If a health plan outsources some functions to a clearinghouse, will the two entities have to use the same CAQH CORE-authorized testing vendor? If not, can test data or results be exchanged between the two testing vendors?

How will the CORE Certification process be affected for a clearinghouse/vendor and a health plan/provider if the clearinghouse/vendor acts on behalf of the health plan/provider for some CAQH CORE Operating Rules?

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.

What certification testing tasks do providers need to accomplish to become CORE-certified?

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.

My organization has achieved CORE Certification; however, none of my trading partners are CORE-certified. Do we have to comply with the CAQH CORE Operating Rules?

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. Trading partner coordination:

Will my organization have to complete the CORE Certification process for each set of CAQH CORE Operating Rules?

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 all sets of CAQH CORE Operating Rules applicable to their business.

My organization is not CORE-certified. Which set of CORE Certification is applicable to us?

Both an entity’s decision to become CORE-certified and determination on which set of CAQH CORE Operating Rules 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.

If we are CORE-certified on a set of CAQH CORE Operating Rules, do we stand to lose the certification if we don't also certify on other operating rule sets?

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.



Is CORE Certification available for stakeholder organizations that are not health plans?

 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.