Certification: HHS Proposed Program and CORE

CORE Certification

Thank you for your interest in CORE Certification. CAQH certifies and awards CORE Certification Seals to entities that create, transmit or use the healthcare administrative and financial transactions addressed by the CAQH CORE Operating Rules. CORE Certification means an entity has demonstrated that its IT system, or product, is operating in conformance with applicable requirements of a specific phase(s) of the CAQH CORE Operating Rules.
 
If you are a health plan, provider, clearinghouse, or vendor interested in information related to the CORE Certification please click HERE.
 
If you are a HIPAA covered health plan interested in learning more about the mandatory HHS health plan certification or compliance process please continue reading below.
 

ACA Section 1104 Mandated Certification Process

Section 1104 of the Patient Protection and Affordable Care Act (ACA) mandates a certification process for health plans only. Per the ACA, health plans must file a statement with HHS, in such form as the Secretary may require, certifying that their data and information systems are in compliance with any applicable standards and associated operating rules.
 
On December 31, 2013​, HHS issued a Notice of Proposed Rulemaking (NPRM) on the ACA-mandated health plan certification. HHS is accepting public comments on the NPRM through April 3, 2014 (previously March 3, 2014). The NPRM includes health plan certification requirements for the eligibility, claim status, electronic funds transfers (EFT), and electronic remittance advice (ERA) transactions. It defines two potential certification options for health plans to meet HHS compliance requirements:
 
Option 1: HIPAA Credential: Under the HIPAA Credential Program it is proposed that health plans will attest to compliance with the HIPAA-mandated standards and operating rules. NOTE: In order to share comments with HHS on the NPRM, CAQH CORE will actively gather industry comments on the proposed HIPAA Credential Program and the other parts of the NPRM. Once HHS issues the Final Rule later in 2014, CAQH CORE, as the proposed administrator, would offer the ability to complete the necessary HIPAA Credential documentation. Prior to publication of the Final Rule, the draft HIPAA Credential documentation, as outlined in the NPRM, will be available on the CAQH CORE website. For more information on Option 1 click HERE.
 
Option 2: CORE Certification: The NPRM proposes to adopt the existing CORE Certification Program, authored and administered by CAQH CORE. Health plans that successfully complete certification testing with a CORE-authorized testing vendor and submit the required documentation will receive a Phase III CORE Certification Seal demonstrating their compliance. CORE Certification is available now. For more information on Option 2 click HERE.
 

Commenting on the NPRM

Industry stakeholders are encouraged to participate in the CAQH CORE efforts that will be used to collect comments on the NPRM. Based on this industry input, CAQH CORE will develop a model letter that both CORE and non-CORE Participants may customize and use as they deem appropriate in submitting comments on the NPRM to HHS. The schedule and deliverables related to creating a model letter are:
 
Deliverable
Date of Issue
by CAQH CORE
Industry Response
Due to CAQH CORE
(Also sent via email to CAQH CORE Contacts)
 
January 21, 2014
 
Open CAQH CORE Call on Initial List
(Presentation and call recording posted on CAQH CORE Education Events webpage)
January 22, 2014, 2pm ET
CORE and non-CORE Participants attended the call.
(Also sent via email to CAQH CORE Contacts)
February 10, 2014
(To be posted on this webpage and sent via email to CAQH CORE Contacts)
Any entity can use all or parts of the model comment letter. Comments are due to HHS by April 3, 2014 (previously March 3, 2014).
 
 
Please contact CORE@caqh.org to be added to the CAQH CORE Contacts email list.
 
NOTE: Organizations that do not create, transmit, or use healthcare administrative and financial transactions, and therefore are ineligible for CORE Certification, can demonstrate their support for the CAQH CORE mission and Operating Rules by applying for and using the CORE Endorser Seal. Please refer to the CORE Endorser Seal: Application Process page for further information.