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Home>Documents>Healthcare>CAQH CORE Non-Compliance Review Request Form

CAQH CORE Non-Compliance Review Request Form

The CAQH Committee on Operating Rules provides this form for reporting potential non-compliance issues. It is intended for CORE-certified entities to formally submit complaints regarding operating rule violations. Ensure accurate completion for effective review.

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How do I fill this out?

To fill out this form, gather the necessary information regarding the complaint. Ensure you have documented examples of violations ready for submission. Follow the structured format provided and complete all required fields.

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How to fill out the CAQH CORE Non-Compliance Review Request Form?

  1. 1

    Collect your contact and organizational information.

  2. 2

    Identify the entity against which you're filing.

  3. 3

    Document at least five examples of the violation.

  4. 4

    Complete all required fields in the form.

  5. 5

    Submit the form within the 90-day submission window.

Who needs the CAQH CORE Non-Compliance Review Request Form?

  1. 1

    Healthcare providers needing to report operating rule violations.

  2. 2

    Health plans seeking to address service non-compliance.

  3. 3

    Vendors that process claims or transactions requiring compliance.

  4. 4

    Clearinghouses managing transactions between parties.

  5. 5

    Any organization involved in healthcare transactions requiring CAQH CORE certification.

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What are the instructions for submitting this form?

Submit the completed CAQH CORE Non-Compliance Review Request Form via email to CORE@caqh.org. Alternatively, you can fax the form to the designated CAQH CORE number. Ensure that all required fields are filled out, and submit within the specified 90-day period for compliance issues.

What are the important dates for this form in 2024 and 2025?

In 2024, ensure to file your complaints within 90 days of the event. Keep track of compliance deadlines and maintain a record of all communications.

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What is the purpose of this form?

The purpose of this form is to facilitate reporting of non-compliance violations among CAQH CORE-certified entities. It serves as an official mechanism for healthcare stakeholders to address potential rule breaches. By submitting this form, organizations can contribute to maintaining compliance standards and improving industry practices.

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Tell me about this form and its components and fields line-by-line.

This form contains various fields pertaining to the complainant's information, the organization being complained against, and details about the violation.
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  • 1. Organization Name: The name of the entity filing the complaint.
  • 2. Type: Category of the organization (e.g., Health Plan, Provider).
  • 3. Contact Information: Details like address, telephone number, and email of the complainant.
  • 4. Violation Details: Specifics about when the alleged violation occurred and relevant examples.
  • 5. Complaint Category: Selection from predefined categories of complaints.

What happens if I fail to submit this form?

Failure to submit this form may result in unresolved compliance issues. Entities will miss the opportunity for formal review and necessary corrections to be made. Without submission, ongoing non-compliance could negatively impact operations.

  • Potential Violations Go Unaddressed: Without a submission, issues may continue unrectified.
  • Loss of Certification: Prolonged non-compliance may jeopardize CORE certification.
  • Inconsistent Standards: Failure to report can lead to a lack of adherence to established operating rules.

How do I know when to use this form?

This form should be used when an entity believes there has been a violation of CAQH CORE Operating Rules. If informal resolution has been attempted unsuccessfully, this form facilitates escalation. Utilize this form to ensure compliance and proper handling of grievances.
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  • 1. When Non-Compliance is Suspected: Use the form to report when you suspect a CORE-certified entity is out of compliance.
  • 2. For Documented Violations: File this form when you have documented examples of non-compliance.
  • 3. Within the Compliance Window: Ensure to file within 90 days of the incident for formal review.

Frequently Asked Questions

What is the purpose of the CAQH CORE Non-Compliance Review Request Form?

This form is used to report potential violations of CAQH CORE Operating Rules by certified entities.

Who can file a complaint using this form?

Healthcare providers, health plans, vendors, clearinghouses, and other CORE-certified entities can file a complaint.

How many examples of violations are required?

At least five documented examples of violations are required over a 30-day period.

What is the timeframe for submitting a complaint?

Complaints must be submitted within 90 days of the most recent compliance violation.

Can I withdraw my complaint after submission?

Yes, entities can withdraw complaints at any time during the process.

Is my complaint information kept confidential?

Yes, details of the complaint remain private and are only used for non-compliance reviews.

What happens if a complaint is found valid?

If an entity is found in violation, its certification may be terminated.

How can I learn more about the filing process?

For additional questions regarding the form, contact CAQH at CORE@caqh.org.

Can I edit the PDF form before submission?

Yes, you can easily edit the PDF form using PrintFriendly's editing tools before submitting.

What types of complaints can be submitted?

Complaints can pertain to various categories such as eligibility and benefits, response time, and system availability.