N.M. Admin. Code § 7.1.22.12

Current through Register Vol. 35, No. 21, November 5, 2024

Section 7.1.22.12 - VERIFICATION OF SUBMITTED DATA

A. Audit requirement: In order to verify the validity, reliability and comparability of data submitted by a data provider, the commission may conduct or contract for an independent audit or approve a plan-contracted audit conducted by an independent organization certified by NCQA to perform HEDIS® audits. Data providers shall participate in the audit process upon request of the commission. ®NCQA registered trademark.

B. Audit process: The commission may design and conduct an audit process solely for the purpose of verifying submitted data that may include one or more of the following activities concerning a data provider:

(1) an audit of the data provider's data collection and reporting processes, including its administrative database;

(2) one or more site visits;

(3) review and verification of the data provider's specifications, source codes, and data elements for each reporting measure;

(4) review of patient confidential information, which shall be limited to cases selected for verification purposes; and

(5) any other reasonable activities necessary to satisfy the purposes of the audit requirement.

C. Confidentiality requirements: All audits of data provider reports shall be conducted in a manner that protects the privacy of individual patients and patient confidential information to the extent consistent with the purposes of the audit. No information obtained during an audit shall be used for any purpose other than to satisfy the audit requirements.

N.M. Admin. Code § 7.1.22.12

8/30/97; Recompiled 10/31/01