To help plans, delegates, and PBMs navigate what’s ahead, BluePeak has developed the ADVISE Framework, a practical, action oriented readiness model aligned to the operational challenges highlighted in the proposed protocols.
A – Align
- Evaluate alignment across systems, workflow platforms, claims adjudication system, and PBM systems
- Identify mapping gaps, data inconsistencies, and cross‑system disconnects
D – Document
- Review documentation standards, templates, notices, SOPs, and case records
- Identify gaps that create member impact, audit exposure, or compliance risk
V – Validate
- Perform universe validation and data tracing
- Reconcile data across systems to prevent Invalid Data Submission (IDS) findings and corrective action requirements
I – Improve
- Review and refine timeliness workflows and escalation paths
- Strengthen monitoring routines to reduce delays and prepare for CMS’s analytics-driven tools
S – Strengthen
- Assess classification logic for initial determinations, grievances, reopenings, and dismissals
- Ensure accuracy and consistency across intake, workflows, and automated systems
E – Enhance
- Evaluate FDR/vendor oversight and performance
- Strengthen reporting dependencies and controls to support 2027 audit requirements
How BluePeak Can Help Plans Prepare for 2027: Powered by the ADVISE Framework
At BluePeak, we believe that preparing for CMS audits and ensuring the ability to produce systematic, compliant reporting is more than meeting regulatory expectations and performing a audit-specific, targeted compliance exercise; it’s about building the kind of operational stability that directly enhances the member experience and ensures daily compliance and readiness, regardless of whether an audit notice is in play. When a plan’s processes work smoothly, members feel the difference through:
- Timely decisions
- Accurate classifications; and
- Strong communication, which reduces frustration, minimizes service failures, and reinforces trust.
This doesn’t just support audit readiness; it also drives measurable improvements in enrollee satisfaction, including fewer calls, grievances, and Complaints Tracking Module (CTM) complaints. As complaint volumes decrease and member interactions improve, plans typically see a positive impact on STAR Ratings, particularly across Consumer Assessment of Healthcare providers and Systems (CAHPS), appeals, and operational performance measures.
BluePeak uses the ADVISE Framework to support plans with:
- System and process alignment reviews
- Documentation and notice accuracy assessments
- Universe validation and data integrity checks
- Timeliness workflow improvement
- Classification and intake analysis
- FDR/vendor oversight strengthening
- Systematic, compliant reporting that stands up to CMS’s increasing reliance on quarterly Service Level Data
