Frequently Asked Questions - vi. Health Care Claims CORE Certification Testing

My organization is a Health Plan. Which rule requirements does my organization have to test for to achieve CORE Certification on CAQH CORE Health Care Claims Operating Rule set?

Submitted by jporras on Thu, 01/14/2021 - 09:10
My organization is a Health Plan. Which rule requirements does my organization have to test for to achieve CORE Certification on CAQH CORE Health Care Claims Operating Rule set?

A Health Plan seeking CORE Certification on the CAQH CORE Health Care Claims Operating Rules must undergo CORE Certification Testing in accordance with the Health Care Claims CAQH CORE Certification Test Suite for:

Organizations are required to successfully complete all applicable test scripts for each of the CAQH CORE Health Care Claims Operating Rules to achieve CORE Certification on Health Care Claims.

A Health Plan that uses a CORE-certified Clearinghouse to meet some of its Health Care Claims requirements may need to engage the clearinghouse when undergoing Health Care Claims 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 Health Care Claims CAQH CORE Certification Test Suite.

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, CORE-certified on the CAQH CORE Health Care Claims 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 Health Care Claims 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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