Medicare Part C and Part D Data Validation (42 C.F.R. 422.516g and 423.514g) - (CMS-10305)

Medicare Part C and Part D Measure
Data Extraction and Sampling Instructions for Data Validation Contractors

August 26, 2010

DRAFT

Prepared by:

Centers for Medicare & Medicaid Services

Center for Drug and Health Plan Choice

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TABLE OF CONTENTS

1.0  OVERVIEW......................................................................................................................... 1

2.0  CONCEPTUAL FRAMEWORK FOR DATA EXTRACTION..................................... 2

3.0  DATA EXTRACTION PROCESS DETAIL .................................................................... 3

3.1  Extraction of the Census ............................................................................................... 3

3.2  Extraction of the Sample Data ...................................................................................... 4

3.3  Evaluating the Data....................................................................................................... 6

4.0  APPENDIX ........................................................................................................................... 7

4.1  Sampling Guidance ....................................................................................................... 7

4.2  File Requirements for Data Transfer to Reviewer ........................................................ 8

4.3  Data Security................................................................................................................. 8

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1.0

OVERVIEW

The purpose of this document is to provide guidance to reviewers regarding drawing and evaluating
census and/or sample files to support validation of Part C and Part D measures.
This document describes guidelines and methodologies for extracting sponsoring organizations’ data for
data validation review. Two methods of data extraction are available to data validation contractors
(reviewers). The first method is referred to as the census. For example, extracting all records used in the
calculation of data elements for a specific measure would constitute extracting a census of data. When
possible, reviewers should attempt to extract the full census. Extracting the census will enable the
reviewer to determine with the greatest precision whether reported measures were submitted accurately.
The second method used for data extraction is a random sample. The random sample is a subset of the
census data. If extraction of the census proves to be too burdensome due to the size or complexity of the
data for a specific measure, a sample of records should be extracted instead.
The use of one or both of the extraction methods described above are key for reviewers as they validate
the quality of the data used to calculate Part C and Part D measures. Examples of characteristics
evaluated using the census data include appropriate date ranges, appropriate data inclusions and
exclusions, correctness of data values, and handling of missing values. When extracting a census is not
practical, the use of a large enough random sample can accomplish the same goals, although the
reviewer will need to rely on statistically valid estimates rather than evaluating the entire population.
The reviewer will determine whether or not supervision is required while the sponsoring organization
extracts census and/or sample files. It is also left to the reviewer’s discretion as to the feasibility of the
sponsoring organization extracting census and/or sample files before, during, or after the on-site visit.

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2.0

CONCEPTUAL FRAMEWORK FOR DATA EXTRACTION

Figure 1 below shows conceptually how sponsoring organizations create aggregated data for submission
into HPMS and where data extraction is incorporated into the data validation review process.
Figure 1: Conceptual Framework for Data Extraction

Final Stage
Data Set or
Sample

Source Census
or Sample  

Data
Provided by
Delegated
Entities

Source
Provider
Files
Source
Claims/
Encounters

Aggregated 
Data 

HPMS

Source/
Enrollment
Source Systems 

Data Warehouse(s) 

Interim Data Sets

Last detailed data set before 
final calculation (Final Stage 
Data Set) 

HPMS Entry

While actual reporting approaches vary significantly from organization to organization, and even between
measures, the general reporting approach can be described as follows:
1. Original data resides on operational systems, such as claims adjudication systems, provider files,
enrollment files, and data systems maintained by delegated entities.
2. Many organizations have analytic warehouses where data is cleansed and put into database
structures to support analysis.
3. Measure calculation begins with a series of extracts, which are manipulated and merged, creating
interim data sets.
4. Data from interim steps are combined into a detailed data set.
5. This detailed data set is aggregated to create sums and counts, which are then entered into
HPMS.
The data extraction process produces at least two sets of validation data for each measure. The first
comes from the endpoint of the calculation, and the second is a corresponding set of extracts drawn from
source data (e.g. data warehouse or operational systems which produce underlying data). If necessary,
the reviewer may request to review source documents that have been used to enter data into a data
warehouse or operational system (e.g. a call log for grievances). If interim data sets are produced, the
reviewer may consider extracting these data to ensure that data sets have been joined properly. Details
on extracting and evaluating the data are outlined in the next section.

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3.0

DATA EXTRACTION PROCESS DETAIL

3.1 Extraction of the Census
Data extraction of the full census will be conducted at the organization’s contract level. Extraction of a full
census will provide the reviewer with the most precise evaluation of how accurately an organization
reports their Part C or Part D data. Extracting the full census is the most straightforward of the two data
extraction methods. The process illustrated in Figure 2 applies to all measures where it is deemed
practical to extract a census.
Figure 2: Application of Sampling Process

4 

1 

Data
Provided by
Delegated
Entities
Source
Provider
Files

2

Source
Census
Data Set(s)

3 

Interim
Census
Data Set(s)

Final Stage
Data Set(s)

Aggregated 
Data 

HPMS

Source
Claims/
Encounters

Source/
Enrollment
Source Systems 

Data Warehouse(s) 

Interim Data Sets

Last detailed data set before

final calculation (Final Stage

Data Set) 

HPMS Entry

1. Identify and Extract “Source Census Data Set(s)”: “Source Census Data Set(s)” will include all
files containing records extracted from one of the originating data source(s) (e.g., organization’s
internal data warehouse, enrollment system). The “Source Census Data Set(s)” will include all fields
referenced in the programming code used to calculate the measure. To identify appropriate
originating data sources and fields and date ranges for the “Source Census Data Set(s),” the reviewer
will refer to the source/programming code, saved data queries, data dictionaries, analysis plans, etc.
provided by the organization.
2. Identify and Extract “Interim Census Data Set(s)” (Optional):
Where applicable, the reviewer will identify “Interim Census Data Sets,” that is, data sets that have
undergone a cleaning process after initial entry into a source system and before being joined to
create the “Final Stage Data Set(s),” All “Interim Census Data Sets” should be identified and clearly
labeled so that the relationship between data extracts is identified and distinguishable.

3. Identify and Extract “Final Stage Data Set(s)”: The reviewer will identify the last clean and
detailed (line item level) data set used prior to aggregating counts and sums for the data measure.

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This is the cleanest and last line item level file before data aggregation for entry into HPMS and is
referred to as the “Final Stage Data Set.” Note that in some cases, multiple “Final Stage Data Sets”
will be identified.
4. Write and Encrypt Data to Secure Storage Device: The organization will transfer all data files
collected to a secure storage device. Organizations undergoing review should coordinate with
reviewers to ensure that the organization’s security software does not interfere with data transfer.
Files requested before or after the on-site visit can be transferred via a secure web portal or by other
methods that comply with regulations governing secure storage and transfer of Personal Health
Information (PHI). See Section 4.2 in the Appendix for instructions on the file format.

3.2 Extraction of the Sample Data
In general, sampling will be conducted at the organization’s contract level. In cases where organizations
have multiple contracts that use the same data sources and processes for each contract, only one
sample is required. This one sample must be randomly drawn from pooled data from all contracts so that
it is representative of the systems and processes across the contracts. For organizations with multiple
contracts, where data sources and processes differ among contracts, separate samples are required for
each unique contract. Based on information obtained during the review, the reviewer will determine
whether the data sources are the same and processes are standardized across an organization’s multiple
contracts; this will aid in determining whether one or more samples need to be drawn. It is the
responsibility of the reviewer to determine the appropriate sample size for each measure. For guidance
on sample size, see Section 4.1 in the Appendix.
Drawing the sample data follows the same six-step process for each measure. Details on each step of
the process are outlined and illustrated at a high-level in Figure 3.
Figure 3: Application of Sampling Process

6

Source
Sample(s)

Data
Provided by
Delegated
Entities
Source
Provider
Files

2

4 

Final
Stage
Sample(s)

Aggregated 
Data 

1

Source
Claims/
Encounters

HPMS

5

Source/
Enrollment
Source Systems 

3 

Final
Stage
List

Data Warehouse(s) 

Interim Data Sets

Interim Stage
Sample(s)

Last detailed data set before 
final calculation (Final Stage 
Data Set)  

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HPMS Entry

4

1. Identify “Final Stage Data Set(s)”: The reviewer will identify the last clean and detailed (line item
level) data set used prior to aggregating counts and sums for the data measure. This is the cleanest
and last line item level file before data aggregation for entry into HPMS and is referred to as the “Final
Stage Data Set.” As with the process of extracting the census, in some cases, multiple “Final Stage
Data Sets” will be identified.
2. Draw random sample to create “Final Stage List”: The reviewer will work with a knowledgeable
organization resource to draw a random list of distinct sampling units (e.g., member IDs, Provider
IDs) from the appropriate “Final Stage Data Set(s).” This list is called the “Final Stage List” and is
required for extracting the source and final stage sample data. Reviewers should use standard
statistical practices when determining sample sizes. Sampling units and sample size for the “Final
Stage List” will vary by measure. In cases where there are multiple “Final Stage Data Sets,” the
reviewer will assure that the “Final Stage List” is representative of all the “Final Stage Data Sets.”
Generally the selection of the “Final Stage List” should be pulled using simple random sampling. For
guidance on these methods, see Section 4.1 in the Appendix. The reviewer may apply more complex
approaches if needed (stratified samples, for example). Determination of the appropriate size and
type of random sample must follow sound statistical principles and be well-documented.
3. Create “Final Stage Sample(s)”: Using the “Final Stage List,” the organization will provide the
reviewer a “Final Stage Sample.” The “Final Stage Sample” will be extracted from the “Final Stage
Data Set” and will include all records associated with the identified sampling units in the “Final Stage
List.” The “Final Stage Sample” will contain all fields from the “Final Stage Data Set.” In cases where
there are multiple “Final Stage Data Sets,” there will be multiple “Final Stage Samples.”
As an example, the Benefit Utilization “Final Stage Sample” will include all records and fields in the
“Final Stage Data Set” associated with the distinct Member IDs identified in the Benefit Utilization
“Final Stage List.”
4. Create “Source Sample(s)”: Using the “Final Stage List,” the organization will provide for the
reviewer one or more “Source Samples.” Each “Source Sample” will be a file containing records
extracted from one of the originating data source(s) (e.g., organization’s internal data warehouse,
enrollment system), and it will include all records within the reporting period(s) associated with the
identified sampled units in the “Final Stage List.” The “Source Sample(s)” will include all fields
referenced in the programming code used to calculate the measure. To identify appropriate
originating data sources and fields for the “Source Sample(s),” the reviewer will refer to the
source/programming code, saved data queries, data dictionaries, analysis plans, or other
documentation provided by the organization.
As an example, the Procedure Frequency measure may have at least two “Source Samples.” One
will consist of all claims from the reporting period associated with the distinct Member IDs identified in
the Procedure Frequency “Final Stage List.” The second will consist of all enrollment records in the
reporting period associated with these Member IDs.
Note: The actual number of records in the “Final Stage Sample(s)” and “Source Sample(s)” will vary,
and in many cases, it will be substantially larger than the “Final Stage List” sample size. For
example, the “Final Stage List” of Member IDs for the Procedure Frequency measure will likely result
in “Source Samples” of more than the total number of Member IDs because of multiple claims and
enrollment records for each member.
Note: If the originating data source is the same as the “Final Stage Data Set,” the “Final Stage
Sample” will be sufficient.
5. Create “Interim Stage Sample(s)”: Where applicable, the reviewer will identify “Interim Stage Data
Sets”, that is, data sets that have undergone a cleaning process after initial entry into a source
system and before being joined to create the “Final Stage Data Set(s).” The reviewer will apply the

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same methodology for extraction of the “Source Sample” as described in Step 4. All “Interim Stage
Samples” should be identified and clearly labeled so that the relationship between data extracts is
identified and distinguishable.
6. Write and Encrypt Data to Secure Storage Device: The organization will transfer all data files to a
secure storage device. Organizations undergoing review should coordinate with reviewers to ensure
that the organization’s security software does not interfere with data transfer. Files requested before
or after the on-site visit can be transferred via a secure web portal or by other methods that comply
with regulations governing secure storage and transfer of Personal Health Information (PHI). See
Section 4.2 in the Appendix for instructions on the file format.

3.3 Evaluating the Data
The reviewer will use each measure’s full census or samples from source, interim, and final stage data
sets to validate against the applicable Part C and/or Part D reporting requirements. Specific validation
checks requiring census or sample data are included in Validation Standard 2 in the Data Validation
Standards and the Findings Data Collection Form. Validation Standard 2 is reproduced below. The
validation of all criteria except for meeting deadlines will be conducted using the extracted data.
Figure 4: Validation Standards Applicable to Extracted Data

VALIDATION STANDARDS
2

A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved data queries, file
layouts, process flows) and census or sample data, if applicable, indicates that data elements for each measure are
accurately identified, processed, and calculated.
Criteria for Validating Measure-Specific Criteria (Refer to measure-specific criteria section below):
 The appropriate date range(s) for the reporting period(s) is captured.
 Data are assigned at the applicable level (e.g., plan benefit package or contract level).
 Appropriate deadlines are met for reporting data (e.g., quarterly).
 Terms used are properly defined per CMS regulations, guidance and Reporting Requirements Technical
Specifications.

The number of expected counts (e.g., number of members, claims, grievances, procedures) are verified; ranges
of data fields are verified; all calculations (e.g., derived data fields) are verified; missing data has been properly
addressed; reporting output matches corresponding source documents (e.g., programming code, saved queries,
analysis plans); version control of reported data elements is appropriately applied; QA checks/thresholds are
applied to detect outlier or erroneous data prior to data submission.
U

As specified in the Data Validation Standards and Findings Data Collection Form, reviewers should
evaluate the data in conjunction with the programming code, spreadsheet formulas, analysis plans, saved
data queries, file layouts, and process flows provided by the organization. The reviewer should evaluate
the data submissions for overall data accuracy for missing information, invalid fields, implausible fields
(range checks), demographic errors, or other errors causing linkage or data aggregation failures. All
results of the data validation findings should be recorded in the Findings Data Collection Form.

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4.0

APPENDIX

4.1 Sampling Guidance
The calculation of each data element requires the organization to pull data from key data sources. The
validation samples will reflect the same process, but will be limited to relatively small samples of data.
Conceptually, selecting a simple random sample follows this process:
1. Use a pseudo-random number generator (e.g., SAS ranuni function or MS Excel’s
Random Number Generator in the Data Analysis dialog box) to assign a uniform random number
to each record in the key data source. 1
0F0F

2. Sort the records by the new random number, from lowest value to highest value.
3. After identifying sample size (n), write the key fields from the first n records of the sorted key data
source to a new file.
Alternate Approach: Organizations using SAS for standard calculation may opt to use Proc
SURVEYSELECT.

In cases where reviewers need to extract a random sample, Table 1 provides guidance on the proper
sample units and the minimum sample sizes for each measure. As mentioned above, reviewers should
use sound statistical principles when determining the appropriate sample size. Refer to item 2 in the
Supporting Statement’s statistical section for further guidance on determining the appropriate sample
size.
Table 1: Sampling Units and Minimum Sample Size for “Final Stage List”
Measure
Part C
Benefit Utilization
Procedure Frequency
Serious Reportable Adverse Events (SRAEs)
Provider Network Adequacy
Grievances
Organization Determinations/Reconsiderations
Employer Group Plan Sponsors
Plan Oversight of Agents
Special Needs Plans (SNPs) Care Management
Part D
Retail, Home Infusion, and LTC Pharmacy Access
Medication Therapy Management Programs (MTMP)
Grievances
Coverage Determinations/Exceptions
Appeals

Sampling Unit

Sample Size 2

Member ID
Member ID
Member ID
Provider ID
Case ID
Case ID
N/A
Agent ID
Member ID

205
205
205
150
150
150
N/A
150
205

N/A
Member ID
Case ID
Case ID
Case ID

N/A
205
150
150
150

1F1F

Note: Random number generators require seed numbers as input, but often have options to use the system clock as a seed. It

is recommended that the organization key in a literal number as a seed, to assure the sample can be replicated if necessary;

these seeds could change from year to year, but should be documented.

2
Depending on the size of the organization, some measures will have populations that are smaller than the recommended

sample size. In these cases, the entire population will be used for selecting the “Final Stage List.”

1

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Measure

Sampling Unit

Sample Size 2

Long-Term Care (LTC) Utilization
Employer/Union-Sponsored Group Health Plan Sponsors
Plan Oversight of Agents

Claim ID
N/A
Agent ID

150
N/A
150

1F1F

4.2 File Requirements for Data Transfer to Reviewer
The organization must write all data files to tab-delimited or comma-delimited text files with variable
names in the first row, and transfer these files to the reviewer’s secure storage device. The organization
must also provide the reviewer a file layout or data dictionary for the data files in either Word documents
or Excel spreadsheets on the same secure storage device. Naming conventions should be consistent
between files and their corresponding layout (e.g., if a sample for Part C Grievances is extracted and
labeled “PartCGrievanceSample.txt”, the corresponding layout should be named
PartCGrievanceLayout.doc). An example file layout is illustrated in Table 2.
Table 2: Example File Layout
Name
M_ID
DOR
M_Status

Description
Member ID
Grievance Date of Receipt
Member Status

Data Type/Length
Character (16)
DateMMDDYYYY
Numeric (2)

Data Values

Calculation
Unique counts
Date

1=Enrolled; 2=Disenrolled

4.3 Data Security
The organization is responsible for ensuring that it has established mutually agreeable methods for
sharing proprietary and/or secure (PHI/PII) information with the reviewer and that the reviewer complies
with all HIPAA privacy and security requirements.

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