Frequently Asked Questions - viii. Premium Payment CORE Certification Testing

My organization is a HIPAA-covered Health Plan. Which CAQH CORE Premium Payment Operating Rule requirements does my organization have to test for in order to achieve CORE Certification on the CAQH CORE Premium Payment Operating Rule set?

Submitted by jporras on Thu, 01/14/2021 - 09:15
My organization is a HIPAA-covered Health Plan. Which CAQH CORE Premium Payment Operating Rule requirements does my organization have to test for in order to achieve CORE Certification on the CAQH CORE Premium Payment Operating Rule set?

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

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

A Health Plan that uses a CORE-certified Clearinghouse to meet some of its Premium Payment requirements may need to engage the clearinghouse when undergoing Premium Payment 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 Premium Payment 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 Premium Payment 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 Premium Payment 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 the premium payment (ASC X12 820) to HIPAA-covered health plans but doesn’t process or conduct any other transactions. Can my solution become CORE-certified if it only sends this transaction?

Submitted by jporras on Thu, 01/14/2021 - 09:17
My organization is a Vendor with a solution/product that sends the premium payment (ASC X12 820) to HIPAA-covered health plans but doesn’t process or conduct any other transactions. Can my solution become CORE-certified if it only sends this transaction?

The Premium Payment operating rules related to the ASC X12 focus on the infrastructure flow between the health plan and sender. There are no CAQH CORE Premium Payment Operating Rules that apply to only senders of the premium payment transaction (820), so there are no associated test scripts or tasks for the CORE Certification Testing. The Premium Payment CAQH CORE Certification Test Suite includes requirements for only the receivers of premium payments (820); i.e., HIPAA-covered Health Plans or their agents, such as third party administrators. 

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