CMS Compliance Review Program
CMS, WEDI and CAQH CORE Webinar Series: Part 2
LogisticsPresentation Slides and How to Participate in Today’s Session
▪ You can download the presentation slides at www.caqh.org/core/events or at www.wedi.org after the webinar.
▪ A copy of the slides and the webinar recording will be emailed to all attendees and registrants in the next 1-2 business days.
▪ Questions can be submitted at any time using the Questions panel on the GoToWebinar dashboard.
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Session Outline
▪ Speaker Introduction
▪ Featured Presentation: Administrative Simplification Enforcement – Compliance Review Program
▪ Q&A
▪ Closing Comments
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Thank You to Our Speakers
Paul AndersonHealth Insurance Specialist
CMS Division of National Standards
Charles StellarPresident and CEO
WEDI
April ToddSenior Vice President
CAQH CORE
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Gladys WheelerLead Health Insurance Specialist
for Compliance EnforcementCMS Division of National Standards
Administrative Simplification Enforcement
Compliance Review Program
July 18, 2019
Compliance Review Program
» Created to ensure compliance amongst covered entities with HIPAA Administrative Simplification rules for electronic health care transactions.
» The Compliance Review Program will conduct periodic reviews with randomly selected entities to assess compliance with HIPAA Administrative Simplification rules.
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Compliance Review Program Cont’d
» HHS will review the following administrative transactions for compliance:
1) Transaction formats
2) Code Sets
3) Unique Identifiers
» Participants will attest to compliance with operating rules.
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Non-compliance
» Covered entities found to be noncompliant will be allowed to undertake corrective actions.
» Covered entities who do not achieve compliance may be subjected to escalated enforcement actions.
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Compliance Review Process
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Optimization Pilot Program
» In 2018, ten organizations were selected to participate in the pilot program. Four clearinghouses and one health plan completed the pilot.
» Participating organizations assisted HHS with optimizing the review process, including review tracking, coordinating and communicating with participating entities, and assessing violations.
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Optimization Pilot Program Results Violations
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57%
20%
19%
4%
Transactions Code Sets Unique ID Operating Rules
Audience Q&A
Enter your question into the “Questions” pane in the lower right hand corner of your screen.
Please submit your questions
▪ The slides and webinar recording will be emailed to attendees and registrants in the next 1-2 business days.
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Thank you for joining us!
Website: www.CAQH.org/CORE
Email: [email protected]
@CAQH@WEDIonline
Website: www.wedi.org
Email: [email protected]
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Additional Resources
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• go.cms.gov/adminsimp website
• Administrative Simplification Email Updates
• Compliance Review video at https://youtu.be/iRF8TvaW4DU
• ASETT to test transactions or file complaints at asett.cms.gov
• [email protected] for questions and comments
• CAQH 2017 Index and savings calculator at CAQH.org
• DNS Regional Office Engagement SharePoint site
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Resources
Madhu Annadata – [email protected]
Chris Gerhardt- [email protected]
Gladys Wheeler – [email protected]
Geanelle Herring – [email protected]
Cecily Austin – [email protected]
Rosali Topper – [email protected]
Paul Anderson – [email protected]
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Contacts –Enforcement Team
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ASETT: Administrative Simplification Enforcement and Testing Tool
CDT: Code on Dental Procedures and Nomenclature
CPT: Current Procedural Terminology
DNS: Division of National Standards
EHRs: electronic health records
EIN: Employer Identification Number
HCPCS: Healthcare Common Procedure Coding System
HIPAA: Health Insurance Portability and Accountability Act of 1996
ICD-10: 10th revision of the International Statistical Classification of Diseases and Related Health
Problems
NDC: National Drug Code
NPI: National Provider Identifier Standard
Acronym Glossary