Are You Prepared for Your Next CMS Program Audit?

Preparation is critical to produce accurate universes and achieve successful CMS Program Audit results.

In November 2021, CMS announced they will send program audit engagement letters to sponsors, starting in February through July 2022. If you ask yourself when should your readiness for a program audit begin? The answer is NOW!

CMS made several significant changes to the audit protocols and universe layouts, and CODY® can help you make sense of it all. We perform system reviews to help design universes, ensuring you get the right data out of your system(s) and into the right universe. We can also help map data from your systems and database tables to the universes for reliable data pulls.

CMS Program Audit ComplianceSome changes to the CY2022 audit protocols include:

Compliance Program Effectiveness (CPE)

  • Combined FTEAM, IA, and IM universes into a new Universe-Compliance Oversight Activities (COA)
  • Removed the ECT Universe

Coverage Determinations, Appeals and Grievances (CDAG)

  • Universes have been consolidated with fields added to define processing timeframes (standard/ expedited)
  • New universe to capture activities related to a Plan’s Drug Management Program (DMP) – Universe 7: Comprehensive Addiction and Recovery Act (CARA) At-Risk Determination

Formulary and Benefit Administration (FA)

  • Removed Rejected Claims Transition – Previous Contract Year (RCT-P) Record Layout

Organizational Determinations, Appeals and Grievances (ODAG)

  • Universes have been consolidated with fields added to define processing timeframes (standard /expedited)
  • Added new tables for Dual Eligible Special Needs Plans determined to be an Applicable Integrated Plan
  • Removed the dismissal table and added “Dismissal” as an option for the request determination in applicable tables
  • Significant changes in column placement will require plans to re-map where data is imported into templates

Special Needs Plan Care Coordination (SNPCC)

  • Updated SNPE: Added, clarified, and removed fields from the SNPE universe

CODY® can also help with:

  • Compliance Program Effectiveness (CPE) Readiness Review – this can be the most challenging during an audit without proper preparation. A readiness review can help identify where you may have gaps in your organization’s ability to detect, correct, and prevent compliance issues. We conduct in-depth interviews of your operational areas for any monitoring they are performing and evaluate your internal auditing process.
  • FDRs Readiness – FDR failures represent a large portion of corrective and enforcement actions from CMS. All readiness activities should actively involve your vendors who perform functions that may be under the purview of a CMS Program Audit.
  • Mock Audits – CODY® can conduct a full audit or target specific program areas and issue a complete report at the end, allowing you to correct any problems BEFORE a CMS Program Audit. Your staff will know what to expect, how to respond to questions and be confident when the time comes. We will also share our tips for a successful audit.

If you received your CMS Program Audit notice and are not sure where to begin, CODY® is here to help. We can support and guide you through the data collection and responses to CMS. We can also help with your end-to-end readiness and support all aspects of the CMS Program Audit.

  • Universe Assessment Review – we can help evaluate universes for adherence to instructions. We load your files into our analytic tools that provide detailed accuracy and quality checks. We advise on any necessary data clean up and recheck your results.
  • Universe Timeliness Review – we review your universes for timeliness standards. Our analytic tools perform checks for timeliness against compliance standards. We provide a detailed report of results and recommended corrective actions.

We’re Here to Help

To find out how CODY® can help your plan ensure audit readiness and maintain compliance, contact us today for a consultation.


About CODY: CODY® works with over 70 government-funded, commercial, and ACA health plans across 50 states and Puerto Rico. We help align internal operations with CMS guidelines to improve regulatory compliance, maximize performance, and streamline member/provider communications across the enterprise. CodySoft® and Synchronicity™, our proprietary suites of software, are designed specifically for health plans. www.codyconsulting.com