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

How does my organization determine the appropriate CAQH CORE stakeholder type category when applying for the Prior Authorization & Referrals Certification Seal?

Submitted by tfuchs@caqh.org on Tue, 03/01/2022 - 11:11
How does my organization determine the appropriate CAQH CORE stakeholder type category when applying for the Prior Authorization & Referrals Certification Seal?

Organizations that can obtain the Prior Authorization & Referrals CORE Certification Seal are categorized into four CORE Certification stakeholder types: Providers, Health Plans, Clearinghouses, and Vendors.

The Prior Authorization & Referrals CAQH CORE Certification Test Suite includes examples of organizations that can obtain the Prior Authorization CORE Certification Seal.  The  Prior Authorization & Referrals CAQH CORE Certification Test Suite also provides guidance as to the type of stakeholders to which the CAQH CORE Prior Authorization & Referrals Operating Rules apply and how to determine when a specific rule’s detailed test script applies to a stakeholder.

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My organization is a HIPAA-covered Health Plan. Which CAQH CORE Prior Authorization & Referrals Operating Rule requirements does my organization have to test for in order to achieve CORE Certification on the CAQH CORE Prior Authorization & Referrals Opera

Submitted by Adam Nichols on Wed, 03/02/2022 - 13:04
My organization is a HIPAA-covered Health Plan. Which CAQH CORE Prior Authorization & Referrals Operating Rule requirements does my organization have to test for in order 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:

  • The CAQH CORE Prior Authorization & Referrals (278) Infrastructure Rule
  • The CAQH CORE Prior Authorization & Referrals (278) Data Content Rule
  • The CAQH CORE Prior Authorization & Referrals Web Portal Rule
  • The CAQH CORE Connectivity Rule vC3.1.0 or CAQH CORE Connectivity Rule v4.0.0

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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