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CMS program audit readiness playbook

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Regulatory compliance

Current CMS universe protocols

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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 five conditions unrelated to the CPE review that require testing during the validation audit
    • CMS will conduct validation of findings when audit results are below the threshold

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