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 requirement to submit 270 eligibility requests only for valid, active Medicare providers and/or suppliers.
Effective January 1, 2009, CMS will strengthen the Medicare provider audit criteria for all HETS 270/271 submitters. CMS will set a 99% match requirement to allow for occasional typographic errors, lags in provider enrollment and updates to data. There, CMS institute audits requiring that no more than 1% of NPI numbers submitters be non-matched in the Medicare NPI crosswalk and that at least 99% of all transactions submitted contain a valid NPI number that appears in the Medicare NPI crosswalk.
Submitters who fail random audits will face suspension of their trading privileges.
HETS 270/271 Suspension Procedures
- If results from a random audit fail audit criteria, the submitter's access will automatically be suspended for the 24 hour period following the audit. The submitter will be notified of this suspension via email.
- After three such suspensions, the submitter's access will be terminated until a written Corrective Action Plan (CAP) outlining steps that will be taken to improve future audit results is submitted and accepted by CMS.
- Submitters with repeated suspensions 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 only valid, active Medicare provider NPI numbers are used to receive beneficiary eligibility information. Your cooperation in this endeavor is vital.
If you have questions about any information contained within this email, please contact the Help Desk immediately.
Medicare Customer Assistance Re: Eligibility (MCARE) Help Desk
1-866-324-7315