What is the overall process, expected timelines, and requirements for recertification?

  1. Recertification is required every three years for an entity to remain CORE-certified.
  2. Recertification renewals may occur anytime during the calendar year, based off initial year of certification.
  3. At a minimum, entities must implement versions of CAQH CORE Operating Rules that were published 24 months prior to the CORE Certification Seal renewal date.
  4. Entities seeking to maintain their certification status must complete the CAQH CORE Recertification Application Form within the recertification renewal year.

How long does my certification remain active?

Once certified, CORE-certified entities must remain conformant with applicable CAQH CORE Operating Rules throughout any system upgrades. An entity’s CORE Certification Seal will remain valid for 3 years, based off the year the certification was awarded. Entities are required to complete the recertification process in order to renew its CORE Certification Seal.

Further, A CORE-certified entity may become de-certified and have their CORE Certification Seal revoked if instances of non-conformance are found and not remedied or if there is a 180-day lapse in renewing certification.

What is the CAQH CORE Health Plan IT System Exemption Policy?

The CAQH CORE Health Plan IT System Exemption Policy allows a health plan seeking CORE Certification to request that a scheduled migration of an existing IT system(s) that represents less than 30 percent of a payer’s market share be exempt from being CORE conformance only if the remainder of the health plan’s IT systems are CORE conformant. The policy requires the new IT system to be CORE conformant by the end of the exemption period, which lasts for 12 months.

Is the CAQH CORE complaint process for CORE-certified entities confidential?

Per the CAQH CORE Enforcement Policy, the details of specific complaints against non-conforming CORE-certified entities remain confidential. Names or other identifying information will not be publicly released by CAQH CORE. This information will only be used and disclosed by CAQH CORE for its non-conformance review by the CAQH CORE Enforcement Committee.

What happens if an organization becomes de-certified?

If a CORE-certified entity is found to be in actual violation of a CAQH CORE Operating Rule(s) and the violation is not remedied per the CAQH CORE enforcement timeline, the entity’s certification will be terminated and its name removed from the CAQH CORE website. De-certified organizations are entitled to seek re-certification by re-completing the CORE Certification process and paying all required fees again. De-certified entities can no longer use the CORE Certification Seal and the entity’s name will be removed from all CAQH CORE listing of CORE-certified entities.

What happens if a CORE-certified organization believes that a CORE-certified trading partner is not conforming to the CAQH CORE Operating Rules?

Under the CAQH CORE Enforcement Policy, CORE-certified organizations are encouraged to privately resolve disputes before submitting a formal complaint of possible non-conformance to CAQH CORE. CAQH CORE enforcement is a complaint-driven process that requires documentation (electronic or paper) demonstrating multiple instances of non-conformance with the CAQH CORE Operating Rules at the specific rule set of CORE Certification.

What happens if an entity that is not CORE-certified buys a CORE-certified entity?

Per the CAQH CORE policies on certification, if a CORE-certified entity is acquired by an entity that is not CORE-certified, the acquiring company will only be allowed to be CORE-certified if the acquired company is the only business that is applicable to the CAQH CORE Operating Rules. Or, if the acquired company continues to operate as a separate subsidiary, it may retain its CORE Certification.

My company is seeking CORE Certification but has many subsidiaries. Do they all have to be conformant with the CAQH CORE Operating Rules?

Per the CAQH CORE policies on certification, a parent corporation seeking CORE Certification will not be certified unless all subsidiaries of the corporation are in conformance with the CAQH CORE Operating Rules. Otherwise, each subsidiary of the parent must individually seek certification and thus would receive its own CORE Certification Seal for the appropriate set of CAQH CORE Operating Rules.