Sample Request Letter_Enclosure I continued

Have
Available
Onsite

X

X

Send
to RO

Have
Available
Onsite

NA

General Information
Deemable
(Y/N)

Send
to RO

Current organization chart with position title and name of
individual responsible for finance, medical management,
provider relations, quality assurance, marketing,
enrollment/disenrollment, claims processing,
appeals/grievances, customer service, MIS. I
X
X
Minutes from Board of Directors Meetings
CHAPTER 2 – ENROLLMENT AND DISENROLLMENT
Associated
Worksheet(s)
Element
Type

Element
Code

Description of Element/General Information
Deemable
(Y/N)

NA

Documentation for all elements excluding NA (and Deemable,
if Deemed). Refer to Review Guide MOEs for examples.
X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

ER01

N

ER02

Enrollment Election Receipt- Date Stamp

Sample

WS-ER1

N

ER03

Enrollment Effective Date (Timeliness)

Sample

WS-ER1

N

ER04

Enrollment Election Completion Process

Sample

WS-ER1 & WS-ER2

N

ER05

Enrollment Acknowledgement (Timeliness)

Sample

WS-ER1

N

ER06

Enrollment Acknowledgement (Notice Content)

Sample

WS-ER1

N

ER07

Denial of Enrollment Prior to Transmission to CMS (Timeliness)

Sample

WS-ER2

N

ER08

Denial of Enrollment Prior to Transmission to CMS (Notice
Content)

Sample

WS-ER2

N

ER11

Submission of Enrollment Transactions to CMS

Sample

WS-ER3

N

ER12

Retroactive Enrollment Requests

Sample

WS-ER3

N

ER18

Appropriate and Timely Action

Sample

WS-ER3

N

ER50
1

Enrollment for SNP Plans

Sample

WS-ER8, WS-ER9,
and WS-ER10

N

ER50
2

Dual Eligible Enrollment (Dual Eligible SNPs Only)

Ongoin
g

N

ER80
2

Group Enrollment into Employer/Union Sponsored Plans

Sample

WS-ER11

N

DN01

Compliant Disenrollment Process

Sample

WS-DN1

N

DN02

Voluntary Disenrollment (Timeliness)

Sample

WS-DN1 & WS-DN2

N

DN03

Voluntary Disenrollment (Notice Content)

Sample

WS-DN1 & WS-DN2

N

DN04

Refund of Premium

Sample

WS-DN1, WS-DN2,
& WS-DN4

Sample

WS-ER1

X

X

X

X

X

X

X

X

X

X

X

N

Policies and procedures for all elements excluding NA. Please
tab relevant sections prior to submissions to CMS.
Narrative response and supporting documentation for each
element excluding NA (and Deemable, if Deemed)
Correct Enrollment Election

X

X

X

X

X

N

DN06

Involuntary Disenrollment for Move Out of Service Area

Sample

WS-DN4

N

DN11

Submission of Appropriate Disenrollment Reason Code

Sample

WS-DN1

N

DN50
1

Involuntary Disenrollment Due to Change in Status of Special
Ned Individuals

Sample

WS-DN5

X
X
CHAPTER 4: BENEFITS AND BENEFICIARY PROTECTIONS
Description of Element/General Information

Associated
Worksheet(s)
Element
Type

NA
Element
Code

Have
Available
Onsite

Deemable
(Y/N)

Send
to RO

Documentation for all elements excluding NA (and
Deemable, if Deemed). Refer to Review Guide MOEs for
examples.
X
Policies and procedures for all elements excluding NA
(and Deemable, if Deemed). Please tab relevant sections
prior to submission to CMS.
X
Narrative response and supporting documentation for
each element excluding NA (and Deemable, if Deemed).
X
N

CS601

Appropriate Compliance with Cost Sharing Rules for MA
Regional Plans

Onsite

Y

HA01

Initial health Assessment Conducted

Onsite

Y

CC01

Continuity of Care Through Community Arrangements

Onsite

X
X
X
CHAPTER 5 - QUALITY
Description of Element/General Information

Associated
Worksheet(s)
Element
Type

NA
Element
Code

Have
Available
Onsite

Deemable
(Y/N)

Send
to RO

Documentation for all elements excluding NA (and
Deemable, if Deemed). Refer to Review Guide MOEs for
examples.
X
Policies and procedures for all elements excluding NA
(and Deemable, if Deemed). Please tab relevant sections
prior to submission to CMS.
X
Narrative response and supporting documentation for
each element excluding NA (and Deemable, if Deemed).
X
Y

QY05

Significant Problems Corrected

Onsite

Y

QY08

Chronic Care Improvement Progam

Onsite

Y

QY09

Quality Improvement Projects

Onsite

Y

QY501

Model of Care (CCIP)

Onsite

X

CHAPTER 6 – PROVIDER RELATIONS
Description of Element/General Information

Associated
Worksheet(s)
Element
Type

NA
Element
Code

Have
Available
Onsite

Deemable
(Y/N)

Send
to RO

Documentation for all elements excluding NA (and
Deemable, if Deemed). Refer to Review Guide MOEs for
examples.
X

X
Policies and procedures for all elements excluding NA
(and Deemable, if Deemed). Please tab relevant sections
prior to submission to CMS.

X

X
Narrative response and supporting documentation for
each element excluding NA (and Deemable, if Deemed).

X

X
Y

PR03

Credentialing Requirements for Physicians and Other
Health Care Professionals

Sample

WS-PR1

X
X
CHAPTER 13 – CLAIMS, ORGANIZATION DETERMINATIONS, APPEALS AND GRIEVANCES
NA

Associated
Worksheet(s)
Element
Type

Description of Element/General Information
Element
Code

Have
Available
Onsite

Deemable
(Y/N)

Send
to RO

Documentation for all elements excluding NA. Refer to
Review Guide MOEs for examples.
X
Policies and procedures for all elements excluding NA.
Please tab relevant sections prior to submission to CMS.
X
Narrative response and supporting documentation for
each element excluding NA (and Deemable, if Deemed).
X
X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

X

N

OC01

Correct Claim Determinations

Sample

WS-OC2

N

OC03

Timely Payment of Non-Contracting Provider Clean
Claims

Sample

WS-OC1

N

OC04

Interest on Clean Claims Paid Late

Sample

WS-OC1

N

OC05

Timely Adjudication of Non-Clean Claims

Sample

WS-OC1& WSOC2

N

OC06

Claim Denials (Notice Content)

Sample

WS-OC2

N

OP01

Standard Pre-Service Denials (Timeliness)

Sample

WS-OP1

N

OP02

Standard Pre-Service Denials (Notice Content)

Sample

WS-OP1

N

OP04

Request for Expedited Organization Determinations
(Timeliness)

Sample

WS-OP2

N

OP05

Expedited Denials (Notice Content)

Sample

WS-OP2

N

OP06

Organization Determination Extensions (Notice Content)

Onsite

N

OP08

Correctly Distinguishes Between Organization
Determinations and Reconsiderations

Sample

WS-OP1 & WSOP2

N

RC01

Favorable Claims Reconsiderations (Timeliness)

Sample

WS-RC1

N

RC02

Adverse Claims Reconsiderations (Timeliness)

Sample

WS-RC2

N

RC03

Effectuation of Third Party Claims Reconsideration
Reversals

Sample

WS-RC2

N

RP01

Favorable Standard Pre-Service Reconsiderations
(Timeliness)

Sample

WS-RP1

X

X

N

RP02

Adverse Standard Pre-Service Reconsiderations
(Timeliness)

Sample

WS-RP2

N

RP03

Effectuation of Third Party Standard Pre-Service
Reconsideration Reversals

Sample

WS-RP2

N

RP05

Requests for Expedited Reconsiderations (Timeliness)

Sample

WS-RP3

N

RP07

Effectuation of Third Party Expedited Reconsideration
Reversals

Sample

WS-RP3

N

GV01

Organization Determinations and Reconsiderations Not
Categorized as Grievances

Sample

WS-GV1

N

GV03

Grievance Decision Notification (Timeliness)

Sample

WS-GV1

N

GV04

Grievance Decision Notification (Notice Content_

Sample

WS-GV1

N

GV05

Method of Grievance Decision Notification

Sample

WS-GV1

X

X
X

X

X

X

X

X

X

X

X

X

ENCLOSURE I
PART D INFORMATION REQUIRED FOR AUDIT
Have
Available
Onsite

X

X

General Information

NA
Deemable
(Y/N)

Send
to RO

X
X
CHAPTER 1 – ENROLLMENT AND DISENROLLMENT
NA

Associated
Worksheet(s)
Element
Type

Description of Element/General Information
Element
Code

Have
Available
Onsite

Deemable
(Y/N)

Send
to RO

Current organization chart with position title and
name of individual responsible for finance,
medical management, provider relations, quality
assurance, marketing, enrollment/disenrollment,
claims processing, appeals/grievances, customer
service, MIS. I
Minutes from Board of Directors Meetings

X

X

X

X

X

X

ER01

X

X

ER01

X

X

ER05

X

X

ER06/ER07

X

X

ER06/ER07

X

X

ER06

X

X

ER08

Policies and procedures for all elements
excluding NA. Please tab relevant sections prior
to submissions to CMS.
Narrative response and supporting documentation
for each element excluding NA (and Deemable, if
Deemed)
The formats that it accepts for enrollment
requests
Enrollment requests received via telephone (For
Part D sponsors who allow telephone enrollment)
The cancellation of enrollment requests
The provision of a notice to acknowledge receipt
of completed enrollment request
The provision of a notice of CMS’ acceptance or
rejection of an enrollment
The provision of an Evidence of Coverage to new
plan members
The provision of materials to enrollees prior to the
effective date of enrollment

Sample

WS-ER1_D

Sample

WS-ER1_D

Sample

WS-ER4_D

Sample

WS-ER1_D

Sample

WS-ER1_D

Sample

WS-ER1_D

Sample

WS-ER1_D

X

X

ER15

The auto- and facilitated-enrollment process for
full benefit dual eligible and other low-income
subsidy eligible beneficiaries, including the
distribution of plan information to auto- and
facilitated-enrolled beneficiaries
The determination of enrollment periods of each
enrollment request received
The confirmation of enrollment for individuals
being claimed by an employer/union group for the
Retiree Drug Subsidy (RDS)
The transmission of enrollment transactions to
CMS
Updating records upon receipt of a TRR from
CMS, to accurately reflect each individual’s
enrollment status

X

X

ER802

X

X

X

X

X

ER09

X

X

ER11

X

X

ER13
ER14

Sample

WS-ER5_D
WS-ER6_D

Sample

WS-ER7_D

Sample

WS-ER8_D
WS-ER1_D

Sample

WS-ER11_D

Group enrollment process

Sample

WS-ER9_D

DN01

The voluntary disenrollment process

Sample

WS-DN1_D

X

DN07

Sample

WS-DN7_D

X

X

DN12

Sample

WS-DN1_D

X

X

LP01

X

X

LP01

X

X

LP02

X

X

LP03

X

X

LP03

X

X

LP03

X

X

LP04

X

X

ER01

Disenrollment for move out of service area
The transmission of voluntary disenrollment
transactions to CMS following receipt of a request
from an enrollee
Making a creditable coverage period
determination
Reporting the correct number of uncovered
months to CMS
Sending and processing creditable coverage
attestations
Adjusting the Late Enrollment Penalty (LEP) if the
beneficiary is or becomes eligible for the low
income subsidy (LIS)
Identifying enrollees who have or will have a
subsequent Initial Enrollment Period (IEP) based
on turning age 65
Reporting adjustments to the LEP based on
subsequent Part D Initial Enrollment Periods
(IEPs)
Informing beneficiaries of the imposition to, or
adjustment of, the Late Enrollment Penalty
Documentation demonstrating the Part D
sponsors internet enrollment process (For Part D
sponsors that allow internet enrollment via the
Part D sposnors web site), including a description
of how the Sponsor provides a tracking
mechanism to provide the individual with
evidence that the internet enrollment request was
received (e.g., screen shots of enrollment web
pages, including all popup windows and
disclaimers shown to beneficiary during the
internet enrollment process, notice to confirm that
enrollment request was received)

Sample

WS-ER1_D

X

X

MR09

Beneficiary notification of formulary changes

Sample

WS-MR4_D

X

X

MR10

The distribution of post-enrollment materials

Sample

WS-MR5_D

X

X

MR13

X

X

MR15

Sample

WS-MR6_D

X

X

MR09

Operation of the Part D sponsors internet website
The distribution of an LIS Rider to beneficiaries
who experience a change in their eligibility for the
low income subsidy
If applicable, documentation demonstrating the
Part D sponsor provides retrospective notice to
affected enrollees if a covered Part D durg is
removed form the formulary because it is deemed
unsafe by the Food and Drug Administration or
removed from the market by the manufacturer
(e.g., list of covered Part D drugs removed from
formulary because it is deemed unsafe or
removed from market, sample of notices sent,
beneficiary communication summary reports or
logs). Not to Sponsor: Please indicate if there are
no cases where the Sponsor removed a covered
part D drug from the formulary for the reasons
stated above during the audit period.

Sample

WS-MR4_D

X

X

MR10

X

X

MR13

X

X

MR15

X
DM02
X
EP01

X

X

DM02

X

EP01

Element
Type

FM04
TP01

X

X

TP02
TP03
FM01

X
FM04
X

WS-MR6_D

Policies and procedures for all elements
excluding NA. Please tab relevant sections prior
to submissions to CMS.
Narrative response and supporting documentation
for each element excluding NA (and Deemable, if
Deemed)
The Part D sponsor’s drug utilization
management program’s ways to prevent overand under-utilization of prescribed medications
The Part D sponsor’s electronic prescription
program
•
Documentation demonstrating the Part D
sponsor’s utilization of quantity vs. time
edits, early refill edits, and other over-/underutilization edits (e.g., system user guide,
reports, sample of actual DUM edits utilized)
Copy of a report that summarizes and evaluates
the sponsor’s ability to prevent over and under
utilization through the selected tools
Documentation demonstrating the Part D sponsor
has established and maintains an electronic
prescription program in accordance with CMS
requirements (e.g., sample of screen shots of
actual electronic prescriptions, reports generated
by the electronic prescribing system, system user
guides)

Element
Code

Deemable
(Y/N)

X

X

Sample

CHAPTER 7 – FORMULARY, TRANSITION PROCESS AND PHARMACY AND THERAPUTICS COMMITTEE
NA
Have
Description of Element/General Information
Associated
Available
Worksheet(s)
Onsite

X

X

WS-MR5_D

Element
Type

Element
Code

X

Send
to RO

Sample

CHAPTER 5 – DRUG UTILIZATION MANAGEMENT, QUALITY ASSURANCE AND ELECTRONIC PRESCRIBING
Have
NA
Description of Element/General Information
Associated
Available
Worksheet(s)
Onsite
Deemable
(Y/N)

Send
to RO

Documentation demonstrating the Part D
sponsor’s distribution of annual post-enrollment
materials (e.g., one copy of each annual member
material mailed, evidence of the date each
material was mailed out to all beneficiaries).
URL of Part D sponsors current Internet
website(s), and instructions for accessing
sections with required components for pharmacy
access, comprehensive formulary, formulary
change notices, and enrollment
Template for Low-Income Subsidy Rider to the
Evidence of Coverage

Policies and procedures for all elements
excluding NA. Please tab relevant sections prior
to submissions to CMS.
Narrative response and supporting documentation
for each element excluding NA (and Deemable, if
Deemed)
Claim adjudication and cost sharing
Transition process for beneficiaries to obtain nonformulary drugs in a retail setting or via home
infusion, safety-net, or I/T/U pharmacies
Transition process for beneficiaries to obtain nonformulary Part D drugs in a long-term care setting
Enrollee notification of a temporary transition
supply of a non-formulary Part D drug
Documentation demonstrating that each of the
Part D sponsor’s formulary versions currently in
use is the most current version on file with CMS
Documentation regarding claim adjudication that
demonstrates that sponsor accurately adjudicates
its benefit at the point of sale

Sample

WS-TP1_D

Sample

WS-TP2_D

Sample

WS-TP1_D

FM04

X

TP01
X

TP01
X
TP02
X
TP02
X
TP03
X

X
CB01
CB02
X
X

CB02

CB03
X

CB01

X

CB01
X

CB02

X
X

CB02

CB02
X

WS-TP1_D

Sample

WS-TP1_D

Sample

WS-TP2_D

Sample

WS-TP2_D

Sample

WS-TP1_D

Associated
Worksheet(s)

Element
Type

X

X

Sample

CHAPTER 9 – TRUE OUT-OF-POCKET COSTS AND COORDINATION OF BENEFITS
NA
Description of Element/General Information
Element
Code

Have
Available
Onsite

Deemable
(Y/N)

Send
to RO

Plan grievances submitted to the Part D sponsor
regarding claim adjudication and cost sharing
System reports and other documentation
regarding the Part D sponsor’s transition process
utilization for beneficiaries in a retail setting or via
home infusion, safety-net, or I/T/U pharmacies
Provider and beneficiary education materials that
describe Sponsor’s transition process for
beneficiaries to obtain non-formulary Part D drugs
in a retail setting or via home infusion, safety-net,
or I/T/U pharmacies
System reports and other documentation
regarding the Part D sponsor’s transition process
utilization for beneficiaries in a long-term care
setting
Provider education materials and beneficiary
education materials that describe Sponsor’s
transition process for beneficiaries to obtain nonformulary Part D drugs in a long-term care setting.
Notice template for notifying enrollees of a
temporary transition supply of a non-formulary
Part D drug

Policies and procedures for all elements
excluding NA. Please tab relevant sections prior
to submissions to CMS.
Narrative response and supporting documentation
for each element excluding NA (and Deemable, if
Deemed)
The coordination of benefits with all other payers
providing coverage for covered Part D drugs
Coordinating benefits and exchanging claims and
payment information with all entities that provide
other prescription drug coverage
Tracking enrollee gross covered drug spend and
TrOOP amounts
Providing enrollees with their gross covered drug
spend and TrOOP balance as of the effective
date of disenrollment, and if the enrollee changes
plans mid-year, providing these data to the new
plan of record
Documentation demonstrating that the Part D
sponsor collects and updates information from
enrollees about their other health insurance (e.g.,
system documentation/reports, survey templates,
communications logs, or copies of EOB
statements sent to enrollees, enrollment forms,
management report on the number of 30-day and
annual surveys distributed and the number of
responses received)
Documentation demonstrating that it reports
information to the COB Contractor and receives
and updates its systems at least weekly to reflect
information on enrollee’s other prescription drug
coverage received from CMS
Documentation demonstrating that the Part D
sponsor has a system to accurately coordinate
benefits and exchange claims and payment
information with entities that provide other
prescription drug coverage (e.g., copies of EOBs
sent to enrollees, Part D sponsor system
documentation/reports, NCPDP “N” transaction
reports, etc.)
Copy of Sponsor’s executed business associate
agreement with the TrOOP Facilitation Contractor
Documentation demonstrating that the Part D
sponsor has a system in place to correctly track
and calculate enrollee TrOOP amounts (e.g.,
NCPDP “N” transaction reports, etc.)

Sample

WS-CB1_D, WSCB2_D

Sample

WS-CB3_D

Sample

WS-CB3_D

Sample

WS-CB4_D, WSCB5_D

Sample

WS-CB1_D, WSCB2_D

Sample

WS-CB1_D, WSCB2_D

Sample

WS-CB3_D

Sample

WS-CB3_D

Sample

WS-CB3_D

CB02
X
CB02
X
CB02
X

CB03
X

CB03

X

CB03

X

X

X

X

X

Sample

WS-CB3_D

Sample

WS-CB3_D

Sample

WS-CB3_D

Sample

WS-CB4_D, WSCB5_D

Sample

WS-CB4_D, WSCB5_D

Sample

WS-CB4_D, WSCB5_D

CHAPTER 18 – GRIEVANCES, COVERAGE DETERMINATIONS AND APPEALS
Description of Element/General Information

Associated
Worksheet(s)
Element
Type

NA

Element
Code

Have
Available
Onsite

Deemable
(Y/N)

Send
to RO

Documentation demonstrating Part D sponsor has
a system in place to allow SPAPs and other
entities that provide other prescription drug
coverage to coordinate benefits
Documentation demonstrating that the Part D
sponsor has a system in place and provides
EOBs to beneficiaries to inform them of their
gross covered drug spend and TrOOP balances
Documentation demonstrating that the Part D
sponsor has a system in place to correctly track
and calculate enrollee TrOOP amount
Documentation that for beneficiaries with midyear plan changes it calculates a beneficiary’s
gross covered drug spend and TrOOP balance
and sends notice of the TrOOP status to the
beneficiary,
Documentation demonstrating that for
beneficiaries with mid-year plan changes it
calculates a beneficiary’s gross covered drug
spend and TrOOP accumulators for each month
the sponsor adjudicated claims for the beneficiary
during the coverage year and , sends this
information to the new plan of record
Documentation demonstrating that it receives via
the NCPDP financial information reporting
standard transaction set the gross covered drug
spend and TrOOP accumulator data from the
beneficiary’s prior plan(s) of record for the
coverage year, uses the data to update/adjust the
beneficiary’s gross covered drug spend and
TrOOP,to adjust any previously adjudicated
claims, if applicable, and to position the
beneficiary correctly in the benefit

Policies and procedures for all elements
excluding NA. Please tab relevant sections prior
to submissions to CMS.
Narrative response and supporting documentation
for each element excluding NA (and Deemable, if
Deemed)

X

X

GV01

The categorization of complaints as inquiries,
grievances, or coverage determinations

Sample

WS-GV1_D, WSCD1_D, WSCD2_D & WSCD3_D

X

X

GV04

Enrollee notification of grievance disposition

Sample

WS-GV1_D

X

X

GV05

Method of grievance responses

Sample

WS-GV1_D

X

X

GV07

Timely response to expedited grievances

Sample

X

X

CD03

Enrollee notification of coverage determinations
Enrollee notification of adverse coverage
determination

Sample

WS-GV2_D
WS-CD1_D, WSCD2_D

X

X

Sample

WS-CD1_D, WSCD2_D

Sample

WS-CD3_D

Sample

WS-CD3_D

Sample

WS-CD3_D
WS-CD1_D, WSCD2_D, WSCD3_D
WS-CD1_D, WSCD2_D, WSCD3_D

CD05

CD06
X

Decisions to accept or deny requests to expedite
coverage determinations

X

X

X

CD07, CD08

X

X

CD09, CD10

Enrollee notification following a decision to deny a
request to expedite a coverage determination
Enrollee notification following a decision on an
expedited coverage determination

X

X

CD11

Effect of failure to provide timely notification on a
standard or expedited coverage determination

Sample

X

X

CE03

Determining cost-sharing for approved exceptions

Sample

X

X

RE03

X

X

RE04

X

X

RE05

X

X

RE07

X

X

RE07

X

X

RE08

Decisions to accept or deny requests to expedite
redeterminations
Enrollee notification following decision to deny a
request to expedite a redetermination
Timely notification and effectuation of standard
redeterminations
Enrollee notification following decision on
expedited redetermination
Requesting medical information required for
making a decision on an expedited
redetermination
Processing expedited coverage redetermination
reversals

X

X

RE10

Forwarding case files to the IRE upon the IRE’s
request in a timely manner

Sample

X

X

RE11

Effect of failure to provide timely notification on a
standard or expedited redetermination

Sample

X

X

RV01

X

X

RV03

Sample

WS-RE3_D

Sample

WS-RE3_D

Sample

WS-RE1_D

Sample

WS-RE3_D

Sample

WS-RE3_D

Sample

Effectuating third party reversals on an appeal
Effectuating third party reversals on an appeal of
an expedited request for a benefit
Informing enrollees—orally and/or in writing—
about inquiries involving excluded drugs or drugs
not covered under Part D. Examples of
acceptable documentation are written notices and
phone scripts.
Informing enrollees of grievance deadline
extension

Sample

WS-RE3_D
WS-RE1_D, WSRE2_D, WSRE3_D
WS-RE1_D, WSRE2_D, WSRE3_D
WS-RE1_D, WSRE2_D,

Sample

WS-RE3_D

Sample

WS-GV1_D, WSCD1_D, WSCD2_D & WSCD3_D

Sample

WS-GV1_D

Sample

WS-GV1_D

Sample

WS-RE1_D

Sample
Sample

WS-RE3_D
WS-CD1_D, WSCD2_D

Sample

WS-CD3_D

Sample

WS-CD3_D

Sample

WS-RE3_D

X

X

GV01

X

X

GV04

X

X

X

X

RE05

X

X

RE07

X

X

CD05

X

X

CD08

X

X

CD10

X

X

RE04

Notification of grievance disposition
Notifying enrollee of an adverse standard
redetermination
Notifying enrollee of an adverse expedited
redetermination
Notifying enrollee of an adverse coverage
determination, whether in part or whole
Notifying enrollee that a request for an expedited
coverage determination is denied
Notifying enrollee of an adverse expedited
coverage determination
Notifying enrollee that a request for an expedited
redetermination is denied

X

X

RE05

Notifying enrollee on requesting a reconsideration

Sample

WS-RE1_D

X

X

RE07

Notifying enrollee on requesting a reconsideration
Documentation demonstrating the Part D
sponsors communication methods for informing
enrollees of complaint categorization (e.g., phone
scripts and notice template for informing enrollees
of complaint categorization)
Documentation demonstrating the Part D
sponsor’s systems for authorizing or providing a
benefit under dispute within 72 hours of receiving
the request for redetermination (e.g., expedited
redetermination logs, system reports)
Low income premium subsidy amount pass
through for employer/union sponsored plans
For Part D sponsors other than Direct Contracts,
the sponsor’s executed contract/written
agreement with employer/union that discusses
low income premium subsidy amounts

Sample

WS-RE3_D

Sample

WS-GV1_D, WSCD1_D, WSCD2_D & WSCD3_D

Sample

WS-RE3_D

Sample

WS-SU2_D

Sample

WS-SU2_D

X

X

X

X

X

X

GV05

GV01

RE08
SU802

SU802
X