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CMS Audit and Suspension CMS Announces New Audit and Suspension Policy effective October 1, 2015


Recently CMS has been conducting audits relating to the HIPAA Eligibility Transaction System (HETS). These audits are to ensure that all submitters (providers, suppliers, and vendors) comply with the HETS Rules of Behavior which may be found HERE.

CMS is taking special note of duplicate transactions, defined as transactions with the same HETS Submitter ID, NPI and Medicare Beneficiary Number (HICN) that occur on the same day. The HETS Rules of Behaviour states under ‘Best Practices’ that the HETS database is updated once daily between the hours of 12:00 AM and 4:00 PM. As a result, duplicate eligibility requests on the same day will result in an identical eligibility response, and are therefore unnecessary.

Beginning on October 1, 2015, CMS will begin to suspend HETS submitters who are found to be submitting excessive duplicate transactions, or are otherwise in violation of the HETS Rules of Behavior. The submitter’s NPI will remain suspended until a corrective action plan is documented and accepted by CMS. Submitters who are repeatedly found to be in violation of the HETS Rules of Behavior may be suspended permanently from access to HETS.

As such it is vital that all stakeholders take the time to review the HETS Rules of Behavior, located at the link below. Additionally, you should ensure that appropriate action is taken across your organization to conform to these rules.

HIPAA Eligibility Transaction System (HETS) Inquires Rules of Behavior