Frequently Asked Questions - Vii. Benefit Enrollment CORE Certification Testing

Organizations that can obtain the Benefit Enrollment CORE Certification Seal are categorized into three CORE Certification stakeholder types: Health Plans, Clearinghouses, and Vendors.

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

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

• The CAQH CORE Benefit Enrollment (834) Infrastructure Rule
• The CAQH CORE Connectivity Rule vC3.1.0 or CAQH CORE Connectivity Rule vC4.0.0

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

A Health Plan that uses a CORE-certified Clearinghouse to meet some of its Benefit Enrollment requirements may need to engage the clearinghouse when undergoing Benefit Enrollment 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 Benefit Enrollment 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 the CAQH CORE Benefit Enrollment 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 Benefit Enrollment 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. 

The CAQH CORE Benefit Enrollment Operating Rules related to the ASC X12 focus on the infrastructure flow between the health plan and sender. There are no Benefit Enrollment 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 Benefit Enrollment CAQH CORE 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.