In a recent milestone for the healthcare system, industry-leading providers, Medicaid programs, health plans, clearinghouses, and product vendors have achieved more than 350 CORE Certifications. Each certification demonstrates a healthcare organization’s commitment to ensuring business transactions flow seamlessly. To date, CORE-certified organizations include health plans that cover 78 percent of commercial lives, 75 percent of Medicare Advantage lives and 44 percent of Medicaid lives in the United States.

CORE Certification is available for four phases of operating rules that encompass eligibility and benefits, claim status, electronic funds transfer and remittance advice, prior authorizations, and enrollment/disenrollment in a health plan. Most of these operating rules are federally mandated. CAQH CORE awards CORE Certification to organizations that successfully complete a robust testing process.

“Increased participation in the CAQH CORE Certification program is an indication of industry commitment to making business transactions more efficient,” said April Todd, Senior Vice President, CORE and Explorations at CAQH. “CAQH is committed to ensuring entities have the resources they need to become CORE-certified and make progress toward electronic adoption.”

In its latest work, CAQH CORE is preparing to finalize Phase V CAQH CORE Operating Rules that address prior authorization. The Phase V CORE Certification process will follow and be available in the coming months.

Visit www.caqhcore.org to learn more.