Frequently Asked Questions - v. Prior Authorization & Referrals CORE Certification Testing

My organization is a Health Plan. Which rule requirements does my organization have to test for to achieve CORE Certification on the CAQH CORE Prior Authorization & Referrals Operating Rule set?

Submitted by tanjarwalla@caqh.org on Thu, 01/07/2021 - 12:32
My organization is a Health Plan. Which rule requirements does my organization have to test for to achieve CORE Certification on the CAQH CORE Prior Authorization & Referrals Operating Rule set?

A Health Plan seeking CORE Certification on Prior Authorization & Referrals Operating Rules must undergo CORE Certification Testing in accordance with the Prior Authorization & Referrals CAQH CORE Certification Test Suite for:

Organizations are required to successfully complete all applicable test scripts for each of the CAQH CORE Prior Authorization & Referrals Operating Rules to achieve CORE Certification on Prior Authorization & Referrals.

A Health Plan that uses a CORE-certified Clearinghouse to meet some of its Prior Authorization & Referrals requirements may need to engage the clearinghouse when undergoing Prior Authorization & Referrals CORE Certification Testing. Because there is a Clearinghouse between the Health Plan’s system and the Provider’s system, the Clearinghouse will act as a “proxy” for some of the CORE Certification requirements outlined in the Prior Authorization & Referrals CAQH CORE Certification Test Suite.

In this case, the Health Plan may not have to undergo CORE Certification Testing for the applicable rule requirements, however, the Clearinghouse will need to undergo the relevant testing and need to become, or already be, CORE-certified on Prior Authorization & Referrals Operating Rules. On the Health Plan’s application, the Health Plan would need to submit a rationale statement to the CAQH CORE-authorized Testing Vendor that explains that certain functions required by the Prior Authorization & Referrals operating rules and thus being tested are managed by a CORE-certified Clearinghouse. The CAQH CORE-authorized Testing Vendor and CAQH CORE Staff will review the rationale statement provided by the Health Plan and also look to the certification for the clearinghouse. 

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