Frequently Asked Questions - Vii. Benefit Enrollment CORE Certification Testing

My organization is a Health Plan. Which rule requirements does my organization have to test for to achieve CORE Certification on Benefit Enrollment Operating Rules?

Submitted by jporras on Thu, 01/14/2021 - 09:12
My organization is a Health Plan. Which rule requirements does my organization have to test for to achieve CORE Certification on Benefit Enrollment Operating Rules?

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:

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. 

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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?

Submitted by jporras on Thu, 01/14/2021 - 09:13
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 Benefit Enrollment Operating Rules related to the X12 834 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.

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