MIPS QCDR Data Validation Audit

Kay Zacharias-Andrews

Modified on: Tue, 6 Aug, 2024 at 2:55 PM

QPP Eligibility Verification

During the MIPS QCDR data validation audit, ACR staff will verify a random sample of QCDR participants' QPP eligibility using the CMS MIPS participation status tool https://qpp.cms.gov/participation-lookup.

TIN/NPI Verification

Prior to submission to CMS, TINs must upload supporting documentation to prove the validity of their TIN. ACR staff will audit all supporting documentation for TIN accuracy during the MIPS QCDR data validation audit.

All NPIs are automatically verified for accuracy at enrollment. The clinician's NPI is validated using ACR's subscription to HIPAASpace web services (https://www.hipaaspace.com) based on the first and last names and NPIs captured in NRDR.

Measures Random Audit Sampling Methodology

The randomized audit will be conducted throughout the performance year and submission period. ACR staff will randomly select 3 percent of the TIN/NPIs (no less than 10 TIN/NPIs, and no greater than 50 TIN/NPIs) for which the NRDR QCDR will submit data to CMS. NPIs will explicitly be designated as eligible for sampling if they have not been sampled within the last five CMS reporting years. For each randomly selected TIN/NPI, 25 percent of their MIPS QCDR patient/exams submitted (no less than 5 and no greater than 50 patients/exams), will be randomly selected for audit by the ACR staff.

Time frames in which you would be notified to participate in the data validation audit

	September	October	November	December	January	February	March
Audit Notification-Quality Measures
Audit Notification-Improvement Activities (IA) and Promoting Interoperability (PI) Measures

What To Expect If You Are Selected

After the TIN/NPIs and exams have been randomly selected, ACR staff will notify the Facility Administrator that their TIN/NPIs have been selected to participate in the data validation audit. During the notification process, the Facility Administrator (FA) will receive two emails and an Excel sheet containing the list of exams to be audited.

Email notification from ACR: Facility Administrators will receive an email from ACR registry staff on behalf of NRDR Support officially notifying user that they have been randomly selected to participate in the data validation audit.
Email invitation from Box Application: Facility Administrators will receive an email from Citrix ShareFile containing a link to the folder we will use to upload documentation for the audit.
List of randomly selected TIN/NPIs and exams: A list of randomly selected exams is posted in your assigned Box folder. The file will contain the following columns for you to identify patient exam in your system: NPI, Exam Unique ID, Exam Date, Age, and Gender.
Upload supporting documentation: Upload patient reports for the requested exams. Additional documentation including images and/or policies may also be requested depending on the measures associated with the exam. All documentation for the audit should be uploaded to your assigned Box audit folder.
Do not submit documentation containing PHI via email. Please use the assigned Box audit folder to ensure all documentation is secure and in one central location.
Notification of error(s): ACR staff will upload a list of any errors discovered with associated TIN/NPI, exam, and measure to the assigned Box audit folder and email the Facility Administrator notifying them of the observed error(s).
If you feel an error was incorrectly identified, please work with ACR staff to coordinate a conference call to review the documentation together.
To assess the depth of the error, an additional 10 exams will be randomly selected for the TIN/NPI and measure combination for which the error was observed. A list of these new exams will be uploaded to the assigned Box audit folder and the Facility Administrator will be emailed notifying them of the additional exams.
Correction of error(s): Quality measures can be corrected by submitting the exam with the correct numerator response in the MIPS portal. After the file is uploaded and the correction is made, ACR staff must verify that the identified error(s) are corrected prior to submission to CMS.
If the identified error(s) is not corrected, the ACR QCDR may not allow the associated TIN/NPI to submit the exam and/or measure for the associated error.
Root cause analysis: The Facility Administrator will work with ACR staff to complete a root cause analysis for the identified error(s).
Audit report: ACR staff will upload a final audit report to the assigned Box audit folder in early June and email the Facility Administrator notifying them that the report is available.
Data Validation Error Report (DVER): The ACR QCDR is required to submit a DVER to CMS outlining the specific errors discovered during the data validation audit. The specific TIN/NPI information is not included, but as indicated in our PA and QCDR attestation, CMS may request all available data for a TIN/NPI participating in our QCDR.

Box Application Troubleshooting

User name: Your user name is the email address on-file in the NRDR portal for your Facility Administrator user profile.
Password Creation: Password creation is a two step process.
- Confirm your personal information: Your first and last name will be pre-populated. If the information is correct, click Continue.
- Create an unique password: Creating an unique password that meets Box's requirements. When complete, click Save and Sign In.
You are unable to view documents uploaded by ACR:
- First: Make sure you are logged in with the user name associated with your Facility Administrator user profile.
- Second: Make sure you are looking in your assigned Box audit folder.
- Third: Email ACR staff for further troubleshooting.
ACR Staff unable to view documents you uploaded: ACR staff can only view documents that reside in folders created for the audit. Please verify that documents were uploaded and saved to your assigned Box audit folder.

MIPS QCDR Data Validation Audit

QPP Eligibility Verification

During the MIPS QCDR data validation audit, ACR staff will verify a random sample of QCDR participants' QPP eligibility using the CMS MIPS participation status tool https://qpp.cms.gov/participation-lookup.

TIN/NPI Verification

Prior to submission to CMS, TINs must upload supporting documentation to prove the validity of their TIN. ACR staff will audit all supporting documentation for TIN accuracy during the MIPS QCDR data validation audit.

All NPIs are automatically verified for accuracy at enrollment. The clinician's NPI is validated using ACR's subscription to HIPAASpace web services (https://www.hipaaspace.com) based on the first and last names and NPIs captured in NRDR.

Measures Random Audit Sampling Methodology

Time frames in which you would be notified to participate in the data validation audit

What To Expect If You Are Selected

Email notification from ACR: Facility Administrators will receive an email from ACR registry staff on behalf of NRDR Support officially notifying user that they have been randomly selected to participate in the data validation audit.

Email invitation from Box Application: Facility Administrators will receive an email from Citrix ShareFile containing a link to the folder we will use to upload documentation for the audit.

List of randomly selected TIN/NPIs and exams: A list of randomly selected exams is posted in your assigned Box folder. The file will contain the following columns for you to identify patient exam in your system: NPI, Exam Unique ID, Exam Date, Age, and Gender.

Upload supporting documentation: Upload patient reports for the requested exams. Additional documentation including images and/or policies may also be requested depending on the measures associated with the exam. All documentation for the audit should be uploaded to your assigned Box audit folder.

Do not submit documentation containing PHI via email. Please use the assigned Box audit folder to ensure all documentation is secure and in one central location.

Notification of error(s): ACR staff will upload a list of any errors discovered with associated TIN/NPI, exam, and measure to the assigned Box audit folder and email the Facility Administrator notifying them of the observed error(s).

If you feel an error was incorrectly identified, please work with ACR staff to coordinate a conference call to review the documentation together.

Correction of error(s): Quality measures can be corrected by submitting the exam with the correct numerator response in the MIPS portal. After the file is uploaded and the correction is made, ACR staff must verify that the identified error(s) are corrected prior to submission to CMS.

If the identified error(s) is not corrected, the ACR QCDR may not allow the associated TIN/NPI to submit the exam and/or measure for the associated error.

Root cause analysis: The Facility Administrator will work with ACR staff to complete a root cause analysis for the identified error(s).

Audit report: ACR staff will upload a final audit report to the assigned Box audit folder in early June and email the Facility Administrator notifying them that the report is available.

Box Application Troubleshooting

User name: Your user name is the email address on-file in the NRDR portal for your Facility Administrator user profile.

Password Creation: Password creation is a two step process.

Confirm your personal information: Your first and last name will be pre-populated. If the information is correct, click Continue.

Create an unique password: Creating an unique password that meets Box's requirements. When complete, click Save and Sign In.

You are unable to view documents uploaded by ACR:

First: Make sure you are logged in with the user name associated with your Facility Administrator user profile.

Second: Make sure you are looking in your assigned Box audit folder.

Third: Email ACR staff for further troubleshooting.

ACR Staff unable to view documents you uploaded: ACR staff can only view documents that reside in folders created for the audit. Please verify that documents were uploaded and saved to your assigned Box audit folder.