Medicare Parts C and D Universal Audit Guide

(Date)
Re: Audit Confirmation Letter
Dear (Name):
This letter is to confirm that a team from the Centers for Medicare & Medicaid Services (CMS)
will conduct a broad based audit of (Company Name) from (Date) – (Date). CMS staff have
already discussed arrangements for this audit with (Name) of your staff. The CMS team will
audit all of the samples in our office.
The purpose of this audit is to assess (Company Name) compliance with the Medicare
Advantage (MA) regulations found at 42 CFR Part 422, Subpart U, SNP regulations found at 42
CFR Part 422, RPPO regulations found at 42 CFR Part 422, Prescription Drug Benefit (Part D)
regulations found at 42 CFR Part 423, and other appropriate CMS standards.
The audit team will consist of (Names) and other Regional Office staff members yet to be
determined. The following team members will lead subteams:
Enrollment/Disenrollment
Claims
Part C Grievances & Reconsiderations
Part C Preservice Decisions
Part C Quality Assurance
Part C Credentialing
Part D/PDP Grievances, Coverage
Determinations, and Appeals
Drug Utilization Mgmt, Formulary/Transition
Late Enrollment Penalty & COB/Troop
All Other Areas

(Name)
(Name)
(Name)
(Name)
(Name)
(Name)
(Name)
(Name)
(Name)
(Name)
(Name)

Because some of the contracts designated for audit are deemed to meet certain requirements
based on your accreditation status, we will not audit those elements that are deemed for the
following platforms: (Platform). For the remaining platforms, the universes for deemed elements
may exclude those contracts that are deemed.
The CMS audit team will meet with you and your staff at your office at 8:30 am on (Date) for the
entrance conference. During the entrance conference, the auditors will discuss the purpose of the
audit, review the agenda, and highlight issues relevant to the review. We would appreciate you
and/or your staff presenting a detailed overview of your current organization and operation. At
the close of the audit, the auditors will hold an exit conference to summarize their preliminary
findings and discuss any unresolved issues. We would appreciate having you, the Medicare
Compliance Officer, other appropriate management staff, and a member of the Board of
Directors, if available, attend both the entrance and exit conferences.
As part of CMS' broad based audit, (Contractor), who has been contracted by CMS, will evaluate
(Company Name)'s Chronic Care Improvement Program and Quality Improvement Projects.

(Company Name) is responsible for providing information documenting your CCIP and QIPs to
CMS' contractor. CMS has made reporting templates available to MA contractors at the
following public website: (Website).
QIP and CCIP information must be reported at the contract level even if CMS is auditing several
contracts simultaneously under a single audit. If a CCIP or QI project design is identical across
multiple contracts, an MAO undergoing a multiple contract audit may submit one report for each
CCIP and QIP and attach an addendum to each report, delineating contract-specific data and any
contract-specific modifications to the over-all design and/or interventions. You must submit only
materials for projects and programs initiated since (Date) or your last broad based audit
(whichever date is later). You may find further instructions within the reporting template.
Along with the information CMS is requesting in the templates, MA contractors may also submit
additional supporting materials (such as: patient educational materials, additional analyses and
graphs, data collection forms, screening forms, questionnaires, phone survey scripts, etc.) for
your QI project reports and CCIP reports. You may contact (Contractor) directly for technical
assistance. (Contractor) may contact you for clarification and supporting material.
No later than (Date), you must send one (l) copy of all project reports and CCIP reports to
Electronic documents:

(Email Address)

Hard copy documents:

(Name)
(Address)

Technical Assistance:

(Email Address)
(Phone Number)

(Contractor) will enter findings in HPMS for these two areas. The findings will be available
within 45 days of receipt of your materials. (Contractor) will also provide detailed scoring of the
QIP and CCIP to you and to CMS.
Contracts Scheduled for Audit
See Enclosure VI for a list of contracts and the designated platforms that will be included in this
audit.
Part C Elements
The CMS audit team will use Version 6.1 of the Medicare Advantage Audit Guide, Version 2.1
of the RPPO Audit Guide, and Version 3.1 of the PFFS Audit Guide, to conduct the Part C audit.
You may access the audit guides in HPMS in the auditing modules. SNP elements appear in the
MA Guide. The Part C audit will cover the following areas:
•
Chapter 2, Enrollment & Disenrollment: EROl, ER02, ER03, ER04, ER05, ER06, ER07,
ER08, ERll, ERI2, ERI8, ER501, ER502, ER802, DNOl, DN02, DN03, DN04, DN06, DNll, and
DN501.

•
Chapter 4, Benefits & Beneficiary Protections: CCO1, CS601, and HAOI
•
Chapter 5, Quality Assurance: QY05, QY08, QY09, and QY501
•
Chapter 6, Provider Relations: PR03
•
Chapter 13, Claims, Organization Determinations, Appeals and Grievances: GVOI,
GV03, GV04, GV05, OCOI, OC03, OC04, OC05, OC06, OPOI, OP02, OP04, OP05, OP06,
OP08, RCOI, RC02, RC03, RPOI, RP02, RP03, RP05, and RP07
MA-PD Part D Elements
The CMS audit team will use Version 3 of the Medicare Advantage Prescription Drug Plan
(MA-PD) Audit Guide to conduct the Part D audit of the "H and R" plans. You may access the
audit guides in HPMS in the auditing modules. The MA-PD Part D audit will cover the
following areas:
•
Chapter 1, Enrollment & DisenroIlment: ER09, ER13, LPOI, LP02, LP03, and LP04
•
Chapter 3, Marketing: MR09, MR10, MR13, and MRl5
•
Chapter 5, Drug Utilization Mgmt: DM02 and EPO 1
•
Chapter 7, Formulary Transition: FMOI, FM04, TP0l, TP02, and TP03
•
Chapter 9, COB/TROOP: CBO 1, CB02, and CB03
•
Chapter 13, Grievances, Coverage Determinations, and Appeals: CD03, CD05, CD06,
CD07, CD08, CD09, CDI0, CD11, CE03, GV01, GV04, GV05, GV07, RE03, RE04, RE05,
RE07, RE08, REl0, RE11, RVOI, and RV03
•
Chapter 15, Policies & Procedures: PPOI
•
Chapter 16, Employer Group Health Plan Premiums: SU802
PDP Part D Elements
The CMS audit team will use Version 3 of the Medicare Prescription Drug Plan (PDP) sponsor
Part D Audit Guide to conduct the Part D audit of the "S" plans. You may access the audit guides
in HPMS in the auditing modules. The PDP Part D audit will cover the following areas:
•
Chapter I, Enrollment & Disenrollment: EROI, EROS, ER06, ER07, ER08, ER09, ERII,
ER13, ERI4, ERIS, ER802, DNOI, DN07, DNI2, LPOI, LP02, LP03, and LP04
•
Chapter 3, Marketing: MR09, MRIO, MR13, and MRIS
•
Chapter 5, Drug Utilization Mgmt: DM02 and EPO I
•
Chapter 7, Formulary Transition: FMOI, FM04, TPOI, TP02, and TP03
•
Chapter 9, COB/TROOP: CBOI, CB02, and CB03
•
Chapter 13, Grievances, Coverage Determinations, and Appeals: CD03, CDOS, CD06,
CD07, CD08, CD09, CD10, CDII, CE03, GVOI, GV04, GVOS, GV07, RE03, RE04,
REOS, RE07, RE08, REIO, REII, RVOI, and RV03
•
Chapter 15, Policies & Procedures: PPO I
•
Chapter 16, Employer Group Health Plan Premiums: SU802
The auditors are not confined solely to the elements contained in the Audit Guides. If the
auditors find indications that you may not be in compliance with other regulatory requirements,
they will investigate the issue further to determine whether your organization is in compliance
with Federal regulations and other appropriate CMS standards.

Enclosure I identifies the information and elements that CMS will evaluate during this audit.
Column I indicates which documentation (Company Name) should send to CMS prior to the
audit. Please note that all policies and procedures and other documentation provided should
reflect your operations during the specified audit period, which is (Date) – (Date). Also, the
following Part D Chapter I elements are waived for the "H" and "R" plans: EROI, EROS, ER06,
ER07, ER08, ERII, ERI4, ERIS, ER802, DNOI, DN07, and DNI2.
Please send us the necessary documentation no later than (Date), and have a copy of the
materials available in a room that the auditors can use as an office during the audit. Make all
other documentation associated with the audit available onsite as well. All documentation
should be available in the room on the first day of the audit. The auditors may request
additional information while onsite.
Please submit the policies that we request in both electronic and hard copy formats. If policies
are lengthy, please highlight relevant portions. We will also need a comprehensive listing of all
the policies and procedures that directly affect Medicare managed care operations. Please
complete and return Enclosure V for this purpose. Enclosure V will serve as a crosswalk between
each element under audit and the documentation, notices, and policies and procedures you are
sending to demonstrate compliance.
Enclosure II identifies the staff that CMS may need to talk with during the audit. Since not all of
the audit team will be onsite (Date), conference calls should be scheduled with your staff familiar
with each area under audit. Interviews involving team members not onsite will be
held via these conference calls. You should make tentative arrangements for these discussions,
starting (Date), after the entrance conference and reserve a sufficient number of rooms for these
discussions. These rooms should be in addition to the room reserved as an office for auditors.
Each discussion should take approximately one hour, unless the enclosure indicates otherwise.
Please send me a draft agenda at least one week before the review. Enclosure III is a sample
agenda format to assist you.
Enclosure IV lists the audit areas that we will sample. This enclosure briefly describes these
areas and asks you to generate a listing of the universe for specific samples, as noted. Please note
that (Company Name) is responsible for obtaining universes from each of its contracted entities
that are delegated to perform functions on its behalf, if applicable. Unlike with Part C, (Company
Name) must combine its own Part D universes with any Part D universes it requests and
receives from its delegated entities prior to submitting them. Please send these listings to the RO,
along with the materials marked with an "X" in Enclosure I, Column 1 no later than (Date). If
you are not able to generate the data described in this enclosure, please call me to discuss
alternative methods.
Approximately six weeks prior to the review, we will notify you of the specific cases selected for
review in our office and the minimum documentation requirements for the sample cases selected.
(Company Name) must send all requested documentation associated with the cases selected to
the RO no later than (Date).
No later than (Date), please send the following documentation to the address below:

(Name)
(Address)
•
•

One (l) copy of the information requested in Enclosure I, Column 1, and
One (l) copy of the information requested in Enclosure IV.

Thank you for your cooperation in scheduling this review. If you have any questions, please call
me at (Phone Number).
Sincerely,
(Name)