CMS recently sent out an announcement about a new audit policy that they’re implementing for their eligibility transactions. This only affects transactions being sent through their EDI system not transactions being sent through DDE. The short version of the policy is as follows:
1. Beginning 10/1, CMS will start randomly auditing transactions in search of instances where the same NPI and HICN are sent multiple times in one day.
2. If they identfy instances where the same beneficiary is being sent excessively by the same provider, they’re going to suspend that NPI from using their eligibility system (HETS).
3. The NPI will remain suspended until a written corrective active plan is submitted to and accepted by CMS.
You should have received some version of this notification from your eligibility vendor but in case you haven’t I’ll link you to the original notice. Please take this very seriously. If you have any automated processes that will repeatedly send the same member, please consider reviewing this process.