Notice of Compliance Review Closure

Form Approved: OMB # 0938-1390

Expiration 12/31/2025

DEPARTMENT OF HEALTH & HUMAN SERVICES

Centers for Medicare & Medicaid Services

7500 Security Boulevard, Mail Stop N1-19-21

Baltimore, Maryland 21244-1850

Notice of Compliance Review Closure

Date of Notice: FULLDATE

CONTACTNAME

JOBTITLE

CENAME

ADDRESS1

ADDRESS2

CITY, ST ZIP

Re: Compliance Review Number XXXXX

Dear FIRSTNAME LASTNAME:

On (month, day, year), the Department of Health and Human Services (HHS), National Standards Group (NSG) within the Centers for Medicare & Medicaid Services (CMS) finalized the <Covered Entity Name> 20XX compliance review.

The compliance review included an assessment of transactions, code sets, unique identifiers, and operating rules based on the <Covered Entity Name> artifacts submitted. It incorporated the use of a validation tool to determine HIPAA compliance with the applicable 5010 ASC X12 standards and implementation guides. In addition, it included a manual review of companion guides and operating rule attestations, if applicable.

On (month, day, year), we received verification of Corrective Action Plan completion, and that <Covered Entity Name> has brought all discovered violations into compliance. This closure notice is to inform you that the compliance review for <Covered Entity Name> is complete and no further action is required. Refer to the enclosed Final Violations Summary Report for additional information and the final status for each violation.

Thank you for working with us towards a successful resolution. To avoid future violations, we encourage all covered entities to periodically validate their electronic transactions using the ASETT validation tool as well as checking their processes for operating rule compliance.

If you have any questions regarding this notice, please send an email to [email protected]. Please include the compliance review number located at the top of this notice.

Sincerely,

Michael Cimmino

Director, National Standards Group

Office of Healthcare Experience and Interoperability

Centers for Medicare & Medicaid Services

Enclosure – Final Violations Summary Report

– Violations Summary Report

VIOLATION # 1

Covered Entity File Name:

Validation Tool Reports

Consolidated Output File Name:

Individual Output File Name(s):

Violation Information

Violation Error ID:

Category:

Violation Description:

Reference(s):

Warrant Corrective Action:

Covered Entity Response

NSG Reply to Covered Entity (NSG Only)

VIOLATION # 2

Covered Entity File Name:

Validation Tool Reports

Consolidated Output File Name:

Individual Output File Name(s):

Violation Information

Violation Error ID:

Category:

Violation Description:

Reference(s):

Warrant Corrective Action:

Covered Entity Response

NSG Reply to Covered Entity (NSG Only)

VIOLATION # 3

Covered Entity File Name:

Validation Tool Reports

Consolidated Output File Name:

Individual Output File Name(s):

Violation Information

Violation Error ID:

Category:

Violation Description:

Reference(s):

Warrant Corrective Action:

Covered Entity Response

NSG Reply to Covered Entity (NSG Only)

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1390 from the year of 2024 through 2025. The objective of the HIPAA Administrative Simplification information collection program is to conduct assessments and identify whether a covered entity is compliant with the HIPAA - adopted standards, and administrative simplification. The time required to complete this information collection is estimated to average less than 10 hours per response (4 forms x 60 minutes/form), including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is mandatory (under 45 CFR § 160.310) If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.