Phase 1: Audit Preparation

A number of activities must take place prior to the onsite audit visit. These activities, as defined by NCQA, include:

• execute contract;
• sign agreements - including: confidentiality, conflict of interest, fees, etc.;
• assign lead auditor;
• provide Baseline Assessment Tool to health plans for completion;
• select mutually agreeable audit dates;
• certify CAHPS sample frames (as required);
• review completed Baseline Assessment Tool;
• select core measures;
• finalize audit team;
• request source code for measures outside of pre-certified software;
• develop agenda for onsite audit;
• review vendor operations and processes; and
• conduct pre-visit conference call to discuss outstanding issues.

The key activity of those listed above is the completion of the Baseline Assessment Tool (BAT) by the client and a thorough review of the completed tool by the auditors.

The BAT is a comprehensive instrument designed by NCQA to collect information from the health plan regarding its structure, information collection and processing (e.g., claims/encounter processing, medical record review processes, membership data processes, provider data processes) and HEDIS reporting procedures (e.g., measure programming/determinations, reporting functions).

Accurate, timely completion of the BAT will assist the auditors in focusing their questions and their document review during the onsite audit. Normally, the BAT is submitted a minimum of 4 to 6 weeks prior to the onsite visit.