CMS CDAG
Coverage Determinations, Appeals and Grievances (CDAG) protocols help to evaluate performance in the areas outlined in the Centers for Medicare
CMS Regulatory Compliance
Knowledge Base
Current CMS Universe Protocols
On December 19, 2023, the HPMS memo 2024 Program Audit Updates was issued containing several announcements effective January 1, 2024. Please note the following summary of the review results:
- Final rule CMS-4201-F included new coverage criteria requirements and use of utilization management (UM) requirements
- 2024 Audits
- Will utilize the newly approved version of the extended CMS-10717
- Routine audits will follow the standard process as in prior years
- Will target new UM requirements during ODAG and CPE review
- Focused audits are to be added for plans not scheduled for routine audits
- Limited to ODAG and CPE areas
- Sponsoring organizations:
- To hire an independent auditor when there are more than 5 conditions unrelated to the CPE review that require testing during the validation audit
- CMS will conduct validation of finds when audit results are below the threshold
CMS ODAG
Organization Determinations, Appeals and Grievances (ODAG) protocols help to evaluate performance in the areas outlined in the Centers for Medicare
CMS CPE
Compliance Program Effectiveness (CPE) protocols help to evaluate performance in the Centers for Medicare and Medicaid Services (CMS) Program Audit
CMS FA
Formulary and Benefit Administration (FA) protocols help to evaluate performance in the Centers for Medicare and Medicaid Services (CMS) Program
CMS SARAG
Medicare-Medicaid Plan Service Authorization Requests, Appeals, and Grievances (MMP-SARAG) protocols help to evaluate performance in the Centers for Medicare and
CMS MMPCC
Medicare-Medicaid Plan Care Coordination (MMPCC) protocols help to evaluate performance in the Centers for Medicare and Medicaid Services (CMS) Program
CMS SNPCC
Special Needs Plans Care Coordination (SNPCC) protocols help to evaluate performance in the Centers for Medicare and Medicaid Services (CMS)
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