CAQH - CORE Certification Step-by-Step

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CORE Certification:

A Step-By-Step Process for Phase I and Phase II

Overview

CORE certification is for entities that create, use, or transmit eligibility and/or claim status data, including clearinghouses, health plans, providers and vendors. Entities that do not create, use or transmit such data, or are a small provider, 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.

The CORE certification process has four components:

  1. Pre-certification Planning and Systems Evaluation
  2. Signing and Submitting the CORE Phase II Pledge/Addendum
  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.

CORE Phase I certification is required prior to or in conjunction with CORE Phase II certification.

The CORE documents required to complete each component step are indicated and accessible through the included links to the CAQH website.

Component 1: Pre-certification Planning and Systems Evaluation

  1. Obtain and review the Rules and Policies
    • Phase I - CORE Rules and Policies Version 1.0.0.
    • Phase II - CORE Rules and Policies Version 2.0.0.
  2. Obtain and review the Certification Policy
    • Phase I - CORE 102: Certification Policy Version 1.0.0.
    • Phase II - CORE 202: Certification Policy Version 2.0.0.
  3. Obtain and review the Testing Policy
    • Phase I - CORE 104: Testing Policy Version 1.0.0.
    • Phase II - CORE 204: Testing Policy Version 2.0.0.
  4. Obtain and review the Master Test Suite
    • Phase I - CORE Master Test Suite Version 1.0.1.
    • Phase II - CORE Phase II Master Test Suite Version 2.0.0.
  5. Obtain and review the Master Test Bed Data
    • Phase I - CORE Master Test Bed Data Version 1.0.1.
    • Phase II - CORE Phase II Master Test Bed Data Version 2.0.0.
  6. Gauge your organization’s ability to adopt and become compliant with the CORE rules by identifying systems/software gaps.
  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.
  9. Determine if your organization is eligible for the CORE Health Plan IT System Exemption by reviewing the appropriate Exemption Policy (Phase I or Phase II). 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. This completed form (signed by an authorized senior executive) must be submitted with your organization’s signed CORE Seal Application (Phase I and/or Phase II).
  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.

Questions: Contact CAQH at (202) 861-6380

Component 2: Sign and Submit the CORE Pledge

  1. Sign the appropriate CORE Pledge (Phase I or Phase II). 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

Questions: Contact CAQH at (202) 861-6380

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
      • Phase I - CORE 104: Testing Policy Version 1.0.0.
      • Phase II - CORE 204: Testing Policy Version 2.0.0.
    2. Obtain and review the Master Test Suite
      • Phase I - CORE Master Test Suite Version 1.0.1.
      • Phase II - CORE Phase II Master Test Suite Version 2.0.0.
    3. Obtain and review the Master Test Bed Data (includes rules against which you will be tested).
      • Phase I - CORE Master Test Bed Data Version 1.0.1.
      • Phase II - CORE Phase II Master Test Bed Data Version 2.0.0.
        1. Upgrade all affected IT systems/software as necessary to bring them into compliance with CORE rules.
        2. Complete internal testing of CORE-ready systems.
        3. Obtain a list of CORE-authorized testing vendors.
        4. Select and contact the CORE-authorized certification testing vendor with whom you wish to work. CORE-authorized testing vendors also may offer pre-certification testing.
  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 or Phase II) 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

CORE Seal Fee* Scale

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 or Phase II). 

     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
  1. Determine your CORE Seal fee by reviewing the fee scale above or on the CORE Seal Application form (Phase I or Phase II).
  2. Complete the appropriate CORE Seal Application(s) (Phase I or Phase II).
  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 or Phase II) Note: The form must be signed by an authorized executive.
    3. If applicable, a Health Plan IT Exemption Request Form. 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

Questions: Contact CAQH at (202) 861-6380

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 or Phase II) 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.

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