Providers who wish to become CORE-certified must comply with all of the CAQH CORE Operating Rules that apply to providers and complete the CORE Certification tests for each rule that applies to providers. See the appropriate CAQH CORE Certification Test Suite, for a list of the provider-specific certification tests. Providers can satisfy the certification requirements by either using a vendor solution or building an in-house solution.

If your organization becomes CORE-certified it is expected to comply with the applicable CAQH CORE rule requirements for your set of CORE Certification. In some cases, CORE Certification requires an entity to coordinate with trading partners in order to achieve and maintain an entity’s own certification.

For each set of CAQH CORE Operating Rules, it is up to individual entities to determine when and if it is feasible to become certified on a particular rule set. CORE-certified organizations are encouraged to become CORE-certified on complementary sets of CAQH CORE Operating Rules that are applicable to their business:

Both an entity’s decision to become CORE-certified and determination on which set of certification is applicable is an internal business decision. An entity’s decision should be based on a review of its business requirements and system capabilities (and those of its trading partners) as well as the scope and functionality of the set of CAQH CORE Operating Rules being considered.

NOTES:

1. CORE-certified entities must demonstrate conformance with all applicable CAQH CORE Operating Rules of the set for which they are certifying.

Your organization should use the CAQH CORE Certification Test Suite and Master Test Bed Data corresponding to the set of CAQH CORE Operating Rules for which your organization is pursuing CORE Certification.

No. It is up to individual organizations to determine when and if it is feasible to become certified on each set of CAQH CORE Operating Rules. An organization’s CORE Certification is active unless the organization loses or does not renew its CORE Certification Seal and is independent of whether or not the organization chooses to certify on additional operating rule sets.

Loss of a CORE Certification Seal is based upon failure to recertify every three years or findings of nonconformance as outlined in the CAQH CORE Enforcement Policy.

Yes. CAQH CORE offers CORE Certification on CAQH CORE Operating Rules to healthcare providers, clearinghouses, and vendor products, including Practice Management Systems, that process the X12 v5010 270/271, X12 v5010 276/277, X12 v5010 835, Healthcare EFT Standard,X12 v5010 837, X12 v5010 278, X12 v5010 834, and/or X12 v5010 820 transactions.

Organizations that share functions, including the entity that has outsourced some functions, may conduct certification testing with different CAQH CORE-authorized testing vendors when seeking CORE Certification.

Any health plan seeking CORE Certification must undergo certification testing for all functions it offers that are covered by the set of CAQH CORE Operating Rules for which the health plan is seeking certification. When a health plan outsources some functions to a clearinghouse, both the health plan and the clearinghouse to which the functions are outsourced will need to undergo CORE Certification testing in order for the health plan to become CORE-certified.