Certification Process
CORE Certification provides assurance to organizations that their IT systems or products conform to operating rules and deliver value afforded by the rules.
Begin the CORE Certification Process by following the steps listed below and join the growing number of organizations that are currently undergoing or have completed CORE Certification. See a list of organizations that are currently undergoing or have completed CORE Certification here.
CORE Certification on specific CAQH CORE rule sets can be completed concurrently or successively.
The CORE Certification process has five components. Each of the components has multiple steps which must be completed prior to moving on to the next component. The documents required to complete each component step are included in the tabs below.
Note: Organizations that do not directly implement the operating rules can demonstrate their support for CAQH CORE’s mission, collaborative industry approach and administrative simplification objectives by applying for and using the CORE Endorser Seal.
Questions? Contact us at core@caqh.org
The Certification Components
Gauge your organization’s ability to adopt and become compliant with the CORE Operating Rules by identifying systems/software and business process gaps and start the collection of efficiency metrics to measure impact of operating rule implementation. The following documents will help you create a project plan to eliminate any gaps found between CAQH CORE rule requirements and your organization’s current capabilities: All gaps should be closed prior to the start of CORE certification testing. Additionally, consider requesting a call with CAQH CORE Staff, who can provide guidance to help with your remediation project.
| Name of Document | Description | Eligibility & Benefits | Claim Status | Payment & Remittance | PA & Referrals | Health Care Claims | Benefit Enrollment | Premium Payment |
|---|---|---|---|---|---|---|---|---|
| CAQH CORE Operating Rules | Lists and explains the transaction-specific operating rules regarding Certification and Certification testing | Eligibility & Benefits | Claim Status | Payment & Remittance | PA & Referrals | Health Care Claims | Benefit Enrollment | Premium Payment |
| CAQH CORE Analysis and Planning Guides | Help entities identify system/software gaps and create a project plan to complete any necessary system remediation | Eligibility & Benefits Analysis & Planning Guide | Claim Status Analysis & Planning Guide | Payment & Remittance Analysis & Planning Guide | PA & Referrals Analysis & Planning Guide | Health Care Claims Analysis & Planning Guide | Benefit Enrollment Analysis & Planning Guide | Premium Payment Analysis & Planning Guide |
| CAQH CORE Master Test Suites | Transaction-specific documents that specify the test scripts that must be met in Certification Testing | Eligibility & Benefits Master Test Suite | Claim Status Master Test Suite | Payment & Remittance Master Test Suite | PA & Referrals Master Test Suite | Health Care Claims Master Test Suite | Benefit Enrollment Master Test Suite | Premium Payment Master Test Suite |
| Master Test Bed Data | Dummy data that must be used in Certification Testing | Eligibility & Benefits Master Test Bed Data | Not Applicable | Not Applicable | PA & Referrals Master Test Bed Data | Not Applicable | Not Applicable | Not Applicable |
| CAQH CORE Operating Rule Implementation Survey Tool | Helps entities understand the impact, costs, and benefits of implementing operating rules | Operating Rule Implementation Survey Tool | ||||||
| CORE Certification Policy | Outlines principles and polices that guide the CORE Certification Program. | CORE Certification Policy | ||||||
| CAQH CORE FAQs | Frequently asked questions and answers serve as helpful resources to organizations, aiding to answer both general and technical questions about CORE Certification and CAQH CORE Operating Rules | FAQS | ||||||
A. Sign and submit the CORE Pledge: The first form to submit is the CORE Pledge. The CORE Pledge must be signed by an authorized executive level employee.
B. Submit the signed CORE Pledge for each of the CAQH CORE Operating Rule transactions that you are pursuing via email, fax, or mail.
Email, Fax, or Postal Service Submission:
Organizations may submit the CORE Pledge via email (CORE@caqh.org), fax: (202) 517-0397 or mail:
CORE, c/o CAQH
2020 K Street, NW
Suite 900
Washington, DC 20006
Your organization may download and/or print the CORE Pledge Forms for the following transaction by clicking the asccoiated links: Eligibility & Benefits, Claim Status, Payment & Remittance, PA & Referral, Health Care Claims, Benefit Enrollment and/or Premium Payment.
Conformance with CAQH CORE Operating Rule can be demonstrated and certified through successful completion of certification testing with a third party CAQH CORE-authorized Testing Vendor, followed by an organization’s successful application for a CORE Certification Seal. CAQH CORE-authorized Testing Vendors are third-party IT companies that have demonstrated expertise in EDI testing are chosen to conduct certification testing for all of the CAQH CORE Operating Rules after a rigorous selection and approval process by CAQH CORE.
Edifecs is a CAQH-authorized Testing Vendor that offers a comprehensive testing solution that allows organizations to self-test via a CORE testing platform. Edifecs has provided CORE Certification Testing services since 2006 and has supported more than 40 certifications. About Edifecs: Edifecs is a leading healthcare technology company with the mission to improve healthcare outcomes, reduce costs and accelerate innovation.
Steps for CORE Certification Testing:
- Register with Edifecs to begin CORE Certification Testing or learn more about the testing process.
- Complete CORE Certification Testing within the 180-day pledge window.
- Contact the CAQH CORE-authorized Testing Vendor with any questions or concerns related to any part of the CORE Certification Testing process.
- Upon successful completion of the CORE Certification Testing, the CAQH CORE-authorized Testing Vendor will provide you with documentation that demonstrates the successful completion of your organization’s CORE Certification Testing. The CAQH CORE-authorized Testing Vendor will also provide a copy of your organization’s CORE Certification Testing to CAQH CORE.
NOTE:
Any fee/cost imposed by the CAQH CORE-authorized Testing Vendor will be independent and separate from the fee charged by CAQH CORE for your organization to obtain the CORE Certification Seal.
Complaints regarding CAQH 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. See the CORE Certification Testing Policy.
After successful completion of CORE Certification Testing, your next step is to apply for the CORE Certification Seal. Applying for the CORE Certification Seal requires you to notify CAQH CORE that certification testing is complete, respond to CORE Certification Measurement Survey and to submit a CAQH CORE Seal Application, a CAQH CORE HIPAA Attestation, a CAQH CORE Certification Fee for each CAQH CORE Operating Rule transaction you are seeking to become CORE-certified.
A. Notify CAQH CORE that CORE Certification Testing with the CAQH CORE-authorized Testing Vendor has been completed.
B. Respond to the CORE Certification Measurement Survey with submission of operating rule efficiency metrics.
C. Submit the CAQH CORE HIPAA Attestation and the CAQH CORE Seal Application for each CAQH CORE Operating Rule transaction that you are pursuing via email (CORE@caqh.org) or mail:
CORE, c/o CAQH
2020 K Street, NW
Suite 900
Washington, DC 20006
Your organization may download and/or print the forms via the following links:
CORE Certification Seal Application
CAQH CORE HIPAA Attestation: Eligibility & Benefits, Claim Status, Payment & Remittance, PA & Referrals, Health Care Claims, Benefit Enrollment or Premium Payment
D. Determine your CORE Seal fee by reviewing the fee scale below.
The fee for the CORE Seal is based upon a stakeholder-specific fee scale. This fee is a one-time cost for each transaction of CORE certification, unless an entity becomes de-certified. For more information about certification and decertification, see the CORE Certification Policy
Organizations pursuing more than one certification at a time are eligible for a discount. For more information on this savings opportunity, please email core@caqh.org
| CORE SEAL FEE* SCALE | |
|---|---|
| Health Plans | |
| Below $75 million in net annual revenue: | $6,000 fee |
| $75 million and above in net annual revenue: | $9,000 fee |
| Clearinghouses | |
| Below $75 million in net annual revenue: | $6,000 fee |
| EHNAC HNAP-EHN accredited | - apply 10% ($600) discount |
| $75 million and above in net annual revenue: | $9,000 fee |
| EHNAC HNAP-EHN accredited | - apply 10% ($900) discount |
| Vendors | |
| Below $75 million in net annual revenue: | $6,000 fee |
| $75 million and above in net annual revenue: | $9,000 fee |
| Providers | |
| Up to $1 billion in net annual revenue: | $750 fee |
| $1 billion and above in net annual revenue: | $2,250 fee |
| Government | |
| Federal or State Government Entities | No fee |
Payment Options:
- TO PAY BY ACH, contact CAQH CORE for an invoice. Send your CORE Seal Application form and HIPAA Attestation form to core@caqh.org.
- TO PAY BY PAPER CHECK, make your check payable to CAQH and send with your completed CORE Seal Application form and HIPAA Attestation form to:
CORE, c/o CAQH
2020 K Street, NW
Suite 900
Washington, DC 20006
4. Upon receiving the CAQH CORE HIPAA Attestation and the CAQH CORE Seal Application, CAQH CORE conducts a robust, multi-level review of the application materials and the Certification Testing results. CAQH 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.
5. A final decision about the CAQH CORE Seal Application is made by CAQH CORE within 30 business days of receiving a complete application, unless there are extenuating circumstances. If so, CAQH CORE will notify the applicant about the reason for an extension to the review.
6. After receiving a CORE Certification Seal:
- The certified entity may market itself as being CORE-certified.
- CAQH CORE will report on its website:
- CORE-certified entities and endorser
- The number of CORE Pledges it has received by stakeholder type
Recertification ensures ongoing conformance of operating rules by CORE-certified organizations over time supporting market needs, evolving technology, mergers/acquisitions and system upgrades.
Guidelines for Recertification:
- Recertification is required every three years for an entity to remain CORE-certified. Recertification renewals may occur anytime during the calendar year, based off initial year of certification.
- After communicating intent to recertify, recertification testing must be completed within 180 days.
- CORE-certified entities will become decertified if there is a 180-day lapse in renewing certification.
- CORE-certified organizations must implement versions of the CAQH CORE Operating Rules that have been published 24 months prior to the CORE Certification Seal renewal date.
Recertification - Step by Step Process:
1. Recertification Planning and Systems Evaluation
- Your organization will need to evaluate for any changes or updates to operating rules, as most recent versions will have to be implemented. Execute any necessary system changes/updates as part of recertification. Begin the collection of efficiency metrics to measure impact of operating rule implementation.
2. Apply for Recertification (CORE Recertification Seal Application Form)
- Communicate intent to recertify and maintain certification status by completing the CORE Recertification Seal Application Form.
- Submit payment for recertification. (Note: Fees for Recertification are ½ of the initial CORE Certification fee)
3. Recertification Testing
- An entity undergoing recertification will need to work with a CORE-authorized testing vendor to perform certification testing based upon criteria outlined in the CAQH CORE Certification Test Suites. (Note: Recertification testing will have a reduced number of test cases and provide opportunitiy to recertify across multiple rule sets at once.)
4. CORE Seal Renewal
- CAQH CORE will grant renewal of the CORE Certification Seal after an entity completes recertification testing, respond to the CORE Certification Measurement Survey, and submits all documentation required. For more information about recertification, see the CAQH CORE Recertification Fact Sheet.
CORE Certification Terms and Conditions
An entity’s CORE Certification Seal remains valid unless a certified entity’s seal is revoked as a result of a validated complaint of nonconformance. For more information on enforcement see the CAQH CORE Enforcement Policy.
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.