Compliance Review Program
The CMS Division of National Standards, on behalf of HHS, is launching the Compliance Review Program to ensure compliance among covered entities with HIPAA Administrative Simplification rules for electronic health care transactions.
In April 2019, HHS will randomly select 9 HIPAA-covered entities—a mix of health plans and clearinghouses—for Compliance Reviews. Any health plan or clearinghouse—not just those who work with Medicare or Medicaid—may be selected. In 2018, HHS piloted the program with health plan and clearinghouse volunteers (PDF)to streamline the compliance review process and identify any system enhancements. In 2019, providers will be able to participate in a separate pilot program on a voluntary basis.
Watch the new CMS video about the Compliance Review Program to learn about why compliance reviews are important for the health care industry and how they will be conducted.
Learn the process CMS uses to conduct compliance reviews with the Compliance Review Infographic (PDF).
More information on the Compliance Review Program:
- Compliance Review Program Information Bulletin (PDF)
- Optimization Pilot Information Bulletin (PDF)
- What to Expect Q&A (PDF)
- Prep Steps (PDF)
Why Compliance Reviews?
Health care providers, health plans, and clearinghouses have encouraged HHS to take proactive steps, including reviews, to ensure compliance with Administrative Simplification transaction standards, which reduce the administrative burden on the health care industry.
HHS’s proactive approach implements a progressive penalty process with the goal of remediation. If an organization isn’t compliant, HHS will work with the entity to resolve any issues. Corrective Action Plans are commonly used to address non-compliance. In cases of willful and egregious noncompliance, monetary penalties may be assessed and calculated on a case by case basis.
Provider Pilot Program
The CMS Division of National Standards, on behalf of HHS, is launching a volunteer Provider Pilot Program to test the compliance review process and to gain insight on compliance with HIPAA Administrative Simplification rules among providers. This follows a successful pilot program for health plans and clearinghouses (PDF) completed in 2018.
In April 2019, HHS will select 3 health care providers from the pool of volunteers to participate.
Learn more about the Provider Pilot Program and how to participate:
To volunteer to participate, email AdministrativeSimplification@cms.hhs.gov by April 24.