CORE Certification: A Step-By-Step Process For Phase I, Phase II and Phase III

Overview

Thank you for your interest in CORE Certification. CAQH certifies and awards CORE Certification Seals to entities that create, transmit or use the administrative 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 a specific phase(s) of the CAQH CORE Operating Rules. Voluntary CORE Certification is available for providers, health plans, clearinghouses, and product vendors.

Organizations that do not create, transmit, or use administrative healthcare transactions, and therefore cannot implement the CAQH CORE Operating Rules, can demonstrate their support for the CORE mission and vision 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.

CORE Certification on phases of the CAQH CORE Operating Rules can be completed concurrently or successively. An entity may choose to test and become certified for Phase I, then Phase II, and later Phase III or undergo combined voluntary CORE Certification testing for all three phases concurrently. To become voluntarily certified on a higher phase of CAQH CORE Operating Rules an entity must be CORE-certified on the earlier phases.

The CORE Certification process has four components:

  1. Pre-certification Planning and Systems Evaluation
  2. Signing and Submitting the CORE Pledge and Appropriate Phase II and Phase III Addenda
  3. CORE Certification Testing
  4. Applying for the CORE Seal

Each of the components has multiple steps which must be completed prior to moving on to the next component. The CORE documents required to complete each component step are indicated and accessible through the included links to the CAQH website.

Questions: Contact CAQH CORE at (202) 861-6380 or at core@caqh.org.

Component 1: Pre-certification Planning and Systems Evaluation

  1. Obtain and review the Rules and Policies
  2. Obtain and review the Certification Policy
  3. Obtain and review the Testing Policy
  4. Obtain and review the Master Test Suite
  5. Obtain and review the Master Test Bed Data (if completing Phase I or Phase II CORE Certification)
  6. Gauge your organization’s ability to adopt and become compliant with the CORE rules by identifying systems/software gaps. CAQH CORE offers Analysis & Planning Guides that can help entities to identify system/software gaps and create a project plan to complete any necessary system remediation:
  7. Consider requesting a call with CAQH staff, who can provide tools to help with your analysis.
  8. Create a project plan to eliminate any gaps found between CORE rule requirements and your organization’s current systems capabilities. All gaps should be closed prior to the start of CORE certification testing. (See F above for a tool that can be used to develop a project plan.)
  9. Determine if your organization is eligible for the CORE Health Plan IT System Exemption by reviewing the appropriate Exemption Policy (Phase I, Phase II, or Phase III). This exemption allows a health plan that has a scheduled migration of an existing IT system(s) to delay certification of that component of its systems until the new one is in place. Migration must be scheduled for completion no later than 12 months from the date of when the health plan is granted CORE Certification.

    If your organization qualifies for this exemption, obtain and complete the Health Plan IT Exemption Request Form (Phase I, Phase II or Phase III). This completed form (signed by an authorized senior executive) must be submitted with your organization’s signed CORE Seal Application (Phase I, Phase II, or Phase III).
  10. Determine when your organization is ready to sign the CORE Pledge.
    NOTE: Organizations seeking CORE certification must complete CORE certification testing within 180 days of submitting the signed CORE Pledge to CAQH. The CORE Pledge must be signed by an authorized executive level employee.

Component 2: Sign and Submit the CORE Pledge

  1. Sign the appropriate CORE Pledge (Phase I, Phase II, or Phase III). NOTE: Organizations seeking CORE certification must complete CORE certification testing within 180 days of submitting the signed CORE Pledge to CAQH. The CORE Pledge must be signed by an authorized executive level employee.
  2. Submit the signed CORE Pledge to CAQH.

    Organizations seeking CORE certification may submit a signed CORE Pledge form via email (CORE@caqh.org), fax: (202) 861-1454, or mail:
    CORE, c/o CAQH
    601 Pennsylvania Avenue, NW
    South Building, Suite 500
    Washington, DC 20004

Component 3: CORE Certification Testing

CORE certification testing is to be completed in three phases: Pre-Testing, Testing and Post-Testing. All stakeholders essential to the success of eligibility and benefits and/or claim status data exchange transactions are addressed in the CORE certification testing process – providers, health plans, clearinghouses, and vendors. CORE testing varies by each stakeholder type.

  1. Pre-certification Phase (this step may be performed prior to submitting the CORE Pledge. CORE-authorized testing vendors also may offer pre-certification testing. Contact your CORE-authorized testing vendor for more information.)
    1. Obtain and review the Testing Policy
    2. Obtain and review the Master Test Suite
    3. Obtain and review the Master Test Bed Data (includes rules against which you will be tested).
  2. Testing Phase
    1. Schedule CORE certification testing with your selected CORE-authorized testing vendor. CORE-authorized vendors are committed to a CORE-certification testing request within 30 business days from when you contact them, unless you ask otherwise.
    2. Complete CORE certification testing within the 180-day pledge window.

  3. Post-Testing Phase
    1. Remediate all systems/software issues identified by the CORE-authorized testing entity and, if necessary, repeat the certification testing.

Questions: Contact the CORE-authorized testing vendor you have selected with any questions or concerns related to any phase of the CORE-certification testing process.

NOTES:

  • Upon successful completion of the certification testing, the CORE-authorized testing vendor will provide you with documentation attesting to the successful completion of your organizations CORE certification testing.
  • Any fee/cost imposed by the CORE-authorized testing vendor will be independent and separate from the fee charged by CORE for your organization to obtain the CORE Seal.
  • Complaints regarding CORE-authorized testing vendors: In the event an entity seeking CORE certification is dissatisfied with its testing results, it may file an appeal with CAQH. CORE will investigate the appeal within 20 business days of receipt of the appeal. If the appeal is deemed valid, CORE will require the CORE-authorized testing entity to retest the entity within 21 business days of CORE’s request. See the appropriate CORE Testing Policy (Phase I, Phase II or Phase III) for more information.

For complaints or appeals regarding the CORE-authorized testing vendor, contact CAQH at (202) 861-6380.

Component 4: Applying For the CORE Seal

  1. Determine your CORE Seal fee by reviewing the fee scale below or on the CORE Seal Application form (Phase I, Phase II, or Phase III).

    The fee for the CORE Seal is based upon a stakeholder-specific fee scale. This fee is a one-time cost for each phase of CORE certification, unless an entity becomes de-certified. For more information about certification and decertification, see the appropriate CORE Certification Policy (Phase I, Phase II or Phase III).
    CORE Seal Fee* Scale
    Health Plans  
    Below $75 million in net annual revenue: $4,000 fee
    $75 million and above in net annual revenue: $6,000 fee
       
    Clearinghouses  
    Below $75 million in net annual revenue: $4,000 fee
         EHNAC HNAP-EHN accredited - apply 10% ($400) discount
    $75 million and above in net annual revenue: $6,000 fee
         EHNAC HNAP-EHN accredited - apply 10% ($600) discount
       
    Vendors  
    Below $75 million in net annual revenue: $4,000 fee
    $75 million and above in net annual revenue: $6,000 fee
       
    Providers  
    Up to $1 billion in net annual revenue: $500 fee
    $1 billion and above in net annual revenue: $1,500 fee
       
    Federal or State Government Entities No Fee

    *Fees are a one-time cost for each Phase of certification

  2. Complete the appropriate CORE Seal Application(s) (Phase I, Phase II, or Phase III).
  3. Package the completed CORE Seal Application form with the following required paperwork:
    1. Successful testing results from a CORE-authorized testing vendor affirming successful completion of CORE certification testing.
    2. Completed HIPAA Attestation Form for the appropriate phase(s) (Phase I, Phase II or Phase III) Note: The form must be signed by an authorized executive.
    3. If applicable, a Health Plan IT Exemption Request Form (Phase I, Phase II or Phase III). The form must include an executive-level attestation stating that the health plan meets the agreed-upon IT system exemption criteria and has the ability to identify those transactions to which the exemption applies.
  4. Submit the CORE Seal Application form with a check for the appropriate CORE Seal fee to:
    CORE, c/o CAQH
    601 Pennsylvania Avenue, NW
    South Building, Suite 500
    Washington, DC 20004
 

NOTES:

  • CORE will inform each CORE Seal applicant of its queue status at the time of its application submission.
  • Upon receiving a CORE Seal Application form, CORE will have a maximum of 20 business days to complete its assessment of the application and respond to the applicant with a clear response of approval or need for clarification.
  • A final decision about the CORE Seal application will be made by CORE in 30 business days, unless there are extenuating circumstances. If so, CORE will notify the applicant about the reason for the assessment extension.
  • The 12-month Health Plan IT System Exemption period will begin on the day that the health plan granted an exemption is granted its CORE Seal.
  • After receiving a CORE Seal, the certified entity may market itself as being CORE-certified.
  • CORE will report on its website:
    • CORE-certified entities and endorsers
    • The number of certification applications it has received by stakeholder type
    • The number that are in process by stakeholder type on a monthly basis

CORE Certification Terms and Conditions

CORE certification will remain valid unless a certified entity’s seal is revoked as a result of a validated complaint of noncompliance. See the appropriate CORE Enforcement Policy (Phase I, Phase II or Phase III) for more information.

After remedying the issue which led to the validated complaint of noncompliance, the decertified entity is free to seek recertification at any time. Decertified entities will need to complete the entire certification process and pay all applicable fees to achieve CORE certification.

NOTE: CORE rules may be substantially modified one time during the first year of each relevant phase if agreed to by a vote of the entire CORE membership. If that substantial modification takes place, all entities (certified for the relevant Phase, or not) will need to complete the entire CORE certification process and pay all applicable fees to achieve CORE certification for the modified set of the relevant Phase rules.

Return to Top