What is the CMS 270/271 submitter relationship audit and suspension policy?

Health Plans: 

  • Medicare

Workflow: 

  • Eligibility and Benefits,
  • General

CMS’s Medicare Rules of Behavior state that submitters should not send duplicate eligibility requests in the same 24-hour period. CMS Medicare is taking steps to reduce these duplicate eligibility requests by implementing an audit and suspension policy for all 270/271 submitters that send duplicate requests using the same National Provider Identifier (NPI) / Health Insurance Claim Number (HICN) combination within a 24-hour period.

Read below for answers to frequently asked questions.

When does this policy go into effect?

It is effective starting October 1, 2015.

What is NaviNet doing to help prevent us from getting suspended?

If your office attempts to search for the same subscriber multiple times in a 24-hour period, NaviNet displays an error message and prevents searching on the subscriber until the next day. The goal of this feature is to help you comply with Medicare's Rules of Behavior, and to ensure continuous access to Medicare Access.

What are the CMS Medicare 270/271 Suspension Procedures?

If results from a random audit are non-compliant with the Medicare Rules of Behavior, the CMS Medicare 270/271 Submitter's relationship with the Provider/Supplier NPI will be suspended until a written Corrective Action Plan (CAP) outlining steps that will be taken to improve future audit results is submitted and accepted by CMS Medicare. The CMS Medicare 270/271 Submitter (NaviNet) will be notified of this NPI relationship suspension via email. It will be the CMS Medicare 270/271 Submitter's responsibility to notify the Medicare Provider/Supplier associated with the NPI.

What will NaviNet do if CMS suspends our usage of Medicare Access?

If CMS notifies NaviNet that use of the Medicare system has been suspended for your Provider/Supplier NPI, we will contact you immediately and share a Corrective Action Plan (CAP) template for you to fill out and return to CMS. CMS will approve or deny CAPS documents within 3 business days of submission date.

What steps can I take to prevent duplicate submissions?

  • Review internal procedures for input of HICN/member ID information when the data is unknown
  • Review the different ways in which the same member's eligibility may be verified multiple times unnecessarily (i.e. are users performing duplicate checks?)
  • Determine whether or not eligibility verification is occurring to Medicare for patients in which there is no indication of Medicare coverage
  • Educate users on not entering invalid HICN combinations causing unintended errors and duplications

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