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Date
2015-09-16
Subject
Medicare HETS 270/271 - CMS Announcing New Audit/Suspension Policy effective October 1, 2015 - September 16, 2015
User Community
HETS 270/271

Medicare HETS 270/271 Submitters:

CMS continues to conduct random audits of HETS 270/271 transactions.  Components of these audits ensure that submitters are complying with the HETS Rules of Behavior. Submitters may review the HETS Rules of Behavior at https://www.cms.gov/Research-Statistics-Data-and-Systems/CMS-Information-Technology/HETSHelp/Downloads/EligibilityTransactionSystemInquiriesRulesofBehavior.pdf.

Effective October 1, 2015, CMS will implement an audit suspension policy for all HETS 270/271 submitters that send excessive transactions during a single day for a National Provider Identifier (NPI) / Health Insurance Claim Number (HICN) combination. NPIs that are identified as non-compliant with the HETS Rules of Behavior during these random audits will face suspension of their HETS Trading Partner privileges with the HETS Submitter ID used in those transactions.

HETS 270/271 Suspension Procedures

  • If results from a random audit fail audit criteria, the HETS 270/271 Submitter’s relationship with the Provider/Supplier NPI will suspended until a written Corrective Action Plan (CAP) outlining steps that will be taken to improve future audit results is submitted to and accepted by CMS. The HETS 270/271 Submitter will be notified of this NPI relationship suspension via email. It will be the HETS 270/271 Submitter’s responsibility to notify the Medicare Provider/Supplier associated with the NPI.
  • Medicare Provider/Suppliers that repeatedly violate this policy will face penalties up to and including permanent suspension of HETS 270/271 trading privileges.

Per the Trading Partner Agreement, all HETS 270/271 submitters must take the necessary steps to ensure that HETS Rules of Behavior are followed. Your cooperation in this endeavor is vital.

Please contact the Help Desk if you have questions.

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