test Bed Data does not align with my organization’s eligibility system format requirements (length/format/datatype).
  10. I am a health plan. My organization’s eligibility system assigns/associates the same Member ID to all individuals in a family, including the subscriber and cannot handle a unique Member ID for a dependent that is different from that assigned to the associated subscriber.
  11. I am a health plan. My organization’s eligibility system does not support identification of a plan number as specified in the REF segment in the CAQH CORE Master Test Bed Data.
  12. I am a health plan. The CAQH CORE Master Test Bed Data has specific payer names expected to be returned, e.g., “PlanA” certification payer, but my organization uses specific plan names.
  13. I am a health plan. Coverage level is listed in the CAQH CORE Master Test Bed Data; however it is listed for at least one test case as employee only. My organization’s eligibility system does not support employee only coverage level and instead uses IND for individual.
  14. I am a health plan. The employee ID used in the CORE Master Test Bed Data does not align with my organization’s eligibility system format requirements (length/format/datatype).
  15. Do providers have to test for all of the Phase I CAQH CORE Operating Rules?
  16. I am a health plan. My Organization’s eligibility system does not support identification of a primary care provider as specified in the CAQH CORE Master Test Bed Data, as we do not support products with primary care providers. Therefore are we required to return this information?
  17. I am a health plan. It appears that in much of the base data the member's address, city, state, zip have been included, which is currently not included in our X12 271 responses. Is this data required or is it okay if the response does not include this information?
  18. When a health plan indicates it does not support dependents, is it necessary for the dependent test cases to be loaded into the health plan's eligibility system?
1. What is the purpose of the Phase I CAQH CORE Certification Master Test Suite?

The Phase I CAQH CORE Certification Master Test Suite Version 1.1.0 defines specific certification testing requirements and detailed test scripts for each of the CAQH CORE Operating Rules to be completed by entities seeking CORE Certification. These detailed test scripts are not intended to exhaustively and comprehensively test all requirements of the CAQH CORE Operating Rules; rather, they focus on a key subset of each rule’s requirements. CAQH CORE-authorized testing vendors use the scenarios and test scripts from the Phase I CAQH CORE Certification Test Suite in their CORE Certification testing products.

2. Does the Phase I CAQH CORE Certification Master Test Suite have to be used for certification on all Phase I CAQH CORE Operating Rules?

Yes, the Phase I CORE Certification Master Test Suite addresses each rule in the Phase I CAQH CORE Operating Rules set. The CORE Certification Master Test Suite is used in order to maintain uniform testing processes and results and to gauge CAQH CORE Operating Rules conformance.

3. Do the test scripts in the Phase I CAQH CORE Certification Master Test Suite address all of the Phase I CAQH CORE Operating Rules?

Yes, each Phase I CAQH CORE Operating Rule has its own set of CORE Certification test scripts in the Phase I CAQH CORE Certification Master Test Suite.

4. What is the purpose of the Phase I CAQH CORE Master Test Bed Data?

The scope of the CAQH CORE Master Test Bed Data is limited to data needed for the entity seeking Phase I CORE Certification to create and populate its internal files and/or databases for internal pre-certification testing and CORE Certification testing for the CAQH CORE 154: Eligibility & Benefits (270/271) Data Content Rule and the CAQH CORE 150 and 151 Acknowledgements Rules.

Thus, CAQH CORE-authorized certification testing vendors will use only the CAQH CORE Master Test Bed Data to conduct CORE Certification testing for the CAQH CORE 154: Eligibility & Benefits (270/271) Data Content Rule and the CAQH CORE 150 and 151 Acknowledgements Rules.

5. Can my organization use internal health plan test data for CORE Certification testing purposes?

No. The CORE Certification Test Suite requires that all organizations seeking CORE Certification be tested using the same Master Test Bed Data. The CAQH CORE Master Test Bed Data is distributed in the standard X12 format so that organizations may easily extract the key data elements and load them into their internal test databases. The CAQH CORE-authorized testing vendors will only use the CAQH CORE Master Test Bed Data to conduct CORE Certification testing for the CAQH CORE 154: Eligibility & Benefits (270/271) Data Content Rule and CAQH CORE 150: Batch Acknowledgements and 151: Real Time Acknowledgements Rules.

6. Can the CAQH CORE Master Test Bed Data be modified (length/format/datatype) in order to load into my organization’s internal system? 

Yes. Refer to the Phase I CAQH CORE Certification Testing Suite Version 1.1.0 Appendix for the specific data elements which can be modified and detailed instructions on use and loading of Master Test Bed Data.

7. Where can my organization obtain the test data required for Phase I CORE Certification?

The CAQH CORE Master Test Bed Data is available on the CAQH website.

8. I am a health plan. The group number used in the CAQH CORE Master Test Bed Data does not align with my organization’s eligibility system requirements for format requirements (length/format/datatype).

The Group number is not validated by either of the CAQH CORE-authorized testing vendors in any of the CORE Certification test scripts. Therefore the Group number can be modified, or not used, by any health plan or information source based on its eligibility system requirements for Group number when undergoing certification testing. This permits health plans or information sources to modify the CAQH CORE Master Test Bed Data Group numbers, and as a consequence any revisions performed by a health plan to the Group number in the CAQH CORE Master Test Bed Data will not be validated during CORE certification testing.

9. I am a health plan. The Member ID (MID) in the CAQH CORE Master Test Bed Data does not align with my organization’s eligibility system format requirements (length/format/datatype).

CAQH CORE-authorized testing vendors can accommodate health plan or information source needs regarding Member ID (MID) in their testing products. Please contact CAQH CORE to inquire about how each vendor deals with this issue. Thus, a health plan or information source may modify the MID in the CAQH CORE Master Test Bed Data in order to load the test data into its eligibility system.

Refer to the Phase I CAQH CORE Certification Testing Suite Version 1.1.0 Appendix for specific data elements which can be modified and detailed instructions on use and loading of Master Test Bed Data. If your plan modifies the CAQH CORE Master Test Bed Data, you will need to report to CAQH how you adjusted the data so lessons learned can be applied to future CAQH CORE Phases.

10. I am a health plan. My organization’s eligibility system assigns/associates the same Member ID to all individuals in a family, including the subscriber and cannot handle a unique Member ID for a dependent that is different from that assigned to the associated subscriber.

CAQH CORE-authorized testing vendors can accommodate health plan or information source needs regarding loading dependents in the CAQH CORE Master Test Bed Data with a unique Member ID (MID) into the health plan or information source eligibility systems as follows:

  • A health plan or information source may load the subscriber in its eligibility system using the MID as specified in the CAQH CORE Master Test Bed Data for the subscriber and then separately load the dependent from the CAQH CORE Master Test Bed Data into it eligibility system as a subscriber using the MID as specified in the CAQH CORE Master Test Bed Data for the dependent

Or alternatively:

  • A health plan or information source may modify the dependent’s MID in the CAQH CORE Master Test Bed Data to correspond to the subscriber’s MID as specified in the Master Test Bed Data and then load the dependent appropriately in its eligibility system.

If your plan modifies the Master Test Bed Data, you will need to report to CAQH CORE how you adjusted the data so lessons learned can be applied to future CAQH CORE Phases.

11. I am a health plan. My organization’s eligibility system does not support identification of a plan number as specified in the REF segment in the CAQH CORE Master Test Bed Data.

The Plan number is not validated by either of the CAQH CORE-authorized testing vendors in any of the certification test scripts. Therefore the Plan number can be modified, or not used, by any health plan or information source based on its eligibility system requirements for Plan number when undergoing certification testing. This permits health plans or information sources to modify the CAQH CORE Master Test Bed Data Plan numbers, and as a consequence any revisions performed by a health plan to the Plan numbers in the Master Test Bed Data will not be validated during CORE certification testing.

If your plan modifies the Master Test Bed Data, you will need to report to CAQH CORE how you adjusted the data so lessons learned can be applied to future CAQH CORE phases.

12. I am a health plan. The CAQH CORE Master Test Bed Data has specific payer names expected to be returned, e.g., “PlanA” certification payer, but my organization uses specific plan names.

The name “PlanA” appears only in the ISA/GS sender/receiver fields and the NM103 segment in the 2100A Information Source loop in the CAQH CORE Master Test Bed Data. The ISA/GS sender/receiver fields as well as the name of the Information Source in loop 2100A are not validated by the CAQH CORE-authorized testing vendors in any of the certification test scripts. Therefore these values can be modified by any health plan or information source based on its eligibility system requirements when undergoing certification testing.

Refer to the Phase I CAQH CORE Certification Test Suite Version 1.1.0 Appendix for specific data elements which can be modified and detailed instructions on use and loading of Master Test Bed Data. If your plan modifies the Master Test Bed Data, you will need to report to CAQH CORE how you adjusted the data so lessons learned can be applied to future CAQH CORE phases.

13. I am a health plan. Coverage level is listed in the CAQH CORE Master Test Bed Data; however it is listed for at least one test case as employee only. My organization’s eligibility system does not support employee only coverage level and instead uses IND for individual.

CAQH CORE-authorized testing vendors can accommodate a health plan or information source modifying the EB02 Coverage Level Code from EMP to IND as needed in order to load the benefit into its eligibility system. Therefore the EB02 Coverage Level Code can be modified, or not used, by any health plan or information source based on its eligibility system requirements for coverage level when undergoing CORE Certification testing.

Data coverage level codes, and as a consequence any revisions performed by a health plan to the coverage level codes in the CAQH CORE Master Test Bed Data will not be validated during CORE Certification testing.

Refer to the Phase I CAQH CORE Certification Test Suite Version 1.1.0 Appendix for specific data elements which can be modified and detailed instructions on use and loading of CAQH CORE Master Test Bed Data. If your plan modifies the CAQH CORE Master Test Bed Data, you will need to report to CAQH CORE how you adjusted the data so lessons learned can be applied to future CAQH CORE Phases.

14. I am a health plan. The employee ID used in the CORE Master Test Bed Data does not align with my organization’s eligibility system format requirements (length/format/datatype).

The Employee ID is not validated by either of the CAQH CORE-authorized testing vendors in any of the certification test scripts. Therefore the Employee ID can be modified, or not used, by a health plan or information source based on its eligibility system requirements for Employee ID when undergoing certification testing. This permits health plans or information sources to modify the CAQH CORE Master Test Bed Data Employee IDs, and as a consequence any revisions performed by a health plan or information source to the Employee ID in the CAQH CORE Master Test Bed Data will not be validated during CORE certification testing.

If your plan modifies the Master Test Bed Data, you will need to report to CAQH CORE how you adjusted the data so lessons learned can be applied to future CAQH CORE Phases.

15. Do providers have to test for all of the Phase I CAQH CORE Operating Rules?

Providers who wish to become Phase I CORE-certified must comply with all of the provider-specific CAQH CORE Operating Rules and complete the CORE Certification test scripts for each rule that apply to providers (See Phase I CAQH CORE Certification Test Suite Version 1.1.0). Providers can satisfy the certification requirements by either using a provider/vendor's solution or a combination of a provider/vendor's solution plus some in-house work.

16. I am a health plan. My Organization’s eligibility system does not support identification of a primary care provider as specified in the CAQH CORE Master Test Bed Data, as we do not support products with primary care providers. Therefore are we required to return this information?

The primary care provider is not validated by the CAQH CORE-authorized testing vendors in any of the CORE Certification test scripts. Therefore the primary care provider can be modified, or not used, by any health plan or information source based on its eligibility system requirements when undergoing CORE Certification testing. This permits health plans or information sources to modify the CAQH CORE Master Test Bed Data Health Plan data, and, as a consequence, any revisions performed by a health plan to the primary care provider data in the CAQH CORE Master Test Bed Data will not be validated during CORE Certification testing.

Refer to the Phase I CAQH CORE Certification Testing Suite Version 1.1.0 Appendix for specific data elements which can be modified and detailed instructions on use and loading of CAQH CORE Master Test Bed Data. If your plan modifies the CAQH CORE Master Test Bed Data, you will need to report to CAQH CORE how you adjusted the data so lessons learned can be applied to future CAQH CORE Phases.

17. I am a health plan. It appears that in much of the base data the member's address, city, state, zip have been included, which is currently not included in our X12 271 responses. Is this data required or is it okay if the response does not include this information?

Any entity seeking Phase I CORE Certification must attest that it is HIPAA compliant. Since the member address information is included in the CAQH CORE Master Test Bed Data, it is expected that health plans will not only load the address information for CORE Certification testing but will also use it to create the appropriate HIPAA-compliant X12 271 response even though the CAQH CORE Operating Rule does not deal with the address information. On the other hand, if your production eligibility system does not currently maintain any member address information then, according to the X12 270/271 Implementation Guide, you would not be required to return it on a X12 271 response.

18. When a health plan indicates it does not support dependents, is it necessary for the dependent test cases to be loaded into the health plan's eligibility system?

If a health plan indicated that it did not support Subscribers w/ Dependents then they would be taken through the tasks using the CAQH CORE Master Test Bed Cases 1 through 16, and they should not receive any data using the Cases 17 through 24.

The only exception to that rule is entities who select to do the non-HTTP/s testing, then the test cases provided to all users come from the Subscriber Only Case 1 through 16 set. This was a default selection made to quickly accommodate the non-HTTP/s testing, and the assumption that even entities who can support Subscribers w/ Dependents can also handle cases where the membership is Subscriber Only.