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

II. Introduction to CORE Certification

C. CORE Certification: Testing

v. Phase IV CORE Certification Testing

  1. How does my organization determine the appropriate CAQH CORE stakeholder type category when applying for the CAQH CORE Phase IV Certification Seal?
  2. My organization is a HIPAA-covered Health Plan. Which Phase IV CAQH CORE Operating Rule requirements does my organization have to test for in order to achieve Phase IV CORE Certification?
  3. My organization is a Vendor with a solution/product that sends the premium payment (ASC X12 820) to HIPAA-covered health plans, but doesn’t process or conduct any other transactions. Can my solution become CORE-certified if it only sends this transaction?
  4. My organization is a vendor with a solution/product that sends benefit enrollment & maintenance information (834) to HIPAA-covered health plans. Can my solution/product become CORE-certified?
  5. My organization is a vendor with a product/solution that only supports one and soon to be two of the four transactions addressed by the CAQH CORE Phase IV Operating Rules. Is my organization able to test that product/solution on only those transaction(s) supported by my product and obtain a CAQH CORE Phase IV Certification Seal?
  6. My organization is a Clearinghouse with a solution that does not support all four of the transactions addressed by the CAQH CORE Phase IV Operating Rules. Is my organization able to test that solution for only those transaction(s) supported by my solution and obtain a CAQH CORE Phase IV Certification Seal?
  7. My organization is a provider. My organization conducts the health care claims and the prior authorization transactions, but does not conduct the enrollment and disenrollment in a health plan transaction or the premium payment transaction. Is my organization able to test for the two transactions that is does conduct and obtain a CAQH CORE Phase IV Certification Seal?
  8. What data content requirements do organizations need to meet in order to obtain a CAQH CORE Phase IV Certification Seal?
  9. In order to become CORE-certified for any CAQH CORE Phase, an organization or product has to undergo CAQH CORE Certification Testing. Where do I go for CAQH CORE Certification Testing?
  10. My organization is interested in pursuing CORE Certification, but a testing task in the CAQH CORE Certification Test Suite does not apply to my organization or its line of business. What do I do?
1. How does my organization determine the appropriate CAQH CORE stakeholder type category when applying for the CAQH CORE Phase IV Certification Seal?

Organizations that can obtain the CAQH CORE Phase IV Certification Seal are categorized into four CORE Certification stakeholder types: Providers, Health Plans, Clearinghouses, and Vendors.

Section 2.2.5 of the Phase IV CAQH CORE Voluntary Certification Test Suite includes examples of organizations that can obtain the Phase IV CAQH CORE Certification Seal.  The Phase IV CAQH CORE Voluntary Certification Test Suite also provides guidance as to the type of stakeholders to which the Phase IV CAQH CORE Operating Rules apply and how to determine when a specific rule’s detailed test script applies to a stakeholder.  For a brief overview, please also see the slides from the Phase IV Certification webinar. 

NOTE: While three of the four CORE Certification stakeholder types share names with HIPAA-covered entities – Health Plans, Providers, and Clearinghouses – for purposes of voluntary CORE Certification, these three CORE Certification stakeholder types encompass a broader group of organizations than what is included in their respective HIPAA definitions. 

2. My organization is a HIPAA-covered Health Plan. Which Phase IV CAQH CORE Operating Rule requirements does my organization have to test for in order to achieve Phase IV CORE Certification?

A Health Plan seeking Phase IV CORE Certification must undergo CAQH CORE Certification Testing in accordance with the Phase IV CAQH CORE Voluntary Certification Test Suite for:

Organizations are required to successfully complete all applicable test scripts for each of the Phase IV CAQH CORE Operating Rules to achieve Phase IV CORE Certification.

A Health Plan that uses a CORE-certified Clearinghouse to meet some of its Phase IV requirements may need to engage the clearinghouse when undergoing Phase IV CAQH 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 Phase IV CAQH CORE Voluntary Certification Test Suite.  This approach was also used in the Phase I-III testing and application submission process so your health plan may be familiar with the needed coordination with your clearinghouse.  

In this case, the Health Plan may not have to undergo CAQH 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, Phase IV CORE-certified. 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 Phase IV 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. 

3. My organization is a Vendor with a solution/product that sends the premium payment (ASC X12 820) to HIPAA-covered health plans, but doesn’t process or conduct any other transactions. Can my solution become CORE-certified if it only sends this transaction?

The Phase IV operating rules related to the ASC X12 focus on the infrastructure flow between the health plan and sender. There are no CAQH CORE Phase IV Operating Rules that apply to only senders of the premium payment transaction (820), so there are no associated test scripts or tasks for the CAQH CORE Certification Testing.  The Phase IV CAQH CORE Voluntary Certification Test Suite includes requirements for only the receivers of premium payments (820); i.e., HIPAA-covered Health Plans or their agents, such as third party administrators. 

4. My organization is a vendor with a solution/product that sends benefit enrollment & maintenance information (834) to HIPAA-covered health plans. Can my solution/product become CORE-certified?

The CAQH CORE Phase IV Operating Rules related to the ASC X12 focus on the infrastructure flow between the health plan and sender. There are no CAQH CORE Phase IV Operating Rules that apply to senders of benefit enrollment & maintenance information (834), so there are no associated test scripts or tasks for the CAQH CORE Certification Testing.  The Phase IV CAQH CORE Voluntary Certification Test Suite includes requirements for only the receivers of the benefit enrollment & maintenance information (834); i.e., HIPAA-covered Health Plans or their agents, such as third party administrators.

5. My organization is a vendor with a product/solution that only supports one and soon to be two of the four transactions addressed by the CAQH CORE Phase IV Operating Rules. Is my organization able to test that product/solution on only those transaction(s) supported by my product and obtain a CAQH CORE Phase IV Certification Seal?

Yes. A Vendor or Clearinghouse product or solution that supports only certain transactions may become CORE-certified on only the CAQH CORE Operating Rules that apply to the transaction or transactions that they support. This is the approach for Phase I-III as well, e.g. some vendors only do eligibility and not claim status. The CAQH CORE Phase IV Certification Seal for a Vendor and Clearinghouse will indicate which of the Phase IV transactions is supported by an organization’s product or solution.

Please see question # above if your product/solution only. However, if your product or solution only sends benefit enrollment & maintenance information (834) and/or premium payments (820) to health plans. 

6. My organization is a Clearinghouse with a solution that does not support all four of the transactions addressed by the CAQH CORE Phase IV Operating Rules. Is my organization able to test that solution for only those transaction(s) supported by my solution and obtain a CAQH CORE Phase IV Certification Seal?

Yes. A Vendor or Clearinghouse product or solution that supports only certain transactions may become CORE-certified on only the CAQH CORE Operating Rules that apply to the transaction or transactions that they support. This is the approach for Phase I-III as well, e.g. some vendors only do eligibility and not claim status. The CAQH CORE Phase IV Certification Seal for a Vendor and Clearinghouse will indicate which of the Phase IV transactions is supported by an organization’s product or solution. 

7. My organization is a provider. My organization conducts the health care claims and the prior authorization transactions, but does not conduct the enrollment and disenrollment in a health plan transaction or the premium payment transaction. Is my organization able to test for the two transactions that is does conduct and obtain a CAQH CORE Phase IV Certification Seal?

Yes. Since providers do not conduct the enrollment and disenrollment in a health plan and premium payment transactions (these transactions are between X and Y), they are not required to complete Phase IV CORE CAQH CORE Certification Testing related to these transactions in order to obtain CAQH CORE Phase IV Certification.

8. What data content requirements do organizations need to meet in order to obtain a CAQH CORE Phase IV Certification Seal?

The Phase IV Operating Rules are focused on infrastructure requirements, e.g. response time, Acknowledgements.  There are no CAQH CORE Phase IV Operating Rule requirements for data content for the four transactions in this rule set, and, therefore, there are no data content test scripts required for Phase IV Certification.  Please note, CAQH CORE is reviewing options for data content for Prior Authorization per its commitment that Phase IV was an initial step. Contact CORE@caqh.org if you are interested in participating in this dialog. 

9. In order to become CORE-certified for any CAQH CORE Phase, an organization or product has to undergo CAQH CORE Certification Testing. Where do I go for CAQH CORE Certification Testing?

CAQH 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 CAQH CORE Certification Testing on all CAQH CORE Operating Rule phases. 

10. My organization is interested in pursuing CORE Certification, but a testing task in the CAQH CORE Certification Test Suite does not apply to my organization or its line of business. What do I do?

In the CAQH 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 Phase IV Quick Start Guide.

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.