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42 C.F.R. § 401.719

Monitoring and sanctioning of qualified entities.

§ 401.719 Monitoring and sanctioning of qualified entities.

(a) CMS will monitor and assess the performance of qualified entities and their contractors using the following methods:

(1) Audits.

(2) Submission of documentation of data sources and quantities of data upon the request of CMS and/or site visits.

(3) Analysis of specific data reported to CMS by qualified entities through annual reports (as described in paragraph (b) of this section) and reports on inappropriate disclosures or uses of beneficiary identifiable data (as described in paragraph (c) of this section).

(4) Analysis of complaints from beneficiaries and/or providers or suppliers.

(b) A qualified entity must provide annual reports to CMS containing information related to the following:

(1) General program adherence, including the following information:

(i) The number of Medicare and private claims combined.

(ii) The percent of the overall market share the number of claims represent in the qualified entity's geographic area.

(iii) The number of measures calculated.

(iv) The number of providers and suppliers profiled by type of provider and supplier.

(v) A measure of public use of the reports.

(2) The provider and supplier data sharing, error correction, and appeals process, including the following information:

(i) The number of providers and suppliers requesting claims data.

(ii) The number of requests for claims data fulfilled.

(iii) The number of error corrections.

(iv) The type(s) of problem(s) leading to the request for error correction.

(v) The amount of time to acknowledge the request for data or error correction.

(vi) The amount of time to respond to the request for error correction.

(vii) The number of requests for error correction resolved.

(3) Non-public analyses provided or sold to authorized users under this subpart, including the following information:

(i) A summary of the analyses provided or sold, including—

(A) The number of analyses.

(B) The number of purchasers of such analyses.

(C) The types of authorized users that purchased analyses.

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