Ensure conformance with Operating Rules

Achieve and maintain Operating Rules 1-4 compliance.

Operating Rules

Organizations have a critical need to electronically share large quantities of data quickly and accurately, regardless of the technology. Operating Rules simplify administration but implementing Operating Rules is not simple and requires collaboration. Organizations cannot simply claim they are compliant, they must prove it or pay stiff penalties. To help organizations verify their compliance to CAQH CORE rules, Edifecs has been hosting a self-testing portal for CAQH CORE Phase I/II/III and IV. Organizations can voluntarily gain CORE Certification through this self-testing portal. Edifecs is the only authorized vendor for CAQH CORE certification

Our Approach

Edifecs offers a full range of software solutions and services to achieve and maintain CORE compliance, improve service, and reduce costly manual operations.

Our orchestration engine supports HIPAA and CORE validation and can manage transaction workflows for all Operating Rules phases. Interactive dashboards and reports track ongoing monitoring to comprehensively track compliance measures and research the root cause of non-compliance issues.


Analysis and assessment

Edifecs offers a suite of capabilities to identify gaps in implementing different phases of Operating Rules and recommend remediation steps.

  • Conducts business process and/or gap assessments for implementation.
  • Transaction support gaps.
  • Transaction content and infrastructure gaps.
  • Identifies current performance levels and gaps associated requiring remediation.
  • Recommends project tasks and participate in critical path activities from analysis, to certification, to extended testing, to ongoing implementation and monitoring of the Operating Rules.

Transaction validation

Operating Rules requires wide range of technical and business centric capabilities for successful implementation and compliance. These capabilities include:

  • Perform HIPAA, CAQH CORE, and partner-specific validations on transactions.
  • Validate eligibility, claims status and electronic funds transfer (EFT) and attachments.
  • Following CORE compliant connectivity protocols and authentication processes.
  • CORE compliant connectivity protocols and authentication (Safe Harbor).
  • Authentication with HTTP MIME / SOAL WSDL technologies.

Production level testing

The Edifecs solution orchestrates a production like trading partner interaction and helps identify implementation gaps that can’t be uncovered during internal testing or CORE certification testing. Production level testing helps identify implementation gaps.

  • Perform production level testing with Edifecs as your trading partner.
  • Access comprehensive test cases covering most of data content and infrastructure.
  • Ensure adequate coverage and completeness of test plans.
  • Access intuitive dashboards to identify gaps and errors per Operating Rule.
  • (Responses, Eligibility, CARC/RARC, ERA/EFT re-association, AAA, Transactions).