Frequently Asked Questions - vi. Phase V CORE Certification Testing

What does it mean to be a CORE Endorser?

Submitted by caqh_admin on Thu, 12/24/2015 - 00:34
What does it mean to be a CORE Endorser?

Organizations that do not create, transmit, or use administrative healthcare transactions, and therefore cannot implement the CAQH CORE Operating Rules, are eligible to become CORE Endorsers.

CORE Endorser Organizations demonstrate their support for the CAQH CORE mission and the CAQH CORE Operating Rules by signing the CORE Endorser Pledge for the appropriate phase (see below) and applying for the respective CORE Endorser Seal.

CORE-endorsing organizations may participate in CAQH CORE public relations campaigns, provide feedback and input when requested to do so by CAQH CORE, and encourage their members/partners to consider becoming CORE-certified. Please refer to the CORE Endorsement Application Process for information on how to obtain a Phase I, Phase II, Phase III, and/or Phase IV CORE Endorser Seal.

NOTE: CORE Endorsers may or may not be CORE Participating Organizations; there is no fee to obtain the CORE Endorser Seal.

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How does my organization determine the appropriate CAQH CORE stakeholder type category when applying for the CAQH CORE Phase V Certification Seal?

Submitted by Adam Nichols on Wed, 11/20/2019 - 12:46
 How does my organization determine the appropriate CAQH CORE stakeholder type category when applying for the CAQH CORE Phase V Certification Seal?

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

Section 2.2.5 of the Phase V CAQH CORE Certification Test Suite includes examples of organizations that can obtain the Phase V CAQH CORE Certification Seal. The Phase V CAQH CORE Certification Test Suite also provides guidance as to the type of stakeholders to which the Phase V CAQH CORE Operating Rules apply and how to determine when a specific rule’s detailed test script applies to a stakeholder.

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.

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

Submitted by Adam Nichols on Wed, 11/20/2019 - 13:00
My organization is a HIPAA-covered Health Plan. Which Phase V CAQH CORE Operating Rule requirements does my organization have to test for in order to achieve Phase V CORE Certification?

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

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

A Health Plan that uses a CORE-certified Clearinghouse to meet some of its Phase V requirements may need to engage the clearinghouse when undergoing Phase V 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 V CAQH CORE Certification Test Suite.  This approach was also used in the Phase I-IV 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 V 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 V 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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What infrastructure requirements do organizations need to meet in order to obtain a CAQH CORE Phase V Certification Seal?

Submitted by Adam Nichols on Wed, 11/20/2019 - 13:04
What infrastructure requirements do organizations need to meet in order to obtain a CAQH CORE Phase V Certification Seal?

The Phase V Operating Rules are focused on data content requirements. There are no CAQH CORE Phase V Operating Rule requirements on infrastructure for the prior authorization transaction in this rule set, and, therefore, there are no infrastructure test scripts required for Phase V Certification. Infrastructure requirements are found within the CAQH CORE Phase IV Operating Rule Requirements.

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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?

Submitted by Adam Nichols on Wed, 11/20/2019 - 13:18
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.

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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?

Submitted by Adam Nichols on Wed, 11/20/2019 - 13:22
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 V 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.

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