Medicare Parts C and D Universal Audit Guide

ENCLOSURE IV
UNIVERSE REQUEST FOR SAMPLES TO BE AUDITED BY CMS FOR MA, MA-PD
AND/OR PDP COMBINED AUDIT
Please provide the audit team with a universe listing for each sample described in Parts I and III
of this document, in the electronic format described below, no later than (Date). Unless
otherwise specified, the universe listing is the complete list of all Medicare beneficiary
transactions that took place during the audit period, from which CMS will randomly choose
“cases” to audit for compliance. All of the samples CMS will audit are for Medicare members of
the MAOs and Part D plans. Each universe described will indicate any delegated entities for
which (Company Name) must provide additional universes. Unless otherwise specified, the
audit period is (Date) – (Date). Please note that the audit period for enrollment and
disenrollment elements was adjusted to (Date) – (Date) to ensure that only one manual version
would apply to the universe and to include all enrollment periods (AEP, OEP, and nonAEP/OEP).
If you are unable to produce any of the universes requested in Parts I or III, please contact
(Name) immediately.
Prior to the audit, the audit team will notify you of the specific cases we will review for each
sample listed under Parts I through IV. Also, we will notify you of the materials necessary to
document each case.
Data Transmission Vehicle
(Company Name) must submit the universe listings for functions performed ONE readable CD
per platform. See Enclosure VI for a list of platforms. In some cases, we have indicated that
universes for certain platforms can be combined with the (Platform). These combined universe
listings should only be shown on the (Company Name) CD. If not possible, or if you have any
questions, please contact (Name).
File Format
The universe listings must be submitted as comma delimited .csv files, with the exception on
(Worksheet), which can be submitted as an .xls (excel) file.
Number of Files
For each worksheet the MAO should submit either:
•
•
•

1 file containing the whole universe (the MAO chooses this option if the file
contains at most 65,530 records)
6 files each containing one month of data (the MAO chooses this option if each month of
data contains at most 65,530 records)
24-26 files each containing one week of data (the MAO chooses this option if each week
of data contains at most 65,530 records).

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In the event that some week contains more than 65,530 records please call the RO to discuss
alternative arrangements.
It is important that no other options be used. For example, it would be unacceptable to submit
two files each with 3 months of data. Similarly it would be unacceptable to give 5 files with 5
months of data and 4 files with the remaining 4 weeks. Only the 3 options above are acceptable
for submission.
Names of Files
All of the files should be named with the three letter code of the worksheet to which the universe
corresponds (example below). Files that contain data for the entire audit period should be named
with the three letter code of the worksheet to which the universe corresponds. Files that contain
data for each month should begin with an “m,” followed by the number of the month that the
data captures, followed by a hyphen and then the three letter code of the worksheet to which the
universe corresponds. Files that contain data for each week should begin with a “w,” followed
by the number of the week that the data captures, followed by a hyphen and then the three letter
code of the worksheet to which the universe corresponds.
For example:
• Suppose the universe for ws-rc2 consists of one file (with all 6 months of data). Then that
file must be named rc2.csv
•

If the universe for ws-rc2 consists of 6 files (one for each month) then the files must be
named m1-rc2.csv, m2-rc2.csv….m6-rc2.csv (or csv files). Name formats must be
strictly adhered to.

•

If the universe for ws-rc2 consists of 24-26 files (one for each week) then the files must
be named w1-rc2.csv, w2-rc2.csv, w3-rc2.csv, w26-rc2.csv, etc.

It is very important that all names adhere exactly to the above format. An actual example: A
particular MAO may have only 300 grievances but 300,000 provider claims. Then
• It would submit one file for grievances: gv1.csv
• It would submit 6 files for claims (each under 65,530) named: m1-oc1.csv, m2-oc1.csv…
Folders and Workbooks
Do not put any files in folders. Except for the HSD-2 files required for (Worksheet), do not put
any files in workbooks. Save the files directly to the CD.
Name of CD-ROM
The CD-ROM for the universes must be named with the platform name: (Platform Name)
Delegated Entities
If you are submitting any files for delegated entities, you must submit the universe listings for
each Part C delegated entity on one CD per delegated entity per platform unless otherwise
specified (e.g., if there are four delegated entities who perform functions for two platforms, you

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must submit eight CDs). You must use the same naming convention for the universes as
described above. Do not add anything to the file name, such as the name of the delegated entity.
Important: unlike with Part C, the MAO or sponsor must combine its own Part D
universes with any Part D universes it requests and receives from its delegated entities prior
to submitting them to the audit team.
Name of CD-ROM for Delegated Entities
The CD-ROM for each Part C delegated entity must be named PLATFORM NAME-(name of
delegated entity-not to exceed 15 letters). Make sure there is a hyphen between the contract
number and the delegated entity’s name. The name of the delegated entity must not contain any
spaces, underlines or periods. It may contain hyphens and upper and lower case letters. For
example, if a delegated entity on the (Platform Name) is See Well Vision Group, the name could
be (Platform Name)-(Company Name)-See-Well-Vision.
Part C Worksheet Field Names
Use the format described below. In particular:
• Do NOT place the word “worksheet” or the worksheet name in the file. The worksheet
name shown in the boxes below is there for your reference only.
• The first row should contain the number of the worksheet columns to which the data
corresponds (as provided below in the Worksheet Field Names boxes). Do NOT place
the words “1st row in submitted file should read:” in the file.
• The 2nd row should contain the names of the worksheet columns to which the data
corresponds (as provided below in the Worksheet Field Names boxes). Do NOT place
the words “2nd row in submitted file should read:” in the file.
• The 3rd row should contain data entered by the MAO
• The file should be flat format—only rows and columns
• There should be no comments, formulas, subtotals or blank rows anywhere in the data.
Please adhere to the format shown below. Each file must contain 2 header rows followed by the
data.
Field formats
• Dates: Must be in (Date) or m/d/yy or m/d/yyyy format. Traditional mainframe
formats (yyyymmdd) are not acceptable.
•

Time: Must be in hh:mm AM/PM.

•

Names: Please use FIRST NAME SPACE LAST NAME format. Please do not use
commas with the names (as this will interfere with the csv feature of some files).

•

HIC #: Please record leading zeroes, if any.

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Part C Worksheet Field Names
Please insert a column entitled Contract Number before column 1 for all Part C and Part D
worksheets.
Worksheet
1st row in submitted file
should read:
2nd row in submitted file
should read:

Worksheet
1st row in submitted file
should read:
2nd row in submitted file
should read:
Worksheet
1st row in submitted file
should read:
2nd row in submitted file
should read:
Worksheet
1st row in submitted file
should read:
2nd row in submitted file
should read:
Worksheet
1st row in submitted file
should read:
2nd row in submitted file
should read:
Worksheet
1st row in submitted file
should read:
2nd row in submitted file
should read:

1

2

7

Member Name

HIC #

Date Denial Notice Sent

1

2

4

Member Name

HIC #

Enrollment Date

1

2

4

Member Name

HIC #

Disenrollment Date

1

2

3

Member Name

Plan ID#

HIC #

1

3

Claim Number

Date Claim Paid

1

3
Date Claim
Denied

Claim Number

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Please provide only the Member Name in column 1 for the worksheets listed below
this statement. Also, please provide only the date (and not the time) the request was
received for worksheets (Worksheet) and (Worksheet) under heading "Date & Time
Expedited Request Received," column 4.
Worksheet
1st row in submitted file
should read:
1
2nd row in submitted file
should read:
Member Name or HIC #
Worksheet
1st row in submitted file
should read:
2nd row in submitted file
should read:

1
Member Name or HIC #

Worksheet
1st row in submitted file
should read:
1
2nd row in submitted file
should read:
Member Name or HIC #
Worksheet
1st row in submitted file
should read:
2nd row in submitted file
should read:

Worksheet
1st row in submitted file
should read:
2nd row in submitted file
should read:

Date Denied

4
Date & Time Expedited Request
Received

7
Date Member Notified

1

4

Member Name or HIC #

Date Recon Request Received

Worksheet
1st row in submitted file
should read:
1
2nd row in submitted file
should read:
Member Name or HIC #
Worksheet
1st row in submitted file
should read:
2nd row in submitted file
should read:

9

9
Date Member Notified

1

4

Member Name or HIC #

Date Recon Request Received

1

4
Date & Time Expedited Recon Request
Member Name or HIC #
Received

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Worksheet
1st row in submitted file
should read:
2nd row in submitted file
should read:

1

4

Member Name or HIC #

Date Grievance Received

The above field names should also be used for the worksheet: (Worksheet)
Part I
Part C Samples to be Selected from MAO Data
(MAO must provide these universes to the audit team.)
Any variances to the audit period and any delegated entities for which universes are required
are specified under the applicable universe description(s) below.
Note: “800 series” plans offered by the MAO must be included in the universe, unless otherwise
specified.

MAO Denial of Enrollment

(Worksheet)

Purpose: To determine if the MAO processes MAO “up front” enrollment denials per CMS
standards.
Universe: All cases that the MAO denied, during the audit period. Only cases that did not result
in an enrollment should be submitted. These denials might be for reasons such as no valid
enrollment period, not residing in the service area, failing to complete the application within
specified timeframes, the presence of ESRD (and no exception), the enrollee's lack of Part A or
B of Medicare, and/or denials because the MAO is closed or has a capacity limit in effect.
Cancellations of enrollment or CMS system rejections are not denials and must not be included
in the universe.
Delegated Entities:

None

Audit Period Variance: December 2008
January 2009
March 2009
April 2009 (weeks of 4/3, 4/10, and 4/17 only)
Platform/Contracts:

(Platform Name / Contract Number)

Note: Combine (Platform Names) into one universe.

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Group Enrollment Requirements

(Worksheet)

Purpose: To determine if group enrollment requirements were met for employer group
enrollees.
Universe: All enrollees in employer/union sponsored plans enrolled using the group enrollment
mechanism that were effective during the audit period.
Delegated Entities: None
Audit Period Variance: December 2008
January 2009
March 2009
April 2009 (weeks of 4/3, 4/10, and 4/17 only)
Platform/Contracts:

(Platform Name / Contract Number)

Involuntary Disenrollment Due to Permanent Move

(Worksheet)

Purpose: To determine if involuntary disenrollments for a permanent move out of the service
area were processed per CMS standards.
Universe: All involuntary disenrollments for permanent moves outside the plan service area that
became effective during the audit period. The universe should include both member requests for
permanent moves outside of the plan's service area and all other involuntary disenrollments for
permanent moves outside of the plan's service area.
Delegated Entities:

None

Audit Period Variance: December 2008
January 2009
March 2009
April 2009 (weeks of 4/3, 4/10, and 4/17 only)
Platform/Contracts:

(Platform Name / Contract Number)

Note: Combine (Platform Names) into one universe.
Involuntary Disenrollment Due to Change in Special Needs Status (Worksheet)
Purpose: To determine if involuntary disenrollment for change in SNP status were processed
per CMS standards.
Universe: All involuntary disenrollments submitted by a SNP for change in SNP eligibility
status.

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Delegated Entities:

None

Audit Period Variance: December 2008
January 2009
March 2009
April 2009 (weeks of 4/3, 4/10, and 4/17 only)
Platform/Contracts:

(Platform Name / Contract Number)

Note: Combine (Platform Names) into one universe.
(Worksheet)

Provider Credentialing

Purpose: To determine compliance with regulatory requirements for the selection and evaluation
of providers in accordance with 42 CFR 422.204(b)(2).
Universe: The Health Services Delivery table, HSD-2, provider list that lists physicians and
other practitioners by county. This table delineates if the credentialing function is delegated or
not. [Note: Nurse practitioners and hospitalists (as long as the hospitalists are not separately
identified in the MAO literature as available to enrollees) listed on HSD-2 will be excluded from
the universe since credentialing is not required for them.]
Delegated Entities:

None

Audit Period Variance:

Only list those providers contracted as of February 28, 2009

Contracts:

(Contract Numbers)

Note: Submit one workbook on the (Company Name) CD-ROM, with a tab for each contract.
Non-Contracted Provider Paid Claims

(Worksheet)

Purpose: To determine if the MAO: (1) pays for: referral services to non-contracted providers,
which were made by the MAO or its contracted providers; and emergency, post stabilization,
temporarily out of area renal dialysis, and urgently needed care, without prior authorization; (2)
pays clean claims from non-contracted providers within 30 days of receipt; (3) makes accurate
decisions regarding what constitutes a clean claim; and (4) pays interest on clean claims not paid
within 30 days of receipt. (A provider is determined to be a "contracting provider" if he/she has
entered into a written agreement with the MAO that includes the provision that prohibits
providers from holding an enrollee liable for payment of any fees that are the obligation of the
MAO [422.502 (i)(3)(i)]. Conversely, a provider is determined to be a "non-contracting
provider" if he/she has not entered into such a written agreement.
Universe: All non-contracted provider paid claims paid during the audit period. A claim
consists of one or more services/line items with a unique bill date and a unique paid date. If at

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least one paid line item in the claim is greater than $0.00 (and no items are denied), the claim
belongs in this universe. There should be only one record in the universe for each entire claim
(line items should be rolled up). Exclude adjustments to claims that were previously processed.
Delegated Entities:

(Name)

Audit Period Variance: October 2008
December 2008
February 2009
Platform/Contracts:

(Platform Name / Contract Number)

Note: (Platform Names) can be combined into one universe. Delegated Entity universes must be
submitted separately.
(Worksheet)

Denied Claims

Purpose: To determine if the MAO: (1) complies with the regulatory requirements to provide
notice of an adverse organization determination; (2) processes claims within 60 days of receipt;
and (3) inappropriately denies services (e.g., Medicare-covered services, emergency and urgently
needed care, and benefits covered in the MAO's Evidence of Coverage). (A provider is
determined to be a "contracting provider" if he/she has entered into a written agreement with the
MAO that includes the provision that prohibits providers from holding an enrollee liable for
payment of any fees that are the obligation of the MAO [422.502 (i)(3)(i)].
Conversely, a provider is determined to be a "non-contracting provider" if he/she has not entered
into such a written agreement.
Universe: All claims denied during the audit period which are: non-contracted provider claims
denied for the following reasons: non-emergent, non-urgent out of area care, non-covered
service, and unauthorized services. (Exclude duplicate claims, routine vision, dental, and
hearing claims, adjustments to claims that were previously processed, claims denied due to
unbundling, and claims denied because the beneficiary was not enrolled in the MAO on the date
of service. A claim consists of one or more services/line items with a unique bill date and a
unique denied date. If one line item in the claim is denied, the claim belongs in this universe.
There should be only one record in the universe for each entire claim (line items should be rolled
up).
Delegated Entities:

(Name)

Audit Period Variance: October 2008
December 2008
February 2009
Platform/Contracts:

(Platform Name / Contract Number)

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Note: (Platform Names) can be combined into one universe. Delegated Entity universes must be
submitted separately.
Standard Pre-Service Denials

(Worksheet)

Purpose: To determine whether the MAO complies with regulatory requirements for timeliness
and member notice when initially denying provider or member requests for service. Also, to
determine whether cases categorized by the MAO as organization determinations are in fact
organization determinations rather than reconsiderations.
Universe: Standard pre-service organization determinations made during the review period that
were not fully favorable to the member. In addition, discontinuation of services that were issued
during the review period, but only when the member believed that the services should have been
continued because they were medically necessary. Discontinuation of services for which the
member did not indicate disagreement, and denials made after the service has been rendered, or
concurrent review denials, are not included in the universe.
Delegated Entities:

(Name)

Audit Period Variance: October 2008
December 2008
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: (Contract Name) can be combined into one universe. Delegated Entity universes must be
submitted separately.
Requests for Expedited Organization Determinations

(Worksheet)

Purpose: To determine if the MAO complies with regulatory requirements for timeliness and
member notice when processing provider or member requests for expedited organization
determinations. Also, to determine if cases categorized as requests for expedited organization
determinations are, in fact, requests for organization determinations rather than requests for
reconsideration or expedited reconsideration.
Universe: All requests for expedited organization determinations received during the audit
period, regardless of whether they were expedited or not.
Delegated Entities:

(Name)

Audit Period Variance: October 2008
December 2008
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

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Note: (Contract Name) can be combined into one universe. Delegated Entity universes must be
submitted separately.
(Worksheet)
Favorable Claims Reconsiderations
Purpose: To determine whether the MAO complies with regulatory requirements for timeliness
and member notice when approving member requests for claims payment on reconsideration.
Universe: All claim reconsideration determinations made during the audit period that resulted in
the MAO reversing its initial denial.
Delegated Entities:

None

Audit Period Variance: October 2008
December 2008
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: (Contract Name) can be combined into one universe.
Unfavorable Claims Reconsiderations

(Worksheet)

Purpose: To determine whether the MAO complies with regulatory requirements for timeliness
and member notice when making fully or partially unfavorable reconsidered determinations on
member requests for claims payment. Also, to determine whether the MAO complies with
regulatory requirements for effectuating claims denials reversed by CMS’ Independent Review
Entity or higher levels of appeal.
Universe: All claims reconsideration determinations made during the audit period that were not
fully favorable to the member. This includes cases that the MAO sent to the IRE for dismissal.
Delegated Entities:

None

Audit Period Variance: October 2008
December 2008
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: (Contract Name) can be combined into one universe.
Favorable Standard Pre-Service Reconsiderations

(Worksheet)

Purpose: To determine if the MAO complies with regulatory requirements for timeliness and
member notice when approving reconsidered member requests for service.

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Universe: All standard pre-service reconsideration determinations made during the audit period
that resulted in the MAO reversing its initial denial.
Delegated Entities:

None

Audit Period Variance: October 2008
December 2008
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: (Contract Name) can be combined into one universe.
Unfavorable Standard Pre-Service Reconsiderations

(Worksheet)

Purpose: To determine if the MAO complies with regulatory requirements for timeliness and
member notice when making fully or partially unfavorable reconsidered determinations on
member requests for service. Also, to determine if the MAO complies with regulatory
requirements for effectuating pre-service denials reversed by CMS’ Independent Review Entity
or higher levels of appeal.
Universe: All standard pre-service reconsideration determinations made during the review
period that were not fully favorable to the member. This includes cases that the MAO sent to the
IRE for dismissal.
Delegated Entities:

None

Audit Period Variance: October 2008
December 2008
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: (Contract Name) can be combined into one universe.
Requests for Expedited Reconsiderations

(Worksheet)

Purpose: To determine if the MAO complies with regulatory requirements for timeliness and
member notice when processing member requests for expedited reconsiderations. Also, to
determine if the MAO complies with regulatory requirements for effectuating pre-service denial
reversals by CMS’ Independent Review Entity or higher levels of appeal when the request for
reconsideration was expedited.

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Universe: All requests for expedited pre-service reconsiderations received during the audit
period, whether or not they were expedited. This includes cases that the MAO sent to the IRE
for dismissal.
Delegated Entities:

None

Audit Period Variance: October 2008
December 2008
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: (Contract Name) can be combined into one universe.
(Worksheet)

Grievances

Purpose: To determine if the MAO complies with regulatory requirements for timeliness and
member notice when processing member grievances. Also, to determine if cases categorized by
the MAO and/or the delegated entity as grievances are in fact grievances rather than requests for
organization determinations or reconsiderations.
Universe(s): All grievances received during the audit period (including those still pending).
Please note that the term “grievance” is meant to include all member concerns that do not fall
within the purview of the Medicare organization determination or reconsideration processes,
regardless of whether the MAO uses other words to describe them, such as “complaint” or
“informal grievance,” etc. This includes issues received telephonically as well as in writing.
This universe should contain only grievances related to Part C services, benefits, etc. In other
words, do not include Part D grievances.
Delegated Entities:

None

Audit Period Variance: October 2008
December 2008
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: (Contract Name) can be combined into one universe.
Complaints

(Worksheet)

Purpose: To determine if the M+CO is responsive to member concerns as they come into the
Customer Service Center. To ensure that the steps and time frames outlined in the M+CO
policies and procedures are being followed and that problem areas are identified, resolved and
shared among M+CO departments. Also, to determine if cases categorized by the M+CO are
being categorized appropriately and resolved using correct plan policies and procedures.

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Universe: All customer service inquiries received during the review period (including those still
pending). Please provide a glossary of complaint codes to facilitate case selection.
Delegated Entities:

None

Audit Period Variance: October 2008
December 2008
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: (Contract Name) can be combined into one universe.

Part II
Part C Samples to be Selected from CMS-Generated Transaction Reply Listings and the
March Monthly Membership Report
(The following is included for your information only; the samples will be selected from CMS
data - do not submit reply listings to the audit team.)
Applications and Enrollment

(Worksheet)

Purpose: To determine if enrollment applications were processed and beneficiaries were
enrolled per CMS standards.
Universe: All action codes 61 and 71 with reply codes 11, 16, 17, 22, 23, 150, and 170 inputs
entered by the MAO, during the audit period, and accepted by CMS, and all action code 60/reply
codes 11, 16, 17, 22, and 23 (retroactive EGHP enrollments) entered by the MAO where the
effective date is one month prior to the payment month or later. Note: This captures current
month EGHP enrollments incorrectly submitted as retroactive enrollments (code 60s).
CMS Enrollment Rejections

(Worksheet)

Purpose: To determine whether the MAO takes appropriate action based on the Transaction
Reply Reports received from CMS.
Universe: All action code 51, 53, 60, 61, 62, 71 and 72/ reply codes 001, 002, 003, 004, 006,
007, 008, 009, 019, 032, 033, 036, 038, 039, 040, 044, 045, 050, 051, 052, 054, 102, 103, 104,
105, 106, 107, 108, 109, 110, 112, 114, 116, 122, 123, 124, 125,126, 130, 133, 156,157, 162,
164, 171, 172, 173, 196, 200, 201, 202, 203,208, 209, 214, 215, and 217.

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Enrollment of Institutional Individuals in a SNP

(Worksheet)

Purpose: To determine if a SNP followed requisite procedures in the enrollment of
institutionalized individuals.
Universe: All enrollments submitted by an institutional SNP.
(Worksheet)

Enrollment of Chronic Care Individuals in a SNP

Purpose: To determine if a SNP followed requisite procedures in the enrollment of individuals
enrolled into a chronic care SNP.
Universe: All enrollments submitted by a chronic care SNP.
Enrollment of Dual Eligible Individuals in a SNP

(Worksheet)

Purpose: To determine if a SNP followed requisite procedures in the enrollment of dual eligible
individuals.
Universe: All enrollments submitted by a dual eligible SNP.
(Worksheet)

Voluntary Disenrollments

Purpose: To determine if voluntary disenrollments were processed per CMS standards.
Universe: All of Action Codes 51 & 53 and reply codes 13, 25, 26 and 151 inputs entered by
the MAO during the review period.
Beginning April 2008, plans are required to include disenrollment reason codes 11, 91, 92, or 93.
Voluntary Disenrollments Through Sources Other Than MAO

(Worksheet)

Purpose: To determine if voluntary disenrollments were processed per CMS standards.
Universe: All transaction reply codes 14 received, and all action codes 53 & 54 inputs/reply
codes 13, 25, and 26 entered by the CMS Call Center (1-800-MEDICAR(E) during the audit
period. Cases involving “automatic” disenrollment (loss of Part A, loss of Part B, or death) are
excluded.
Part III
Part D Samples to be Selected from Sponsor Data
(Sponsor must provide these universes to the audit team.)
Any variances to the audit period and any delegated entities for which universes are required
are specified under the applicable universe description(s) below.

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Please insert a column entitled Contract Number before column 1 for all Part C and Part D
worksheets.
Universes Required from Part D Sponsor Data

Enrollment and Disenrollment

Worksheet
Universe: All requests to cancel enrollment received during the audit period.
1st row in submitted file should
Date Enrollment Cancellation Request
read:
Beneficiary Name
HIC #
Received

Audit Period Variance: December 2008
January 2009
March 2009
April 2009 (weeks of 4/3, 4/10, and 4/17 only)
Platform/Contracts:

(Platform Name / Contract Number)

Worksheet

Universe: For PDPs: All enrollments of auto-enrolled beneficiaries that were
received via TRR during the audit period, regardless of effective date. For MAPDs: MA-only plan members for whom the MAO learns of full dual eligibility
during audit period, regardless of effective date and regardless of whether the
member opted out of Part D.

1st row in submitted file should
read:
Beneficiary Name

HIC #

Enrollment Effective Date

Audit Period Variance: December 2008
January 2009
March 2009
April 2009 (weeks of 4/3, 4/10, and 4/17 only)
Platform/Contracts:

(Platform Name / Contract Number)

Note: Combine (Platform Names) into one universe.

Worksheet

Universe: For PDPs: All facilitated-enrollment transactions received via TRR
during the audit period, regardless of enrollment effective date. For MA-PDs: MAonly plan members who were identified as needing to be considered for FE,
regardless of the effective date of the facilitated enrollment conducted by the
MAO and regardless of whether the member opted out of Part D.

1st row in submitted file should
read:
Beneficiary Name

HIC #

Enrollment Effective Date

Audit Period Variance: December 2008
January 2009
March 2009
April 2009 (weeks of 4/3, 4/10, and 4/17 only)
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Platform/Contracts:

(Platform Name / Contract Number)

Note: Combine (Platform Names) into one universe.
Worksheet

Universe: All beneficiary enrollments made under a Special Enrollment Period
that became effective during the audit period.

1st row in submitted file should
read:
Beneficiary Name

HIC #

Enrollment Effective Date

Audit Period Variance: December 2008
January 2009
March 2009
April 2009 (weeks of 4/3, 4/10, and 4/17 only)
Platform/Contracts:

(Platform Name / Contract Number)

Universe: All enrollees in employer/union sponsored plans that were enrolled
using group enrollment mechanism.
1st row in submitted file should
1st row in submitted
read:
Beneficiary Name
file should read:
Beneficiary Name
Worksheet

Audit Period Variance: December 2008
January 2009
March 2009
April 2009 (weeks of 4/3, 4/10, and 4/17 only)
Platform/Contracts:

(Platform Name / Contract Number)

Worksheet

Universe: All involuntary disenrollments due to permanent move outside the plan
service area that became effective during the audit period. The universe should
include both member requests for disenrollment due to permanent moves outside
of the plan's service area and all other involuntary disenrollments due to
permanent moves outside of the plan's service area. Note: Auto and facilitated
enrollees should be excluded from the Universe as those individuals should not
be disenrolled when an out-of-area address cannot be confirmed.

1st row in submitted file should
read:
Beneficiary Name

HIC #

Disenrollment Effective Date

Audit Period Variance: December 2008
January 2009
March 2009
April 2009 (weeks of 4/3, 4/10, and 4/17 only)
Platform/Contracts: (Platform Name / Contract Number)

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Marketing
Universe: All beneficiaries affected by at least one of the Part D sponsor’s
formulary maintenance changes that became effective during the audit period.
Method of notification of formulary
maintenance change (e.g., Prior Notice:
1st row in submitted file should
EOB, Prior Notice: Separate Notice,
read:
Beneficiary Name
HIC#
Pharmacy notice with 60 day refill)
Worksheet

Audit Period Variance: October 2008
January 2009
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: Combine all Platforms into one universe and place on the (Contract Name) CD.
Universe: All beneficiaries who were born on the specific days of their birth
Worksheet
month as shown in the Audit Period Variance below.
1st row in submitted file should
read:
Beneficiary Name HIC#
Enrollment Effective Date

Audit Period Variance: For All Platforms/Contracts shown below:
• All members effective during October 2008 who were born on the
19th or 20th of their birth month.
• All members effective during January 2009 who were born on the
15th or 16th of their birth month.
• All members effective during February 2009 who were born on the
11th or 12th of their birth month.
For (Contract Number):
• All members effective during February 2009 who were born on the
15th of their birth month.
Platform/Contracts:

(Platform Name / Contract Number)

Note: Combine (Platform Names) into one universe.
Universe: All beneficiaries who experience a change in their eligibility for the Low
Income Subsidy during the audit period. This does not include annual
recertification’s that do not result in an actual change in Low Income Subsidy
eligibility.

Worksheet
1st row in submitted file should
read:
Beneficiary Name

HIC#

Change in LIS Eligibility Date

Audit Period Variance: October 2008
January 2009
February 2009

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Platform/Contracts:

(Platform Name / Contract Number)

Note: Combine (Platform Names) into one universe.
Transition Process
Universe: All beneficiaries for whom the Sponsor provided a transitional first fill
Worksheet
in the retail setting during the audit period.
1st row in submitted file should
read:
Beneficiary Name
HIC #
Date of Temporary Transition Fill

Audit Period Variance: December 2008
January 2009
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: Combine all Platforms into one universe and place on the (Contract Name) CD.

Worksheet
1st row in submitted file should read:

Universe: All beneficiaries in a Long Term Care facility for whom the
Sponsor provided a transitional first fill during the audit period
Beneficiary Name
HIC #

Audit Period Variance: December 2008
January 2009
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: Combine all Platforms into one universe and place on the (Contract Name) CD.
Coordination of Benefits
Worksheet
1st row in submitted file should read:

Universe: All enrollees who submitted completed surveys providing
information on other health insurance.
Beneficiary Name
HIC #

See Below
Worksheet
1st row in submitted file should read:

Universe: All enrollees for whom CMS provided other health insurance
information or other payer information to Part D sponsor.
Beneficiary Name
HIC #

See Below
Note: Combine (Platform Names) into one universe. Provide separate universes for (Contract
Name).

Page 19 of 24

Worksheet
1st row in submitted file should read:

Universe: All claims for enrollees with other drug coverage during the first
week of the audit period.
Beneficiary Name
HIC #

See Below
Worksheet
1st row in submitted file should read:

Universe: All beneficiaries who disenrolled during the coverage year and
enrolled in a new Part D plan.
Beneficiary Name
HIC #

See Below
Worksheet
1st row in submitted file should read:

Universe: All beneficiaries who enrolled during coverage year that can be
identified as coming from another Part D plan.
Beneficiary Name
HIC #

The following applies to call Coordination of Benefits worksheets listed above:
Audit Period Variance:
September 2008
October 2008
January 2009
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: With the exception of (Worksheet), combine all Platforms into one universe and place on
the (Contract Name) CD.
Grievances, Coverage Determinations and Appeals
The Part D sponsor must follow CMS guidance (Prescription Drug Benefit Manual, Chapter 18,
Rev 2, 6-22-06, Section 40.2) in defining the date and time a grievance, request, or supporting
statement is received.
•

Universe: All standard grievances received during the audit period (including
those still pending). Although the Part D sponsor may use another term to
describe it, please note that the term “grievance” is meant to include any
complaint or dispute, other than one that involves a coverage determination,
expressing dissatisfaction with any aspect of the operations, activities, or
behavior of a Part D sponsor, regardless of whether remedial action is
requested. This includes issues received verbally (telephone) as well as in
writing. This universe should contain only grievances related to Part D
services, benefits, etc. In other words, do not include Part C grievances.

Worksheet
1st row in submitted file should Enrollee Name or
read:
HIC #

Part D sponsor Grievance Type, as defined in the
Medicare Part D Reporting Requirements. Each Date
grievance should be categorized as Fraud &
Grievance
Abuse, Enrollment/Disenrollment, Benefit
Received

Page 20 of 24

Package, Pharmacy Access/Network, Marketing,
Customer Service, Confidentiality/Privacy, Quality
of Care, or Other.

Audit Period Variance: September 2008
October 2008
January 2009
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: Combine all Platforms into one universe and place on the (Contract Name) CD.
•

Universe: All expedited grievances received during the audit period
(including those still pending), where the complaint involves a refusal by the
Part D sponsor to grant an enrollee’s request for an expedited coverage
determination or an expedited redetermination, and the enrollee has not yet
purchased or received the drug that is in dispute. This universe should
contain only grievances related to Part D services, benefits, etc. In other
words, do not include Part C grievances.

Worksheet
1st row in submitted file should Enrollee Name or
read:
HIC #

Grievance Type (Expedited
Coverage Determination
Refusal, Expedited
Redetermination Refusal)

Date and Time Expedited
Grievance Received

Audit Period Variance: September 2008
October 2008
January 2009
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: Combine all Platforms into one universe and place on the (Contract Name) CD.

Universe: All requests for standard coverage determinations concerning drug
benefits received during the audit period.
Type of Benefit
Determination
Requested (For
example, non1st row in submitted file should Enrollee Name or
formulary and tier
read:
HIC #
exceptions requests) Date and Time Request Received
Worksheet

Audit Period Variance: September 2008
October 2008
January 2009
February 2009

Page 21 of 24

Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: Combine all Platforms into one universe and place on the (Contract Name) CD.
Universe: All requests for standard coverage determinations concerning
payments from the member, received during the audit period.
Type of Benefit
Determination
Requested (For
example, non1st row in submitted file should Enrollee Name or
formulary and tier
read:
HIC #
exceptions requests) Date and Time Request Received
Worksheet

Audit Period Variance: September 2008
October 2008
January 2009
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: Combine universes by source: one universe for all platforms and contracts processed by
the (PBM Name), and one universe for all platforms and contracts processed by (Company
Name).
Universe: All requests for expedited coverage determinations received during the
audit period.
Type of Benefit
1st row in submitted file should Enrollee Name or
Determination
read:
HIC #
Requested
Date and Time Expedited Request Received
Worksheet

Audit Period Variance: September 2008
October 2008
January 2009
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: Combine all Platforms into one universe and place on the (Contract Name) CD.
Universe: All requests for standard redeterminations concerning drug benefits
made during the audit period. This includes cases sent to the IRE for dismissal.
Type of Benefit
Redetermination
Requested (For
example, nonst
1 row in submitted file should Enrollee Name or
formulary and tier
read:
HIC #
exceptions requests) Date Request Received
Worksheet

Audit Period Variance: September 2008
October 2008
Page 22 of 24

January 2009
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: Combine all Platforms into one universe and place on the (Contract Name) CD.
Universe: All requests for standard redeterminations concerning payment made
during the audit period. This includes cases sent to the IRE for dismissal.
Type of Benefit
1st row in submitted file should Enrollee Name or
Redetermination
read:
HIC #
Requested
Date Request Received
Worksheet

Audit Period Variance: September 2008
October 2008
January 2009
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: Combine all Platforms into one universe and place on the (Contract Name) CD.
Universe: All requests for expedited coverage redeterminations received during
the audit period, whether or not they were expedited. This includes cases sent to
Worksheet
the IRE for dismissal.
Type of Benefit
Redetermination
Requested (For
example, non1st row in submitted file should Enrollee Name or
formulary and tier
read:
HIC #
exceptions requests) Date and Time Expedited Request Received

Audit Period Variance: September 2008
October 2008
January 2009
February 2009
Platform/Contracts:

All platforms and contracts as shown on Enclosure VI.

Note: Combine all Platforms into one universe and place on the (Contract Name) CD.
Employer Subsidy
Worksheet

Universe: All low-income subsidy eligible enrollees in employer/union sponsored
plans.

1st row in submitted file should
read:
Beneficiary Name

HIC #

Enrollment Effective Date

Audit Period Variance: September 2008 – February 2009

Page 23 of 24

Platform/Contracts: All platforms and contracts as shown on Enclosure VI, excluding
(Platform Name)
Note: Combine (Platform Names) into one universe.
Part IV
Part D Samples to be Selected from CMS-Generated Transaction Reply Listings
(The following is included for your information only; the samples will be selected from CMS
data - do not submit reply listings to the audit team.)
Universe: All regular enrollments (i.e., not auto-enrollments or facilitated
enrollments or Special Enrollment Period enrollments) that the Part D sponsor
Worksheet
submitted to CMS during the audit period.
1st row in submitted file should
Date Completed Enrollment Request
read:
Beneficiary Name
HIC #
Received by the Part D sponsor
Universe: All beneficiaries who attempted to enroll during the audit period, but
had their enrollment rejected by CMS because the beneficiary had employer
Worksheet
subsidy status.
1st row in submitted file should
Date of CMS’ Initial Rejection of the
read:
Beneficiary Name
HIC #
Enrollment
Universe: All Transaction Reply Reports received from CMS during the audit
Worksheet
period.
1st row in submitted file should
Date of the Weekly Transaction Reply
read:
Beneficiary Name
HIC #
Report
Universe: All voluntary disenrollments that became effective during the audit
period. (Voluntary disenrollment is defined as a beneficiary-initiated
disenrollment submitted through the Sponsor, through 1-800-Medicare, or
through enrollment in another Part D plan.)

Worksheet
1st row in submitted file should
read:
Beneficiary Name

HIC #

Disenrollment Effective Date

Page 24 of 24