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pdfFindings Data Collection Form: Benefit Utilization
2.1 Benefit Utilization
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Benefit Utilization
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
ea
Cr sure
ite -S
ria pe
ID cific
Name of Reviewer:
Standard/ Substandard ID
1
Standard/Sub-standard Description
A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved data
queries, file layouts, process flows) indicates that all source documents accurately capture required data
fields and are properly documented.
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
1.a
Source documents and output are properly secured so that source documents can be retrieved at any
time to validate the information submitted to CMS via HPMS.
Review Results:
1.b
Source documents create all required data fields for reporting requirements.
Review Results:
1.c
Source documents are error-free (e.g., programming code and spreadsheet formulas have no messages
or warnings indicating errors).
Review Results:
1.d
All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID, rather
than Field1 and maintain the same field name across data sets).
Review Results:
1.e
Data file locations are referenced correctly.
Review Results:
1.f
If used, macros are properly documented.
Review Results:
1.g
Source documents are clearly and adequately documented.
Review Results:
1.h
Titles and footnotes on reports and tables are accurate.
Review Results:
1.i
Version control of source documents is appropriately applied.
Review Results:
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.
2.a
The appropriate date range(s) for the reporting period(s) is captured.
MSC-1
2.b
2.c
2.d
Review Results:
Review Results:
Organization meets deadline for reporting annual data to CMS by 8/31.
Terms used are properly defined per CMS regulations, guidance and Reporting Requirements Technical
Specifications.
MSC-4
Review Results:
Organization properly assigns data to the applicable CMS contract and plan benefit package.
Appropriate deadlines are met for reporting data (e.g., quarterly).
MSC-3
Data Sources:
Organization reports data based on the required reporting period of 1/1 through 12/31 and
includes claims paid through 6/30 of the following year.
Data are assigned at the applicable level (e.g., plan benefit package or contract level).
MSC-2
Findings:
Select "Y" or "N"
from Sections in
White Only
Review Results:
Organization accurately maps Plan Benefit Package (PBP) Service Category services to the
Corresponding MA Medical Utilization and Expenditure Experience Category per the chart
provided in Appendix 3 of the Medicare Part C Plan Reporting Requirements Technical
Specifications Document, and includes all Part B services excluded from the other benefit
categories in the “Other Medicare Part B” Service Category.
DRAFT – Meets Section 508 Compliance Standards
1
Findings Data Collection Form: Benefit Utilization
2.1 Benefit Utilization
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Benefit Utilization
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
ea
Cr sure
ite -S
ria pe
ID cific
Name of Reviewer:
Standard/ Substandard ID
2.e
MSC-5
MSC-6
Data Element 1.1
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Data Element 1.2
Review Results:
Data Element 1.3
Review Results:
Data Element 1.4
Review Results:
Data Element 1.5
Review Results:
Data Element 1.6
Review Results:
MSC-5a: Includes members who were enrolled for at least one month
during the reporting period.
[Data Elements 1.3, 1.11, 1.19, 1.27, 1.35, 1.43, 1.51, 1.59, 1.67, 1.75,
1.83, 1.91, 1.97, 1.103, 1.109, 1.115, 1.121, 1.127 for reporting in
Column C]
Data Element 1.7
Review Results:
Data Element 1.8
Review Results:
Data Element 1.9
Review Results:
MSC-5b: Includes members who had access to each of the following
services: Inpatient Facility; Skilled Nursing Facility; Home Health;
Ambulance; DME/Prosthetics/Supplies; OP Facility-Emergency; OP
Facility-Surgery; OP Facility-Other; Professional; Part B Rx; Other
Medicare Part B; Transportation (Non-Covered); Dental (Non-Covered);
Vision (Non-Covered); Hearing (Non-Covered); Health & Education (NonCovered); Other (Non-Covered); and Medical.
[Data Elements 1.3, 1.11, 1.19, 1.27, 1.35, 1.43, 1.51, 1.59, 1.67, 1.75,
1.83, 1.91, 1.97, 1.103, 1.109, 1.115, 1.121, 1.127 for reporting in
Column C]
Data Element 1.10
Review Results:
Data Element 1.11
Review Results:
Data Element 1.12
Review Results:
Data Element 1.13
Review Results:
Data Element 1.14
Review Results:
Data Element 1.15
Review Results:
Data Element 1.16
Review Results:
Data Element 1.17
Review Results:
Data Element 1.18
Review Results:
Data Element 1.19
Review Results:
Data Element 1.20
Review Results:
Data Element 1.21
Review Results:
Data Element 1.22
Review Results:
Data Element 1.23
Review Results:
Data Element 1.24
Review Results:
Data Element 1.25
Review Results:
MSC-6c: Correctly sums the total utilization of each service listed above Data Element 1.26
by calculating the total number of services used by members during the
reporting period.
Data Element 1.27
Data Elements 1.6, 1.14, 1.22, 1.30, 1.38, 1.46, 1.54, 1.62, 1.70, 1.78,
1.86, 1.94, 1.100, 1.106, 1.112, 1.118, 1.124 for reporting in Column F]
Data Element 1.28
Review Results:
Standard/Sub-standard Description
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.
Applicable Measure-Specific Criteria:
MSC-5: Organization accurately calculates the number of members with
access to services, including the following criteria:
MSC-6: Organization accurately calculates member utilization of benefits,
including the following criteria:
MSC-6a: Includes unique members that incurred a service in the
specified category for each of the following services during the reporting
period: Inpatient Facility; Skilled Nursing Facility; Home Health;
Ambulance; DME/Prosthetics/Supplies; OP Facility-Emergency; OP
Facility-Surgery; OP Facility-Other; Professional; Part B Rx; Other
Medicare Part B; Transportation (Non-Covered); Dental (Non-Covered);
Vision (Non-Covered); Hearing (Non-Covered); Health & Education (NonCovered); Other (Non-Covered); and Medical.
[Data Elements 1.4, 1.12, 1.20, 1.28, 1.36, 1.44, 1.52, 1.60, 1.68, 1.76,
1.84, 1.92, 1.98, 1.104, 1.110, 1.116, 1.122, 1.128 for reporting in
Column D]
MSC-6b: Correctly selects the appropriate code to identify how the
organization captures utilization data for each service listed above.
[Note to reviewer : The organization may determine which utilization
type to use when categorizing services, but it must assign a consistent
“utilization type” for each service category.]
[Data Elements 1.5, 1.13, 1.21, 1.29, 1.37, 1.45, 1.53, 1.61, 1.69, 1.77,
1.85, 1.93, 1.99, 1.105, 1.111, 1.117, 1.123 for reporting in Column E]
DRAFT – Meets Section 508 Compliance Standards
Findings:
Y"" or "N
N""
Select "Y
from Sections in
White Only
Review Results:
Review Results:
2
Findings Data Collection Form: Benefit Utilization
2.1 Benefit Utilization
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Benefit Utilization
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
ea
Cr sure
ite -S
ria pe
ID cific
Name of Reviewer:
Standard/ Substandard ID
MSC-7
Data Element 1.29
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Data Element 1.30
Review Results:
Data Element 1.31
Review Results:
Data Element 1.32
Review Results:
Data Element 1.33
Review Results:
Data Element 1.34
Review Results:
Data Element 1.35
Review Results:
Data Element 1.36
Review Results:
Data Element 1.37
Review Results:
Data Element 1.38
Review Results:
MSC-7c: Includes all benefits paid for with federal funding, state funding, Data Element 1.39
group sponsor funding, and member premiums.
[Data Elements 1.7, 1.15, 1.23, 1.31, 1.39, 1.47, 1.55, 1.63, 1.71, 1.79,
Data Element 1.40
1.87, 1.95, 1.101, 1.107, 1.113, 1.119, 1.125, 1.129 for reporting in
Column G]
Data Element 1.41
Review Results:
MSC-7d: Includes all benefits furnished during the reporting period,
regardless of their representation in the approved bid.
[Data Elements 1.7, 1.15, 1.23, 1.31, 1.39, 1.47, 1.55, 1.63, 1.71, 1.79,
1.87, 1.95, 1.101, 1.107, 1.113, 1.119, 1.125, 1.129 for reporting in
Column G]
Data Element 1.42
Review Results:
Data Element 1.43
Review Results:
Data Element 1.44
Review Results:
MSC-7e: Includes benefits regardless of a member’s ESRD status.
[Data Elements 1.7, 1.15, 1.23, 1.31, 1.39, 1.47, 1.55, 1.63, 1.71, 1.79,
1.87, 1.95, 1.101, 1.107, 1.113, 1.119, 1.125, 1.129 for reporting in
Column G]
Data Element 1.45
Review Results:
Data Element 1.46
Review Results:
Data Element 1.47
MSC-8: Organization accurately calculates the amounts of member cost
sharing, including the following criteria [Note to reviewer : The organization
must provide the reviewer and CMS with a brief narrative explaining how
Data Element 1.48
the cost-sharing amounts are derived.]:
Review Results:
MSC-8a: Includes only cost sharing liability of the member (which may or Data Element 1.49
may not be paid in full), and not the amount charged by the provider.
[Data Elements 1.8, 1.16, 1.24, 1.32, 1.40, 1.48, 1.56, 1.64, 1.72, 1.80,
Data Element 1.50
1.88, 1.96, 1.102, 1.108, 1.114, 1.120, 1.126, 1.130 for reporting in
Column H]
Data Element 1.51
Review Results:
MSC-8b: Correctly sums the total cost-sharing amount that members
paid directly to providers during the reporting period for each of the
following services: Inpatient Facility; Skilled Nursing Facility; Home
Health; Ambulance; DME/Prosthetics/Supplies; OP Facility-Emergency;
OP Facility-Surgery; OP Facility-Other; Professional; Part B Rx; Other
Medicare Part B; Transportation (Non-Covered); Dental (Non-Covered);
Vision (Non-Covered); Hearing (Non-Covered); Health & Education (NonCovered); Other (Non-Covered); and Medical.
[Data Elements 1.8, 1.16, 1.24, 1.32, 1.40, 1.48, 1.56, 1.64, 1.72, 1.80,
1.88, 1.96, 1.102, 1.108, 1.114, 1.120, 1.126, 1.130 for reporting in
Column H]
Data Element 1.52
Review Results:
Data Element 1.53
Review Results:
Data Element 1.54
Review Results:
Data Element 1.55
Review Results:
Data Element 1.56
Review Results:
Data Element 1.57
Review Results:
Standard/Sub-standard Description
MSC-7: Organization accurately calculates the amounts of plan
reimbursement, including the following criteria:
MSC-7a: Correctly sums the total amount reimbursed from the plan to
providers during the reporting period for each of the following services:
Inpatient Facility; Skilled Nursing Facility; Home Health; Ambulance;
DME/Prosthetics/Supplies; OP Facility-Emergency; OP Facility-Surgery;
OP Facility-Other; Professional; Part B Rx; Other Medicare Part B;
Transportation (Non-Covered); Dental (Non-Covered); Vision (NonCovered); Hearing (Non-Covered); Health & Education (Non-Covered);
Other (Non-Covered); and Medical.
[Data Elements 1.7, 1.15, 1.23, 1.31, 1.39, 1.47, 1.55, 1.63, 1.71, 1.79,
1.87, 1.95, 1.101, 1.107, 1.113, 1.119, 1.125, 1.129 for reporting in
Column G]
MSC-7b: Includes all benefits paid for whether they are covered by
Medicare or not.
[Data Elements 1.7, 1.15, 1.23, 1.31, 1.39, 1.47, 1.55, 1.63, 1.71, 1.79,
1.87, 1.95, 1.101, 1.107, 1.113, 1.119, 1.125, 1.129 for reporting in
Column G]
MSC-8
DRAFT – Meets Section 508 Compliance Standards
Findings:
Y"" or "N
N""
Select "Y
from Sections in
White Only
Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
3
Findings Data Collection Form: Benefit Utilization
2.1 Benefit Utilization
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Benefit Utilization
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
ea
Cr sure
ite -S
ria pe
ID cific
Name of Reviewer:
Standard/ Substandard ID
MSC-9
Data Element 1.58
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Data Element 1.59
Review Results:
Data Element 1.60
Review Results:
MSC-8d: Includes all benefits paid for with federal funding, state
funding, group sponsor funding, and member premiums.
[Data Elements 1.8, 1.16, 1.24, 1.32, 1.40, 1.48, 1.56, 1.64, 1.72, 1.80,
1.88, 1.96, 1.102, 1.108, 1.114, 1.120, 1.126, 1.130 for reporting in
Column H]
Data Element 1.61
Review Results:
Data Element 1.62
Review Results:
Data Element 1.63
Review Results:
MSC-8e: Includes all benefits furnished during the reporting period,
regardless of their representation in the approved bid.
[Data Elements 1.8, 1.16, 1.24, 1.32, 1.40, 1.48, 1.56, 1.64, 1.72, 1.80,
1.88, 1.96, 1.102, 1.108, 1.114, 1.120, 1.126, 1.130 for reporting in
Column H]
Data Element 1.64
Review Results:
Data Element 1.65
Review Results:
Data Element 1.66
Review Results:
MSC-8f: Includes benefits regardless of a member’s ESRD status.
[Data Elements 1.8, 1.16, 1.24, 1.32, 1.40, 1.48, 1.56, 1.64, 1.72, 1.80,
1.88, 1.96, 1.102, 1.108, 1.114, 1.120, 1.126, 1.130 for reporting in
Column H]
Data Element 1.67
Review Results:
Data Element 1.68
Review Results:
Data Element 1.69
Review Results:
Data Element 1.70
Review Results:
Data Element 1.71
Review Results:
Data Element 1.72
Review Results:
Data Element 1.73
Review Results:
Data Element 1.74
Review Results:
Data Element 1.75
Review Results:
MSC-9b: Number calculated for total payments for each of the following Data Element 1.76
non-covered services must be $0: Transportation (Non-Covered); Dental
(Non-Covered); Vision (Non-Covered); Hearing (Non-Covered); Health & Data Element 1.77
Education (Non-Covered); and Other (Non-Covered)
[For reporting in column J]
Data Element 1.78
Review Results:
Data Element 1.79
MSC-10: Organization accurately calculates the amounts of Medicare
actuarial equivalent (cost-sharing), including the following criteria [Note to
reviewer : The organization must provide the reviewer and CMS with a brief Data Element 1.80
narrative explaining how the Medicare actuarial equivalent amounts are
derived.]:
Data Element 1.81
Review Results:
Data Element 1.82
Review Results:
Data Element 1.83
Review Results:
Data Element 1.84
Review Results:
Data Element 1.85
Review Results:
Data Element 1.86
Review Results:
Standard/Sub-standard Description
MSC-8c: Includes all benefits paid for whether they are covered by
Medicare or not
[Data Elements 1.8, 1.16, 1.24, 1.32, 1.40, 1.48, 1.56, 1.64, 1.72, 1.80,
1.88, 1.96, 1.102, 1.108, 1.114, 1.120, 1.126, 1.130 for reporting in
Column H]
MSC-9: Organization accurately calculates the amounts of total payments
to providers for Medicare covered services, including the following criteria
[Note to reviewer : The organization must provide the reviewer and CMS
with a brief narrative explaining how the payment amounts for Medicarecovered services are derived.]:
MSC-9a: Correctly sums the total payments made to providers during
the reporting period for services covered under original Medicare for
each of the following services: Inpatient Facility; Skilled Nursing Facility;
Home Health; Ambulance; DME/Prosthetics/Supplies; OP FacilityEmergency; OP Facility-Surgery; OP Facility-Other; Professional; Part B
Rx; Other Medicare Part B; and Medical.
[Data Elements 1.9, 1.17, 1.25, 1.33, 1.41, 1.49, 1.57, 1.65, 1.73, 1.81,
1.89, 1.131 for reporting in column J]
MSC-10
MSC-10a: Uses appropriate actuarial equivalent factors (as based on the
2010 bid pricing tool) to calculate the cost sharing that would be
required for covered services using original Medicare requirements for
each of the following services: Inpatient Facility; Skilled Nursing Facility;
Home Health; Ambulance; DME/Prosthetics/Supplies; OP FacilityEmergency; OP Facility-Surgery; OP Facility-Other; Professional; Part B
Rx; Other Medicare Part B; and Medical.
[Data Elements 1.10, 1.18, 1.26, 1.34, 1.42, 1.50, 1.58, 1.66, 1.74, 1.82,
1.90, 1.132 for reporting in column L]
DRAFT – Meets Section 508 Compliance Standards
Findings:
Y"" or "N
N""
Select "Y
from Sections in
White Only
Review Results:
Review Results:
Review Results:
Review Results:
4
Findings Data Collection Form: Benefit Utilization
2.1 Benefit Utilization
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Benefit Utilization
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
ea
Cr sure
ite -S
ria pe
ID cific
Name of Reviewer:
Standard/ Substandard ID
MSC-11
MSC-12
MSC-13
MSC-14
Data Element 1.87
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Data Element 1.88
Review Results:
Data Element 1.89
Review Results:
MSC-11: Organization accurately calculates the total number of members,
including the following criteria:
Data Element 1.90
Review Results:
MSC-11a: Includes all members who were enrolled for at least one
month during the reporting period.
[Data Element 1.133]
Data Element 1.91
Review Results:
Data Element 1.92
Review Results:
MSC-12: Organization accurately calculates the number of member months Data Element 1.93
during the reporting period.
Review Results:
MSC-12a: Includes all plan members whether they used a service or not. Data Element 1.94
[Data Element 1.134]
Review Results:
Data Element 1.95
Review Results:
Data Element 1.96
Review Results:
MSC-13a: Includes all premium payments during the reporting period
from members (regardless of ESRD status), employer/union groups,
State Medicaid agencies, and other third parties.
[Data Element 1.135]
Data Element 1.97
Review Results:
Data Element 1.98
Review Results:
MSC-14: Organization accurately calculates the amount of CMS revenue
collected, including the following criteria:
Data Element 1.99
Review Results:
MSC-14a: Includes all revenue received from CMS under the contract
during the reporting period.
[Data Element 1.136]
Data Element 1.100
Review Results:
Data Element 1.101
Review Results:
MSC-14b: Includes rebates applied to Part A and Part B services.
[Data Element 1.136]
Data Element 1.102
Review Results:
Data Element 1.103
Review Results:
Data Element 1.104
Review Results:
Data Element 1.105
Review Results:
MSC-15: Organization accurately calculates the amount of CMS rebates for Data Element 1.106
Part A and Part B services, including the following criteria:
Review Results:
Data Element 1.107
Review Results:
MSC-15a: Includes all CMS rebates for Part A and Part B services and
additional non-prescription drug benefits collected under the contract
during the reporting period.
[Data Element 1.137]
Data Element 1.108
Review Results:
Data Element 1.109
Review Results:
MSC-15b: Excludes rebates designated to reduce Part B and Part D
premiums.
[Data Element 1.137]
Data Element 1.110
Review Results:
Data Element 1.111
Review Results:
Data Element 1.112
Review Results:
MSC-16a: Includes all reserves for outstanding claims from the reporting Data Element 1.113
period.
[Data Element 1.138]
Data Element 1.114
Review Results:
Standard/Sub-standard Description
MSC-10b: Number calculated for actuarial equivalent (cost-sharing) for
each of the following non-covered services must be $0: Transportation
(Non-Covered); Dental (Non-Covered); Vision (Non-Covered); Hearing
(Non-Covered); Health & Education (Non-Covered); and Other (NonCovered).
[For reporting in column L]
MSC-13: Organization accurately calculates the amount of premiums
collected, including the following criteria:
MSC-14c: Includes amounts received from CMS from final risk
adjustment settlement to be included in the August MMR.
[Data Element 1.136]
MSC-15
MSC-16
MSC-16: Organization accurately calculates the amount of reserves for
outstanding claims, including the following criteria:
MSC-16b: Includes claims that have not been submitted to the
organization and claims that have been received but not yet processed.
[Data Element 1.138]
Review Results:
Data Element 1.115
Review Results:
Data Element 1.116
Review Results:
Data Element 1.117
Review Results:
DRAFT – Meets Section 508 Compliance Standards
Findings:
Y"" or "N
N""
Select "Y
from Sections in
White Only
5
Findings Data Collection Form: Benefit Utilization
2.1 Benefit Utilization
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Benefit Utilization
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
ea
Cr sure
ite -S
ria pe
ID cific
Name of Reviewer:
Standard/ Substandard ID
3
3.a
Data Element 1.118
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Data Element 1.119
Review Results:
Data Element 1.120
Review Results:
Data Element 1.121
Review Results:
Data Element 1.122
Review Results:
Data Element 1.123
Review Results:
Data Element 1.124
Review Results:
Data Element 1.125
Review Results:
Data Element 1.126
Review Results:
Data Element 1.127
Review Results:
Data Element 1.128
Review Results:
Data Element 1.129
Review Results:
Data Element 1.130
Review Results:
Data Element 1.131
Review Results:
Data Element 1.132
Review Results:
Data Element 1.133
Review Results:
Data Element 1.134
Review Results:
Data Element 1.135
Review Results:
Data Element 1.136
Review Results:
Data Element 1.137
Review Results:
Data Element 1.138
Review Results:
Standard/Sub-standard Description
Organization implements appropriate policies and procedures for data submission, including the following:
Data Sources:
Data elements are accurately entered into the HPMS tool and entries match corresponding source
documents.
3.b
Data files are properly uploaded into HPMS according to any HPMS templates provided.
Review Results:
3.c
All source, intermediate, and final stage data sets relied upon to enter data into HPMS are archived.
Review Results:
4
Findings:
Y"" or "N
N""
Select "Y
from Sections in
White Only
Organization implements appropriate policies and procedures for periodic data system updates (e.g.,
changes in enrollment, provider/pharmacy status, claims adjustments).
Data Sources:
Review Results:
5
Organization implements appropriate policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).
Data Sources:
Review Results:
DRAFT – Meets Section 508 Compliance Standards
6
Findings Data Collection Form: Benefit Utilization
2.1 Benefit Utilization
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Benefit Utilization
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
ea
Cr sure
ite -S
ria pe
ID cific
Name of Reviewer:
Standard/ Substandard ID
6
7
Standard/Sub-standard Description
If organization’s data systems underwent any changes during the reporting period (e.g., as a result of a
merger, acquisition, or upgrade): Organization provided documentation on the data system changes and,
upon review, there were no issues that significantly impacted data reported.
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
Findings:
Y"" or "N
N""
Select "Y
from Sections in
White Only
Review Results:
If data collection, validation, and/or reporting for this data measure is delegated to another entity:
Data Sources:
Organization regularly monitors the quality and timeliness of the data collected, validated, and/or reported
by the delegated entity or first tier/ downstream contractor.
Review Results:
DRAFT – Meets Section 508 Compliance Standards
7
Findings Data Collection Form: Procedure Frequency
2.2 Procedure Frequency
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Procedure Frequency
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
1
Standard/Sub-standard Description
A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved data
queries, file layouts, process flows) indicates that all source documents accurately capture required data
fields and are properly documented.
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
1.a
Source documents and output are properly secured so that source documents can be retrieved at any
time to validate the information submitted to CMS via HPMS.
Review Results:
1.b
Source documents create all required data fields for reporting requirements.
Review Results:
1.c
Source documents are error-free (e.g., programming code and spreadsheet formulas have no messages
or warnings indicating errors).
Review Results:
1.d
All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID, rather
than Field1 and maintain the same field name across data sets).
Review Results:
1.e
Data file locations are referenced correctly.
Review Results:
1.f
If used, macros are properly documented.
Review Results:
1.g
Source documents are clearly and adequately documented.
Review Results:
1.h
Titles and footnotes on reports and tables are accurate.
Review Results:
1.i
Version control of source documents is appropriately applied.
Review Results:
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.
2.a
The appropriate date range(s) for the reporting period(s) is captured.
MSC-1
2.b
2.c
2.d
Review Results:
Review Results:
Organization properly assigns data to the applicable CMS contract.
Appropriate deadlines are met for reporting data (e.g., quarterly).
MSC-3
Data Sources:
Organization reports data based on the required reporting period of 1/1 through 12/31.
Data are assigned at the applicable level (e.g., plan benefit package or contract level).
MSC-2
Findings:
Select "Y" or "N"
from Sections in
White Only
Review Results:
Organization meets deadline for reporting annual data to CMS by 5/31 and (for organizations
that submit HEDIS data) reports applicable procedure frequency data elements in accordance
with NCQA’s timetable for data submission.
Terms used are properly defined per CMS regulations, guidance and Reporting Requirements Technical
Specifications
DRAFT – Meets Section 508 Compliance Standards
1
Findings Data Collection Form: Procedure Frequency
2.2 Procedure Frequency
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Procedure Frequency
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
2.e
MSC-4
Data Element 2.1
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Data Element 2.2
Review Results:
Data Element 2.3
Review Results:
Data Element 2.4
Review Results:
Data Element 2.5
Review Results:
Data Element 2.6
MSC-4a: Includes all members that received the specified procedures
with dates of service that occur during the reporting period (if a member
received the same procedure multiple times within the reporting period, Data Element 2.7
includes that member only once for the applicable data element).
[Data Elements 2.1 – 2.23]
Data Element 2.8
Review Results:
MSC-4b: Properly uses all code types (i.e., CPT, ICD-9-CM Procedure, ICD Data Element 2.9
9-CM Diagnosis, MS-DRG) to identify procedures in a non-duplicative
manner.
Data Element 2.10
[Data Elements 2.1 – 2.23]
Review Results:
MSC-4c: Accurately maps non-standard codes to the standard codes
provided by CMS in Appendix 4 of the Part C Reporting Requirements
Technical Specifications Document.
[Data Elements 2.1 – 2.23]
Data Element 2.11
Review Results:
Data Element 2.12
Review Results:
MSC-4d: Properly sorts by each of the following procedures: Cardiac
Catheterization; Open Coronary Angioplasty; PTCA or Coronary
Atherectomy with CABG; PTCA or Coronary Atherectomy with insertion
of drug-eluting coronary artery stent(s); PTCA or Coronary Atherectomy
with insertion of non-drug-eluting coronary artery stent(s); PTCA or
Coronary Atherectomy without insertion of Coronary Artery Stent; Total
Hip Replacement; Total Knee Replacement; Bone Marrow Transplant;
Heart Transplant; Heart/Lung Transplant; Kidney Transplant; Liver
Transplant; Lung Transplant; Pancreas Transplant; Pancreas/Kidney
Transplant; CABG; Gastric Bypass; Excision or Destruction of Lesion or
Tissue of Lung; Excision of Large Intestine; Mastectomy; Lumpectomy;
and Prostatectomy.
[Data Elements 2.1 – 2.23]
Data Element 2.13
Review Results:
Data Element 2.14
Review Results:
Data Element 2.15
Review Results:
Data Element 2.16
Review Results:
Data Element 2.17
Review Results:
Data Element 2.18
Review Results:
Data Element 2.19
Review Results:
Data Element 2.20
Review Results:
Data Element 2.21
Review Results:
Data Element 2.22
MSC-4f: For Data Elements 2.19 through 2.23, includes only members
with the specified cancer diagnosis that received the following
procedures: Excision or Destruction of Lesion or Tissue of Lung; Excision Data Element 2.23
of Large Intestine; Mastectomy; Lumpectomy; and Prostatectomy.
[Data Elements 2.19 – 2.23]
Review Results:
Standard/Sub-standard Description
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.
Applicable Measure-Specific Criteria:
MSC-4: Organization accurately calculates the number of members
receiving the specified procedures, including the following criteria:
MSC-4e: For Data Elements 2.3 through 2.6, includes members that
received the applicable procedures during the same admission (i.e.,
procedures do not need to occur on the same date of service).
[Data Elements 2.3 – 2.6]
3
3.a
Organization implements appropriate policies and procedures for data submission, including the following:
Review Results:
Review Results:
Review Results:
Review Results:
Data Sources:
Data elements are accurately entered into the HPMS tool and entries match Data Element 2.1
corresponding source documents.
Review Results:
Data Element 2.2
Review Results:
Data Element 2.3
Review Results:
Data Element 2.4
Review Results:
Data Element 2.5
Review Results:
DRAFT – Meets Section 508 Compliance Standards
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
2
Findings Data Collection Form: Procedure Frequency
2.2 Procedure Frequency
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Procedure Frequency
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Data Element 2.6
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Data Element 2.7
Review Results:
Data Element 2.8
Review Results:
Data Element 2.9
Review Results:
Data Element 2.10
Review Results:
Data Element 2.11
Review Results:
Data Element 2.12
Review Results:
Data Element 2.13
Review Results:
Data Element 2.14
Review Results:
Data Element 2.15
Review Results:
Data Element 2.16
Review Results:
Data Element 2.17
Review Results:
Data Element 2.18
Review Results:
Data Element 2.19
Review Results:
Data Element 2.20
Review Results:
Data Element 2.21
Review Results:
Data Element 2.22
Review Results:
Data Element 2.23
Review Results:
Standard/Sub-standard Description
3.b
Data files are properly uploaded into HPMS according to any HPMS templates provided.
3.c
All source, intermediate, and final stage data sets relied upon to enter data into HPMS are archived.
4
Organization implements appropriate policies and procedures for periodic data system updates (e.g.,
changes in enrollment, provider/pharmacy status, claims adjustments).
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Review Results:
Data Sources:
Review Results:
5
Organization implements appropriate policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).
Data Sources:
Review Results:
6
7
If organization’s data systems underwent any changes during the reporting period (e.g., as a result of a
merger, acquisition, or upgrade): Organization provided documentation on the data system changes and,
upon review, there were no issues that significantly impacted data reported.
Data Sources:
If data collection, validation, and/or reporting for this data measure is delegated to another entity:
Organization regularly monitors the quality and timeliness of the data collected, validated, and/or reported
by the delegated entity or first tier/ downstream contractor.
Data Sources:
DRAFT – Meets Section 508 Compliance Standards
Review Results:
Review Results:
3
Findings Data Collection Form: Serious Reportable Adverse Events (SRAEs)
2.3 Serious Reportable Adverse Events (SRAEs)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Serious Reportable Adverse Events (SRAEs)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
1
Standard/Sub-standard Description
A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved data
queries, file layouts, process flows) indicates that all source documents accurately capture required data
fields and are properly documented.
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
1.a
Source documents and output are properly secured so that source documents can be retrieved at any
time to validate the information submitted to CMS via HPMS.
Review Results:
1.b
Source documents create all required data fields for reporting requirements.
Review Results:
1.c
Source documents are error-free (e.g., programming code and spreadsheet formulas have no messages
or warnings indicating errors).
Review Results:
1.d
All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID, rather
than Field1 and maintain the same field name across data sets).
Review Results:
1.e
Data file locations are referenced correctly.
Review Results:
1.f
If used, macros are properly documented.
Review Results:
1.g
Source documents are clearly and adequately documented.
Review Results:
1.h
Titles and footnotes on reports and tables are accurate.
Review Results:
1.i
Version control of source documents is appropriately applied.
Review Results:
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.
2.a
The appropriate date range(s) for the reporting period(s) is captured.
MSC-1
2.b
2.c
2.d
Review Results:
Review Results:
Organization properly assigns data to the applicable CMS contract.
Appropriate deadlines are met for reporting data (e.g., quarterly).
MSC-3
Data Sources:
Organization reports data based on the required reporting period of 1/1 through 12/31.
Data are assigned at the applicable level (e.g., plan benefit package or contract level).
MSC-2
Findings:
Select "Y" or "N"
from Sections in
White Only
Review Results:
Organization meets deadline for reporting annual data to CMS by 5/31.
Terms used are properly defined per CMS regulations, guidance and Reporting Requirements Technical
Specifications
DRAFT – Meets Section 508 Compliance Standards
1
Findings Data Collection Form: Serious Reportable Adverse Events (SRAEs)
2.3 Serious Reportable Adverse Events (SRAEs)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Serious Reportable Adverse Events (SRAEs)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
2.e
Standard/Sub-standard Description
The number of expected counts (e.g., number of members, claims,
Data Element 3.1
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 Element 3.2
data submission.
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Review Results:
Applicable Measure-Specific Criteria:
MSC-4
MSC-4: Organization accurately calculates the total number of surgeries,
including the following criteria:
MSC-4a: Includes all surgeries with dates of service that occur during the Data Element 3.3
reporting period.
[Data Element 3.1]
Review Results:
MSC-4b: Includes only surgeries that occur in an acute hospital setting.
[Data Element 3.1]
Data Element 3.4
MSC-5
Review Results:
MSC-5: Organization accurately calculates the total number of surgeries,
including the following criteria:
MSC-5a: Accurately maps SRAEs to the codes provided by CMS in
Appendix 5 of the Part C Reporting Requirements Technical
Specifications Document, Table 2. [Note to reviewer : Organizations may Data Element 3.5
map non-standard, homegrown codes, or events/conditions that are
typically documented by hospital review personnel to the applicable
SRAE. It is not necessary for an SRAE claim to contain every qualifier to
be counted.]
[Data Elements 3.2–3.5]
MSC-5b: Includes all specified SRAEs that are confirmed during the
reporting period (even if the event actually occurred during a previous
reporting period).
[Data Elements 3.2-3.5]
Data Element 3.6
MSC-5c: Includes any supplemental information provided by the hospital
regarding SRAEs that are confirmed during the reporting period (even if
the event actually occurred during a previous reporting period).
Data Element 3.7
[Data Elements 3.2-3.5]
MSC-5d: Includes SRAEs identified by paid claims as well as claims denied
only due to being a nonreimbursable SRAE.
[Data Elements 3.2-3.5]
Data Element 3.8
MSC-5e: Excludes adverse health conditions present upon admission (if
an SRAE is reported on a claim and there is an “n” (No) in the Present on
Admission (POA) field, this is considered a “confirmation” that the SRAE
was acquired during the hospital stay).
[Data Elements 3.2-3.5]
Data Element 3.9
Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
MSC-5f: Properly assigns each event to a single applicable SRAE
category.
[Data Elements 3.2-3.5]
Data Element 3.10
MSC-5g: Properly sorts by each of the following events: Surgeries on
wrong body part; Surgeries on wrong patient; Wrong surgical procedures
on a patient; and Surgeries with post-operative death in normal health
patient.
[Data Elements 3.2– 3.5]
MSC-6
MSC-6: Organization accurately calculates the number of hospital acquired
conditions (HACs), including the following criteria:
Data Element 3.11
DRAFT – Meets Section 508 Compliance Standards
Review Results:
Review Results:
2
Findings Data Collection Form: Serious Reportable Adverse Events (SRAEs)
2.3 Serious Reportable Adverse Events (SRAEs)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Serious Reportable Adverse Events (SRAEs)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Standard/Sub-standard Description
MSC-6a: Accurately maps HACs to the codes provided by CMS in
Appendix 5 of the Part C Reporting Requirements Technical
Specifications Document, Table 3. [Note to reviewer : Organizations may
map non-standard, homegrown codes, or events/conditions that are
typically documented by hospital review personnel to the applicable
Data Element 3.12
SRAE. It is not necessary for an HAC claim to contain every qualifier to be
counted.]
[Data Elements 3.6–3.16]
MSC-6b: Includes all specified HACs that are confirmed during the
reporting period (even if the event actually occurred during a previous
reporting period). The diagnosis code and procedure code may be on the Data Element 3.13
same claim or on different claims, and may or may not be on the same
date of service.
[Data Elements 3.6-3.16]
MSC-6c: Includes any supplemental information provided by the hospital
regarding HACs that are confirmed during the reporting period (even if
the event actually occurred during a previous reporting period).
[Data Elements 3.6-3.16]
Data Sources and Review Results:
Enter
review results and/or data sources
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Review Results:
Review Results:
Data Element 3.14
Review Results:
MSC-6e: Excludes adverse health conditions present upon admission (if Data Element 3.15
an SRAE is reported on a claim and there is an “n” (No) in the Present on
Admission (POA) field, this is considered a “confirmation” that the SRAE
was acquired during the hospital stay).
[Data Elements 3.6-3.16]
Review Results:
Data Element 3.16
Review Results:
MSC-6g: Properly sorts by each of the following HACs: Foreign object
retained after surgery; Air embolism events; Blood incompatibility
events; Stage III & IV pressure ulcers; Fractures; Dislocations; Intracranial Data Element 3.17
injuries; Crushing injuries; Burns; Vascular catheter-associated infections;
and Catheter-associated UTIs.
[Data Elements 3.6– 3.16]
Review Results:
MSC-6d: Includes HACs identified by paid claims as well as claims denied
only due to being a nonreimbursable HAC.
[Data Elements 3.6-3.16]
MSC-6f: Properly assigns each HAC to a single applicable HAC category.
[Data Elements 3.6-3.16]
MSC-7
MSC-7: Organization accurately calculates the number of HACs, including
the following criteria:
Data Element 3.18
MSC-7a: Accurately maps HACs to the codes provided by CMS in
Appendix 5 of the Part C Reporting Requirements Technical
Specifications Document, Table 4. [Note to reviewer : Organizations may
map non-standard, homegrown codes, or events/conditions that are
typically documented by hospital review personnel to the applicable
SRAE. It is not necessary for an HAC claim to contain every qualifier to be
counted.]
Data Element 3.19
[Data Elements 3.17–3.21]
MSC-7b: Includes all specified HACs that are confirmed during the
reporting period (even if the event actually occurred during a previous
reporting period). The diagnosis code and procedure code may be on
the same claim or on different claims, and may or may not be on the
same date of service.
[Data Elements 3.17-3.21]
Data Element 3.20
Review Results:
Review Results:
Review Results:
MSC-7c: For Data Element 3.18, includes SSI diagnosis codes with a date
of service that extends 30 days from the date of the procedure.
[Data Elements 3.18]
DRAFT – Meets Section 508 Compliance Standards
3
Findings Data Collection Form: Serious Reportable Adverse Events (SRAEs)
2.3 Serious Reportable Adverse Events (SRAEs)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Serious Reportable Adverse Events (SRAEs)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Standard/Sub-standard Description
MSC-7d: For Data Element 3.19, includes SSI diagnosis codes with a date Data Element 3.21
of service that extends 365 days from the date of the procedure.
[Data Elements 3.19]
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
MSC-7e: Includes any supplemental information provided by the hospital
regarding HACs that are confirmed during the reporting period (even if
the event actually occurred during a previous reporting period).
[Data Elements 3.17-3.21]
MSC-7f: Includes HACs identified by paid claims as well as claims denied
only due to being a nonreimbursable HAC.
[Data Elements 3.17-3.21]
MSC-7g: Excludes adverse health conditions present upon admission (if
an SRAE is reported on a claim and there is an “n” (No) in the Present on
Admission (POA) field, this is considered a “confirmation” that the SRAE
was acquired during the hospital stay).
[Data Elements 3.17– 3.21]
MSC-7h: Properly assigns each HAC to a single applicable HAC category.
[Data Elements 3.17– 3.21]
MSC-7i: Properly sorts by each of the following HACs: Manifestations of
poor glycemic control; SSI (mediastinitis) after CABG; SSI after certain
orthopedic procedures; SSI following bariatric surgery for obesity; and
DVT and pulmonary embolism following certain orthopedic procedures.
[Data Elements 3.17– 3.21]
3
3.a
Organization implements appropriate policies and procedures for data submission, including the following:
Data Sources:
Data elements are accurately entered into the HPMS tool and entries match Data Element 3.1
corresponding source documents.
Review Results:
Data Element 3.2
Review Results:
Data Element 3.3
Review Results:
Data Element 3.4
Review Results:
Data Element 3.5
Review Results:
Data Element 3.6
Review Results:
Data Element 3.7
Review Results:
Data Element 3.8
Review Results:
Data Element 3.9
Review Results:
Data Element 3.10
Review Results:
Data Element 3.11
Review Results:
Data Element 3.12
Review Results:
Data Element 3.13
Review Results:
DRAFT – Meets Section 508 Compliance Standards
4
Findings Data Collection Form: Serious Reportable Adverse Events (SRAEs)
2.3 Serious Reportable Adverse Events (SRAEs)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Serious Reportable Adverse Events (SRAEs)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Data Element 3.14
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Data Element 3.15
Review Results:
Data Element 3.16
Review Results:
Data Element 3.17
Review Results:
Data Element 3.18
Review Results:
Data Element 3.19
Review Results:
Data Element 3.20
Review Results:
Data Element 3.21
Review Results:
Standard/Sub-standard Description
3.b
Data files are properly uploaded into HPMS according to any HPMS templates provided.
3.c
All source, intermediate, and final stage data sets relied upon to enter data into HPMS are archived.
4
Organization implements appropriate policies and procedures for periodic data system updates (e.g.,
changes in enrollment, provider/pharmacy status, claims adjustments).
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Review Results:
Data Sources:
Review Results:
5
Organization implements appropriate policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).
Data Sources:
Review Results:
6
7
If organization’s data systems underwent any changes during the reporting period (e.g., as a result of a
merger, acquisition, or upgrade): Organization provided documentation on the data system changes and,
upon review, there were no issues that significantly impacted data reported.
Data Sources:
If data collection, validation, and/or reporting for this data measure is delegated to another entity:
Organization regularly monitors the quality and timeliness of the data collected, validated, and/or reported
by the delegated entity or first tier/ downstream contractor.
Data Sources:
DRAFT – Meets Section 508 Compliance Standards
Review Results:
Review Results:
5
Findings Data Collection Form: Provider Network Adequacy
2.4 Provider Network Adequacy
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Provider Network Adequacy
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
1
Standard/Sub-standard Description
A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved data
queries, file layouts, process flows) indicates that all source documents accurately capture required data
fields and are properly documented.
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
1.a
Source documents and output are properly secured so that source documents can be retrieved at any
time to validate the information submitted to CMS via HPMS.
Review Results:
1.b
Source documents create all required data fields for reporting requirements.
Review Results:
1.c
Source documents are error-free (e.g., programming code and spreadsheet formulas have no messages
or warnings indicating errors).
Review Results:
1.d
All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID, rather
than Field1 and maintain the same field name across data sets).
Review Results:
1.e
Data file locations are referenced correctly.
Review Results:
1.f
If used, macros are properly documented.
Review Results:
1.g
Source documents are clearly and adequately documented.
Review Results:
1.h
Titles and footnotes on reports and tables are accurate.
Review Results:
1.i
Version control of source documents is appropriately applied.
Review Results:
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.
2.a
The appropriate date range(s) for the reporting period(s) is captured.
MSC-1
2.b
2.c
2.d
Review Results:
Review Results:
Organization properly assigns data to the applicable CMS contract.
Appropriate deadlines are met for reporting data (e.g., quarterly).
MSC-3
Data Sources:
Organization reports data based on the required reporting period of 1/1 through 12/31.
Data are assigned at the applicable level (e.g., plan benefit package or contract level).
MSC-2
Findings:
Select "Y" or "N"
from Sections in
White Only
Review Results:
Organization meets deadline for reporting annual data to CMS by 2/28.
Terms used are properly defined per CMS regulations, guidance and Reporting Requirements Technical
Specifications.
DRAFT – Meets Section 508 Compliance Standards
1
Findings Data Collection Form: Provider Network Adequacy
2.4 Provider Network Adequacy
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Provider Network Adequacy
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
2.e
MSC-4
Standard/Sub-standard Description
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.
Applicable Measure-Specific Criteria:
MSC-4: Organization accurately calculates the number of primary care
physicians (PCPs) in the network on the first day of the reporting period,
including the following criteria:
MSC-4a: Includes only physicians that are contracted in the network as
of the first day of the reporting period, using the contracting date, not
the credentialing date.
[Data Elements 4.1–4.6]
Review Results:
Data Element 4.3
Review Results:
Data Element 4.4
Review Results:
Data Element 4.5
Review Results:
Data Element 4.6
Review Results:
Data Element 4.7
Review Results:
Data Element 4.8
Review Results:
Review Results:
Data Element 4.13
Review Results:
Data Element 4.14
Review Results:
MSC-5: Organization accurately calculates the number of PCPs in the
Data Element 4.15
network continuously through the reporting period, including the following
criteria:
Data Element 4.16
Review Results:
Data Element 4.17
Review Results:
Data Element 4.18
Review Results:
Data Element 4.19
MSC-5b: Includes all physicians that are identified as able to serve as a
member’s primary care physician (regardless of whether or not they are
considered a PCP and a specialist). [Note to reviewer : If the organization Data Element 4.20
does not recognize one or more of the PCP types listed below as a
primary care physician, it must still include that type as a PCP for the
Data Element 4.21
purposes of this reporting.]
[Data Elements 4.7–4.12]
Data Element 4.22
Review Results:
MSC-5a: Includes only physicians that are defined as having been
continuously in the network through the reporting period, using the
contracting date, not the credentialing date.
[Data Elements 4.7–4.12]
Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
Data Element 4.23
Review Results:
Data Element 4.24
Review Results:
MSC-6: Organization accurately calculates the number of PCPs added to the Data Element 4.25
network during the reporting period, including the following criteria:
Review Results:
Data Element 4.26
Review Results:
Data Element 4.27
Review Results:
Data Element 4.28
Review Results:
Data Element 4.29
Review Results:
MSC-5c: Properly sorts by each of the following PCP types: General
Medicine; Family Medicine; Internal Medicine; Obstetricians;
Pediatricians; and State Licensed Nurse Practitioners.
[Data Elements 4.7–4.12]
MSC-6
Data Element 4.2
Data Element 4.9
MSC-4b: Includes all physicians that are identified as able to serve as a
member’s primary care physician (regardless of whether or not they are
considered a PCP and a specialist). [Note to reviewer : If the organization Data Element 4.10
does not recognize one or more of the PCP types listed below as a
primary care physician, it must still include that type as a PCP for the
Data Element 4.11
purposes of this reporting.]
[Data Elements 4.1–4.6]
Data Element 4.12
MSC-4c: Properly sorts by each of the following PCP types: General
Medicine; Family Medicine; Internal Medicine; Obstetricians;
Pediatricians; and State Licensed Nurse Practitioners.
[Data Elements 4.1–4.6]
MSC-5
Data Element 4.1
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
MSC-6a: Includes only physicians whose effective date of contracted
network participation occurs after the first day of the reporting period,
using the contracting date, not the credentialing date.
[Data Elements 4.13–4.18]
DRAFT – Meets Section 508 Compliance Standards
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
2
Findings Data Collection Form: Provider Network Adequacy
2.4 Provider Network Adequacy
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Provider Network Adequacy
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Standard/Sub-standard Description
Data Element 4.30
MSC-6b: Includes all physicians that are identified as able to serve as a
member’s primary care physician (regardless of whether or not they are
considered a PCP and a specialist). [Note to reviewer : If the organization Data Element 4.31
does not recognize one or more of the PCP types listed below as a
primary care physician, it must still include that type as a PCP for the
Data Element 4.32
purposes of this reporting.]
[Data Elements 4.13–4.18]
Data Element 4.33
MSC-8
Review Results:
Review Results:
Review Results:
Data Element 4.35
Review Results:
Data Element 4.36
Review Results:
Data Element 4.37
Review Results:
MSC-7a: Includes only physicians who are contracted in the network and Data Element 4.38
identified as accepting new patients as of the first day of the reporting
period, using the contracting date, not the credentialing date.
Data Element 4.39
[Data Elements 4.19–4.24]
Review Results:
Data Element 4.40
Review Results:
Data Element 4.41
MSC-7b: Includes all physicians that are identified as able to serve as a
member’s primary care physician (regardless of whether or not they are
considered a PCP and a specialist). [Note to reviewer : If the organization Data Element 4.42
does not recognize one or more of the PCP types listed below as a
primary care physician, it must still include that type as a PCP for the
Data Element 4.43
purposes of this reporting.]
[Data Elements 4.19–4.24]
Data Element 4.44
Review Results:
MSC-7c: Properly sorts by each of the following PCP types: General
Medicine; Family Medicine; Internal Medicine; Obstetricians;
Pediatricians; and State Licensed Nurse Practitioners.
[Data Elements 4.19–4.24]
Data Element 4.45
Review Results:
Data Element 4.46
Review Results:
MSC-8: Organization accurately calculates the number of PCPs accepting
new patients at the end of the reporting period, including the following
criteria:
Data Element 4.47
Review Results:
Data Element 4.48
Review Results:
Data Element 4.49
Review Results:
Data Element 4.50
Review Results:
Data Element 4.51
Review Results:
Data Element 4.52
MSC-8b: Includes all physicians that are identified as able to serve as a
member’s primary care physician (regardless of whether or not they are
considered a PCP and a specialist). [Note to reviewer : If the organization Data Element 4.53
does not recognize one or more of the PCP types listed below as a
primary care physician, it must still include that type as a PCP for the
Data Element 4.54
purposes of this reporting.]
[Data Elements 4.25–4.30]
Data Element 4.55
Review Results:
Data Element 4.56
Review Results:
Data Element 4.57
Review Results:
Data Element 4.58
Review Results:
Data Element 4.59
Review Results:
MSC-7: Organization accurately calculates the number of PCPs accepting
new patients at the beginning of the reporting period, including the
following criteria:
MSC-8a: a. Includes only physicians who are contracted in the network
and identified as accepting new patients as of the last day of the
reporting period, using the contracting date, not the credentialing date.
[Data Elements 4.25–4.30]
MSC-8c: Properly sorts by each of the following PCP types: General
Medicine; Family Medicine; Internal Medicine; Obstetricians;
Pediatricians; and State Licensed Nurse Practitioners.
[Data Elements 4.25–4.30]
MSC-9
Review Results:
Data Element 4.34
MSC-6c: Properly sorts by each of the following PCP types: General
Medicine; Family Medicine; Internal Medicine; Obstetricians;
Pediatricians; and State Licensed Nurse Practitioners.
[Data Elements 4.13–4.18]
MSC-7
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
MSC-9: Organization accurately calculates the number of PCPs in the
network on the last day of the reporting period, including the following
criteria:
DRAFT – Meets Section 508 Compliance Standards
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
3
Findings Data Collection Form: Provider Network Adequacy
2.4 Provider Network Adequacy
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Provider Network Adequacy
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Data Element 4.60
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Data Element 4.61
Review Results:
Data Element 4.62
MSC-9b: Includes all physicians that are identified as able to serve as a
member’s primary care physician (regardless of whether or not they are
considered a PCP and a specialist). [Note to reviewer : If the organization Data Element 4.63
does not recognize one or more of the PCP types listed below as a
primary care physician, it must still include that type as a PCP for the
Data Element 4.64
purposes of this reporting.]
[Data Elements 4.31–4.36]
Data Element 4.65
Review Results:
Standard/Sub-standard Description
MSC-9a: Includes only physicians that are contracted in the network as
of the last day of the reporting period, using the contracting date, not
the credentialing date.
[Data Elements 4.31–4.36]
MSC-9c: Properly sorts by each of the following PCP types: General
Medicine; Family Medicine; Internal Medicine; Obstetricians;
Pediatricians; and State Licensed Nurse Practitioners.
[Data Elements 4.31–4.36]
MSC-10
MSC-11
MSC-12
Review Results:
Review Results:
Review Results:
Data Element 4.66
Review Results:
Data Element 4.67
Review Results:
MSC-10: Organization accurately calculates the number of
specialists/facilities in the network on the first day of the reporting period,
including the following criteria:
Data Element 4.68
Review Results:
Data Element 4.69
Review Results:
MSC-10a: a. Includes only specialists/facilities defined as having been in
network on the first day of the reporting period, using the contracting
date, not the credentialing date.
[Data Elements 4.37–4.46]
Data Element 4.70
Review Results:
Data Element 4.71
Review Results:
MSC-10b: Includes all applicable specialists (regardless of whether or not Data Element 4.72
they have dual specialties or are considered a PCP and a specialist).
[Data Elements 4.37–4.46]
Data Element 4.73
Review Results:
MSC-10c: Property sorts by each of the following specialty/facility types: Data Element 4.74
Hospitals; Home Health Agencies; Cardiologist; Oncologist;
Pulmonologist; Endocrinologist; Skilled Nursing Facilities;
Data Element 4.75
Rheumatologist; Ophthalmologist; and Urologist.
[Data Elements 4.37–4.46]
Data Element 4.76
Review Results:
MSC-11: Organization accurately calculates the number of
specialists/facilities continuously in the network through the reporting
period, including the following criteria:
Data Element 4.77
Review Results:
Data Element 4.78
Review Results:
MSC-11a: Includes only specialists/facilities defined as having been
continuously in the network through the reporting period, using the
contracting date, not the credentialing date.
[Data Elements 4.47–4.56]
Data Element 4.79
Review Results:
Data Element 4.80
Review Results:
MSC-11b: Includes all applicable specialists (regardless of whether or not Data Element 4.81
they have dual specialties or are considered a PCP and a specialist).
[Data Elements 4.47–4.56]
Data Element 4.82
Review Results:
MSC-11c: Properly sorts by each of the following specialty/facility types: Data Element 4.83
Hospitals; Home Health Agencies; Cardiologist; Oncologist;
Pulmonologist; Endocrinologist; Skilled Nursing Facilities;
Data Element 4.84
Rheumatologist; Ophthalmologist; and Urologist.
[Data Elements 4.47–4.56]
Data Element 4.85
Review Results:
Data Element 4.86
Review Results:
Data Element 4.87
Review Results:
MSC-12: Organization accurately calculates the number of
specialists/facilities added to the network during the reporting period,
including the following criteria:
DRAFT – Meets Section 508 Compliance Standards
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
4
Findings Data Collection Form: Provider Network Adequacy
2.4 Provider Network Adequacy
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Provider Network Adequacy
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
MSC-13
Data Element 4.88
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Data Element 4.89
Review Results:
MSC-12b: Includes all applicable specialists (regardless of whether or not Data Element 4.90
they have dual specialties or are considered a PCP and a specialist).
[Data Elements 4.57–4.66]
Data Element 4.91
Review Results:
MSC-12c: Properly sorts by each of the following specialty/facility types: Data Element 4.92
Hospitals; Home Health Agencies; Cardiologist; Oncologist;
Pulmonologist; Endocrinologist; Skilled Nursing Facilities;
Data Element 4.93
Rheumatologist; Ophthalmologist; and Urologist.
[Data Elements 4.57–4.66]
Data Element 4.94
Review Results:
Standard/Sub-standard Description
MSC-12a: Includes only specialists/facilities whose effective date of
network participation occurs after the first day of the reporting period,
using the contracting date, not the credentialing date.
[Data Elements 4.57–4.66]
Data Element 4.95
MSC-13: Organization accurately calculates the number of
specialists/facilities in the network accepting new patients at the start of the
reporting period, including the following criteria:
Data Element 4.96
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
MSC-13a: Includes only specialists/facilities that are contracted in the
network as of the last day of the reporting period, using the contracting
date, not the credentialing date.
[Data Elements 4.67–4.76]
MSC-13b: Includes all applicable specialists (regardless of whether or not
they have dual specialties or are considered a PCP and a specialist).
[Data Elements 4.67–4.76]
MSC-13c: Properly sorts by each of the following specialty/facility types:
Hospitals; Home Health Agencies; Cardiologist; Oncologist;
Pulmonologist; Endocrinologist; Skilled Nursing Facilities;
Rheumatologist; Ophthalmologist; and Urologist.
[Data Elements 4.67–4.76]
MSC-14
MSC-14: Organization accurately calculates the number of
specialists/facilities in the network accepting new patients at the end of the
reporting period, including the following criteria:
MSC-14a: Includes only specialists/facilities that are contracted in the
network as of the last day of the reporting period, using the contracting
date, not the credentialing date.
[Data Elements 4.77–4.86]
MSC-14b: Includes all applicable specialists (regardless of whether or not
they have dual specialties or are considered a PCP and a specialist).
[Data Elements 4.77–4.86]
MSC-14c: Properly sorts by each of the following specialty/facility types:
Hospitals; Home Health Agencies; Cardiologist; Oncologist;
Pulmonologist; Endocrinologist; Skilled Nursing Facilities;
Rheumatologist; Ophthalmologist; and Urologist.
[Data Elements 4.77–4.86]
MSC-15
MSC-15: Organization accurately calculates the number of
specialists/facilities in the network on the last day of the reporting period,
including the following criteria:
MSC-15a: Includes only specialists/facilities that are contracted in the
network as of the last day of the reporting period, using the contracting
date, not the credentialing date.
[Data Elements 4.87–4.96]
MSC-15b: Includes all applicable specialists (regardless of whether or not
they have dual specialties or are considered a PCP and a specialist).
[Data Elements 4.87–4.96]
DRAFT – Meets Section 508 Compliance Standards
5
Findings Data Collection Form: Provider Network Adequacy
2.4 Provider Network Adequacy
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Provider Network Adequacy
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
3
3.a
Data Sources and Review Results:
Enter
review results and/or data sources
Standard/Sub-standard Description
MSC-15c: Properly sorts by each of the following specialty/facility types:
Hospitals; Home Health Agencies; Cardiologist; Oncologist;
Pulmonologist; Endocrinologist; Skilled Nursing Facilities;
Rheumatologist; Ophthalmologist; and Urologist.
[Data Elements 4.87–4.96]
Organization implements appropriate policies and procedures for data submission, including the following:
Data Sources:
Data elements are accurately entered into the HPMS tool and entries match Data Element 4.1
corresponding source documents.
Review Results:
Data Element 4.2
Review Results:
Data Element 4.3
Review Results:
Data Element 4.4
Review Results:
Data Element 4.5
Review Results:
Data Element 4.6
Review Results:
Data Element 4.7
Review Results:
Data Element 4.8
Review Results:
Data Element 4.9
Review Results:
Data Element 4.10
Review Results:
Data Element 4.11
Review Results:
Data Element 4.12
Review Results:
Data Element 4.13
Review Results:
Data Element 4.14
Review Results:
Data Element 4.15
Review Results:
Data Element 4.16
Review Results:
Data Element 4.17
Review Results:
Data Element 4.18
Review Results:
Data Element 4.19
Review Results:
Data Element 4.20
Review Results:
Data Element 4.21
Review Results:
Data Element 4.22
Review Results:
Data Element 4.23
Review Results:
Data Element 4.24
Review Results:
Data Element 4.25
Review Results:
DRAFT – Meets Section 508 Compliance Standards
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
6
Findings Data Collection Form: Provider Network Adequacy
2.4 Provider Network Adequacy
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Provider Network Adequacy
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Data Element 4.26
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Data Element 4.27
Review Results:
Data Element 4.28
Review Results:
Data Element 4.29
Review Results:
Data Element 4.30
Review Results:
Data Element 4.31
Review Results:
Data Element 4.32
Review Results:
Data Element 4.33
Review Results:
Data Element 4.34
Review Results:
Data Element 4.35
Review Results:
Data Element 4.36
Review Results:
Data Element 4.37
Review Results:
Data Element 4.38
Review Results:
Data Element 4.39
Review Results:
Data Element 4.40
Review Results:
Data Element 4.41
Review Results:
Data Element 4.42
Review Results:
Data Element 4.43
Review Results:
Data Element 4.44
Review Results:
Data Element 4.45
Review Results:
Data Element 4.46
Review Results:
Data Element 4.47
Review Results:
Data Element 4.48
Review Results:
Data Element 4.49
Review Results:
Data Element 4.50
Review Results:
Data Element 4.51
Review Results:
Data Element 4.52
Review Results:
Data Element 4.53
Review Results:
Data Element 4.54
Review Results:
Data Element 4.55
Review Results:
Data Element 4.56
Review Results:
Standard/Sub-standard Description
DRAFT – Meets Section 508 Compliance Standards
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
7
Findings Data Collection Form: Provider Network Adequacy
2.4 Provider Network Adequacy
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Provider Network Adequacy
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Data Element 4.57
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Data Element 4.58
Review Results:
Data Element 4.59
Review Results:
Data Element 4.60
Review Results:
Data Element 4.61
Review Results:
Data Element 4.62
Review Results:
Data Element 4.63
Review Results:
Data Element 4.64
Review Results:
Data Element 4.65
Review Results:
Data Element 4.66
Review Results:
Data Element 4.67
Review Results:
Data Element 4.68
Review Results:
Data Element 4.69
Review Results:
Data Element 4.70
Review Results:
Data Element 4.71
Review Results:
Data Element 4.72
Review Results:
Data Element 4.73
Review Results:
Data Element 4.74
Review Results:
Data Element 4.75
Review Results:
Data Element 4.76
Review Results:
Data Element 4.77
Review Results:
Data Element 4.78
Review Results:
Data Element 4.79
Review Results:
Data Element 4.80
Review Results:
Data Element 4.81
Review Results:
Data Element 4.82
Review Results:
Data Element 4.83
Review Results:
Data Element 4.84
Review Results:
Data Element 4.85
Review Results:
Data Element 4.86
Review Results:
Data Element 4.87
Review Results:
Standard/Sub-standard Description
DRAFT – Meets Section 508 Compliance Standards
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
8
Findings Data Collection Form: Provider Network Adequacy
2.4 Provider Network Adequacy
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Provider Network Adequacy
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Data Element 4.88
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Data Element 4.89
Review Results:
Data Element 4.90
Review Results:
Data Element 4.91
Review Results:
Data Element 4.92
Review Results:
Data Element 4.93
Review Results:
Data Element 4.94
Review Results:
Data Element 4.95
Review Results:
Data Element 4.96
Review Results:
Standard/Sub-standard Description
3.b
Data files are properly uploaded into HPMS according to any HPMS templates provided.
3.c
All source, intermediate, and final stage data sets relied upon to enter data into HPMS are archived.
4
Organization implements appropriate policies and procedures for periodic data system updates (e.g.,
changes in enrollment, provider/pharmacy status, claims adjustments).
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Review Results:
Data Sources:
Review Results:
5
Organization implements appropriate policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).
Data Sources:
Review Results:
6
7
If organization’s data systems underwent any changes during the reporting period (e.g., as a result of a
merger, acquisition, or upgrade): Organization provided documentation on the data system changes and,
upon review, there were no issues that significantly impacted data reported.
Data Sources:
If data collection, validation, and/or reporting for this data measure is delegated to another entity:
Organization regularly monitors the quality and timeliness of the data collected, validated, and/or reported
by the delegated entity or first tier/ downstream contractor.
Data Sources:
DRAFT – Meets Section 508 Compliance Standards
Review Results:
Review Results:
9
Findings Data Collection Form: Grievances (Part C)
2.5 Grievances (Part C)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Grievances (Part C)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
1
Standard/Sub-standard Description
A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved data
queries, file layouts, process flows) indicates that all source documents accurately capture required data
fields and are properly documented.
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
1.a
Source documents and output are properly secured so that source documents can be retrieved at any
time to validate the information submitted to CMS via HPMS.
Review Results:
1.b
Source documents create all required data fields for reporting requirements.
Review Results:
1.c
Source documents are error-free (e.g., programming code and spreadsheet formulas have no messages
or warnings indicating errors).
Review Results:
1.d
All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID, rather
than Field1 and maintain the same field name across data sets).
Review Results:
1.e
Data file locations are referenced correctly.
Review Results:
1.f
If used, macros are properly documented.
Review Results:
1.g
Source documents are clearly and adequately documented.
Review Results:
1.h
Titles and footnotes on reports and tables are accurate.
Review Results:
1.i
Version control of source documents is appropriately applied.
Review Results:
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.
2.a
The appropriate date range(s) for the reporting period(s) is captured.
MSC-1
2.b
2.c
2.d
Review Results:
Review Results:
Organization meets deadlines for reporting quarterly data to CMS by 5/31, 8/31, 11/30, and
2/28.
Terms used are properly defined per CMS regulations, guidance and Reporting Requirements Technical
Specifications.
MSC-4
Review Results:
Organization properly assigns data to the applicable CMS contract or plan benefit package.
Appropriate deadlines are met for reporting data (e.g., quarterly).
MSC-3
Data Sources:
Organization reports data based on the required reporting periods of 1/1 through 3/31, 4/1
through 6/30, 7/1 through 9/30, and 10/1 through 12/31.
Data are assigned at the applicable level (e.g., plan benefit package or contract level).
MSC-2
Findings:
Select "Y" or "N"
from Sections in
White Only
Review Results:
Organization properly defines the term “Grievance” in accordance with 42 CFR §422.564 and
the Medicare Managed Care Manual Chapter 13, Sections 10.1 and 20.2. Requests for
organization determinations or appeals are not categorized as grievances.
DRAFT – Meets Section 508 Compliance Standards
1
Findings Data Collection Form: Grievances (Part C)
2.5 Grievances (Part C)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Grievances (Part C)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
2.e
MSC-5
Standard/Sub-standard Description
The number of expected counts (e.g., number of members, claims,
Data Element 5.1
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.
Applicable Measure-Specific Criteria:
MSC-5: Organization accurately calculates the total number of grievances,
including the following criteria:
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Data Element 5.2
Review Results:
Data Element 5.3
Review Results:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
MSC-5a: Includes all grievances that were completed (i.e., organization
has notified member of its decision) during the reporting period,
regardless of when the grievance was received.
[Data Elements 5.1–5.7]
MSC-5b: Includes grievances regardless of whether the event or
incidence of the grievance was filed late (i.e., more than 60 calendar
days after the event).
[Data Elements 5.1–5.7]
MSC-5c: If a grievance contains multiple issues filed by a single
complaint, each issue is calculated as a separate grievance.
[Data Elements 5.1–5.7]
MSC-5d: If a beneficiary files a grievance and then files a subsequent
grievance on the same issue prior to the organization’s decision or the
deadline for decision notification (whichever is earlier), then the issue is
counted as one grievance.
[Data Elements 5.1–5.7]
Data Element 5.4
MSC-5e: If a beneficiary files a grievance and then files a subsequent
grievance on the same issue after the organization’s decision or deadline
for decision notification (whichever is earlier), then the issue is counted
as a separate grievance.
[Data Elements 5.1–5.7]
Review Results:
MSC-5f: Includes all methods of grievance receipt (e.g., telephone, letter,
fax, in-person.
[Data Elements 5.1– 5.7]
MSC-5g: Includes all grievances regardless of who filed the grievance
(e.g., member or appointed representative).
[Data Elements 5.1– 5.7]
MSC-5h: Includes only grievances that are filed directly with the
Data Element 5.5
organization (e.g., excludes all complaints that are only forwarded to the
organization from the CMS Complaint Tracking Module (CTM) and not
filed directly with the organization).
[Data Elements 5.1–5.7]
Review Results:
MSC-5i: Includes grievances regarding services covered under plan
benefits, even if they are not services that would be covered under Fee
For Service (FFS) Medicare.
[Data Elements 5.1–5.7]
MSC-5j: For MA-PD contracts: Includes only grievances that apply to the Data Element 5.6
Part C benefit (If a clear distinction cannot be made for an MA-PD, cases
are reported as Part C grievances).
[Data Elements 5.1–5.7]
MSC-6
Review Results:
MSC-6: Organization accurately calculates the number of grievances by
category, including the following criteria:
DRAFT – Meets Section 508 Compliance Standards
2
Findings Data Collection Form: Grievances (Part C)
2.5 Grievances (Part C)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Grievances (Part C)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
MSC-7
Standard/Sub-standard Description
MSC-6a: Properly sorts the total number of grievances by grievance
category: Fraud and Abuse; Enrollment/Disenrollment Access/Benefit
Package; Marketing; Confidentiality and Privacy; Quality of Care; and
Expedited Grievances.
[Data Elements 5.1–5.7]
MSC-6b: Assigns all additional categories tracked by the organization
that are not listed above as Other.
[Data Elements 5.1–5.7]
Data Sources and Review Results:
Enter
review results and/or data sources
Data Element 5.7
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Review Results:
MSC-7: Organization accurately categorizes all expedited grievances based
on the following criteria:
MSC-7a: Complaints involving an MAO’s decision to invoke an extension
in an organization determination or reconsideration.
[Data Element 5.6]
MSC-7b: Complaints involving an MAO’s refusal to grant a request for an
expedited organization determination or reconsideration.
[Data Element 5.6]
3
3.a
Organization implements appropriate policies and procedures for data submission, including the following:
Data elements are accurately entered into the HPMS tool and entries match Data Element 5.1
corresponding source documents.
Review Results:
Data Element 5.2
Review Results:
Data Element 5.3
Review Results:
Data Element 5.4
Review Results:
Data Element 5.5
Review Results:
Data Element 5.6
Review Results:
Data Element 5.7
Review Results:
3.b
Data files are properly uploaded into HPMS according to any HPMS templates provided.
3.c
All source, intermediate, and final stage data sets relied upon to enter data into HPMS are archived.
4
Data Sources:
Organization implements appropriate policies and procedures for periodic data system updates (e.g.,
changes in enrollment, provider/pharmacy status, claims adjustments).
Review Results:
Data Sources:
Review Results:
5
Organization implements appropriate policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).
Data Sources:
Review Results:
6
7
If organization’s data systems underwent any changes during the reporting period (e.g., as a result of a
merger, acquisition, or upgrade): Organization provided documentation on the data system changes and,
upon review, there were no issues that significantly impacted data reported.
Data Sources:
If data collection, validation, and/or reporting for this data measure is delegated to another entity:
Organization regularly monitors the quality and timeliness of the data collected, validated, and/or reported
by the delegated entity or first tier/ downstream contractor.
Data Sources:
DRAFT – Meets Section 508 Compliance Standards
Review Results:
Review Results:
3
Findings Data Collection Form: Organization Determinations/Reconsiderations (Part C)
2.6 Organization Determinations/Reconsiderations (Part C)
Organization Name:
Contract Number:
Data Measure:
Organization Determinations/Reconsiderations (Part C)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
1
Standard/Sub-standard Description
A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved data
queries, file layouts, process flows) indicates that all source documents accurately capture required data
fields and are properly documented.
Enter
Data Sources and Review Results:
review results and/or data sources
Data Sources:
1.a
Source documents and output are properly secured so that source documents can be retrieved at any
time to validate the information submitted to CMS via HPMS.
Review Results:
1.b
Source documents create all required data fields for reporting requirements.
Review Results:
1.c
Source documents are error-free (e.g., programming code and spreadsheet formulas have no messages
or warnings indicating errors).
Review Results:
1.d
All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID, rather
than Field1 and maintain the same field name across data sets).
Review Results:
1.e
Data file locations are referenced correctly.
Review Results:
1.f
If used, macros are properly documented.
Review Results:
1.g
Source documents are clearly and adequately documented.
Review Results:
1.h
Titles and footnotes on reports and tables are accurate.
Review Results:
1.i
Version control of source documents is appropriately applied.
Review Results:
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.
2.a
The appropriate date range(s) for the reporting period(s) is captured.
MSC-1
2.b
2.c
2.d
Review Results:
Review Results:
Organization meets deadlines for reporting quarterly data to CMS by 5/31, 8/31, 11/30, and
2/28. [Note to reviewer : Due to a revision to the technical specifications for this measure, the
reviewer should confirm that the contract reported 1st quarter 2010 data for data elements
6.1 and 6.4, but it should not penalize the contract if the contract did not report these two
data elements by 5/31. ]
Terms used are properly defined per CMS regulations, guidance and Reporting Requirements Technical
Specifications.
MSC-4
Review Results:
Organization properly assigns data to the applicable CMS contract.
Appropriate deadlines are met for reporting data (e.g., quarterly).
MSC-3
Data Sources:
Organization reports data based on the required reporting periods of 1/1 through 3/31, 4/1
through 6/30, 7/1 through 9/30, and 10/1 through 12/31.
Data are assigned at the applicable level (e.g., plan benefit package or contract level).
MSC-2
Findings:
"N"
Select "Y" or "N"
from Sections in
White Only
Review Results:
Organization properly defines the term “Organization Determination” in accordance with 42 CFR
§422.566(b) and the Medicare Managed Care Manual Chapter 13, Sections 10.1 and 20.2.
DRAFT – Meets Section 508 Compliance Standards
1
Findings Data Collection Form: Organization Determinations/Reconsiderations (Part C)
2.6 Organization Determinations/Reconsiderations (Part C)
Organization Name:
Contract Number:
Data Measure:
Organization Determinations/Reconsiderations (Part C)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
MSC-7
Standard/Sub-standard Description
Organization properly defines the term “Reconsideration” in accordance
with the Medicare Managed Care Manual Chapter 13, Section 70.
DRAFT – Meets Section 508 Compliance Standards
Data Sources and Review Results:
Enter
review results and/or data sources
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
2
Findings Data Collection Form: Organization Determinations/Reconsiderations (Part C)
2.6 Organization Determinations/Reconsiderations (Part C)
Organization Name:
Contract Number:
Data Measure:
Organization Determinations/Reconsiderations (Part C)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
2.e
MSC-5
Standard/Sub-standard Description
The number of expected counts (e.g., number of members, claims,
Data Element 6.1
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.
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Applicable Measure-Specific Criteria:
MSC-5: Organization accurately calculates the total number of organization
determinations, including the following criteria:
MSC-5a: Includes all organization determinations (Part C only) with a
date of final decision that occurs during the reporting period, regardless
of when the request for organization determination was received.
[Data Elements 6.1 – 6.3]
MSC-5b: Includes all organization determinations that involve services
covered under Medicare only or Medicare and Medicaid.
[Data Elements 6.1 – 6.3]
MSC-5c: Includes all network and non-network organization
determinations made as a result of a request being submitted to the plan
(e.g., does not include a lab test covered during a physician’s office visit). Data Element 6.2
[Data Elements 6.1 – 6.3]
Review Results:
MSC-5d: Includes payment denials that result in zero payment being
made to non-contract providers.
[Data Elements 6.1 – 6.3]
MSC-5e: Includes organization determinations from delegated entities.
[Data Elements 6.1 – 6.3]
MSC-5f: Includes only organization determinations that are filed directly
with the organization or its delegated entities (e.g., excludes all
organization determinations that are only forwarded to the organization
from the CMS Complaint Tracking Module (CTM) and not filed directly
with the organization or delegated entity).
[Data Elements 6.1 – 6.3]
MSC-5g: Includes all methods of organization determination request
receipt (e.g., telephone, letter, fax, in-person).
[Data Elements 6.1 – 6.3]
MSC-5h: Includes all organization determinations regardless of who filed Data Element 6.3
the request (e.g., member or appointed representative).
[Data Elements 6.1 – 6.3]
Review Results:
MSC-5i: Excludes decisions to continue coverage of a service that was
already approved (i.e., includes initial requests only).
[Data Elements 6.1 – 6.3]
MSC-5j: Excludes dismissals or withdrawals.
[Data Elements 6.1 – 6.3]
MSC-5k: Excludes Quality Improvement Organization (QIO) reviews of a
member’s request to continue Medicare-covered services (e.g., a SNF
stay).
[Data Elements 6.1 – 6.3]
DRAFT – Meets Section 508 Compliance Standards
3
Findings Data Collection Form: Organization Determinations/Reconsiderations (Part C)
2.6 Organization Determinations/Reconsiderations (Part C)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Organization Determinations/Reconsiderations (Part C)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
MSC-6
MSC-6a: Properly sorts the total number of organization determinations
by final decision: Fully Favorable (e.g., decisions where the organization
approves coverage or payment, in whole, for the service or item
requested (including requested quantity or number of visits, if
applicable)), Partially Favorable (e.g., denial with a “part” that has been
approved), or Adverse (e.g., denial of entire request).
[Data Elements 6.1 – 6.3]
MSC-8
Data Sources and Review Results:
Enter
review results and/or data sources
Standard/Sub-standard Description
MSC-6: Organization accurately calculates the number of organization
determinations by final decision, including the following criteria:
Data Element 6.4
Review Results:
Data Element 6.5
Review Results:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
MSC-8: Organization accurately calculates the total number of
reconsiderations, including the following criteria:
MSC-8a: Includes all reconsiderations (Part C only) with a date of final
decision that occurs during the reporting period, regardless of when the
request for reconsideration was received.
[Data Elements 6.4 – 6.6]
MSC-8b: Includes all reconsiderations that involve services covered
under Medicare only or Medicare and Medicaid.
[Data Elements 6.4 – 6.6]
MSC-8c: Includes all network and non-network reconsiderations made as
a result of a request being submitted to the plan (e.g., does not include a
lab test covered during a physician’s office visit).
[Data Elements 6.4 – 6.6]
MSC-8d: Includes payment denials that result in zero payment being
made to non-contract providers.
[Data Elements 6.4 – 6.6]
MSC-8e: Includes all reviews of partially favorable and adverse
organization determinations.
[Data Elements 6.4 – 6.6]
MSC-8f: Includes reconsiderations made by or forwarded from delegated
entities.
[Data Elements 6.4 – 6.6]
MSC-8g: Includes all reviews of a member’s request to continue
Medicare-covered services (e.g., if a member misses the QIO’s deadline).
[Data Elements 6.4 – 6.6]
MSC-8h: Excludes dismissals or withdrawals.
[Data Elements 6.4 – 6.6]
MSC-8i: Excludes QIO reviews.
[Data Elements 6.4 – 6.6]
MSC-8j: Includes reconsideration cases forwarded to the Independent
Review Entity (IRE).
[Data Elements 6.4 – 6.6]
MSC-8k: Includes all methods of reconsideration request receipt (e.g.,
telephone, letter, fax, in-person).
[Data Elements 6.4 – 6.6]
DRAFT – Meets Section 508 Compliance Standards
4
Findings Data Collection Form: Organization Determinations/Reconsiderations (Part C)
2.6 Organization Determinations/Reconsiderations (Part C)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Organization Determinations/Reconsiderations (Part C)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Standard/Sub-standard Description
MSC-8l: Includes all reconsiderations regardless of who filed the request
(e.g., member, appointed representative, provider).
[Data Elements 6.4 – 6.6]
Data Element 6.6
Data Sources and Review Results:
Enter
review results and/or data sources
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Review Results:
MSC-8m: Includes only reconsiderations that are filed directly with the
organization or its delegated entities (e.g., excludes all reconsiderations
that are only forwarded to the organization from the CMS Complaint
Tracking Module (CTM) and not filed directly with the organization or
delegated entity).
[Data Elements 6.4 – 6.6]
MSC-9
MSC-9: Organization accurately calculates the number of reconsiderations
by final decision, including the following criteria:
MSC-9a: Properly sorts the total number of reconsiderations by final
decision: Fully Favorable (e.g., decisions where the organization
approves coverage or payment, in whole, for the service or item
requested (including requested quantity or number of visits, if
applicable)); Partially Favorable (e.g., denial with a “part” that has been
approved); or Adverse (e.g., denial of entire request).
[Data Elements 6.4 – 6.6]
3
3.a
Organization implements appropriate policies and procedures for data submission, including the following:
Data elements are accurately entered into the HPMS tool and entries match Data Element 6.1
corresponding source documents.
Review Results:
Data Element 6.2
Review Results:
Data Element 6.3
Review Results:
Data Element 6.4
Review Results:
Data Element 6.5
Review Results:
Data Element 6.6
Review Results:
3.b
Data files are properly uploaded into HPMS according to any HPMS templates provided.
3.c
All source, intermediate, and final stage data sets relied upon to enter data into HPMS are archived.
4
Data Sources:
Organization implements appropriate policies and procedures for periodic data system updates (e.g.,
changes in enrollment, provider/pharmacy status, claims adjustments).
Review Results:
Data Sources:
Review Results:
5
Organization implements appropriate policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).
Data Sources:
Review Results:
6
If organization’s data systems underwent any changes during the reporting period (e.g., as a result of a
merger, acquisition, or upgrade): Organization provided documentation on the data system changes and,
upon review, there were no issues that significantly impacted data reported.
DRAFT – Meets Section 508 Compliance Standards
Data Sources:
Review Results:
5
Findings Data Collection Form: Organization Determinations/Reconsiderations (Part C)
2.6 Organization Determinations/Reconsiderations (Part C)
Organization Name:
Contract Number:
Data Measure:
Organization Determinations/Reconsiderations (Part C)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
7
Standard/Sub-standard Description
If data collection, validation, and/or reporting for this data measure is delegated to another entity:
Organization regularly monitors the quality and timeliness of the data collected, validated, and/or reported
by the delegated entity or first tier/ downstream contractor.
DRAFT – Meets Section 508 Compliance Standards
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Review Results:
6
Findings Data Collection Form: Employer Group Plan Sponsors (Part C)
2.7 Employer Group Plan Sponsors (Part C)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Employer Group Plan Sponsors (Part C)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
1
Standard/Sub-standard Description
A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved data
queries, file layouts, process flows) indicates that all source documents accurately capture required data
fields and are properly documented.
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
1.a
Source documents and output are properly secured so that source documents can be retrieved at any
time to validate the information submitted to CMS via HPMS.
Review Results:
1.b
Source documents create all required data fields for reporting requirements.
Review Results:
1.c
Source documents are error-free (e.g., programming code and spreadsheet formulas have no messages
or warnings indicating errors).
Review Results:
1.d
All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID, rather
than Field1 and maintain the same field name across data sets).
Review Results:
1.e
Data file locations are referenced correctly.
Review Results:
1.f
If used, macros are properly documented.
Review Results:
1.g
Source documents are clearly and adequately documented.
Review Results:
1.h
Titles and footnotes on reports and tables are accurate.
Review Results:
1.i
Version control of source documents is appropriately applied.
Review Results:
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.
2.a
The appropriate date range(s) for the reporting period(s) is captured.
MSC-1
2.b
2.c
2.d
Review Results:
Review Results:
Organization properly assigns data to the applicable CMS contract or plan benefit package.
Appropriate deadlines are met for reporting data (e.g., quarterly).
MSC-3
Data Sources:
Organization reports data based on the required reporting period of 1/1 through 12/31.
Data are assigned at the applicable level (e.g., plan benefit package or contract level).
MSC-2
Findings:
Select "Y" or "N"
from Sections in
White Only
Review Results:
Organization meets deadline for reporting annual data to CMS by 2/28.
Terms used are properly defined per CMS regulations, guidance and Reporting Requirements Technical
Specifications.
DRAFT – Meets Section 508 Compliance Standards
1
Findings Data Collection Form: Employer Group Plan Sponsors (Part C)
2.7 Employer Group Plan Sponsors (Part C)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Employer Group Plan Sponsors (Part C)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
2.e
Standard/Sub-standard Description
Data Element 7.1
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
Data Element 7.2
control of reported data elements is appropriately applied; QA
checks/thresholds are applied to detect outlier or erroneous data prior to
data submission.
Data Sources and Review Results:
Enter
review results and/or data sources
MSC-5
MSC-5: The organization’s “Employer Address” data field accurately reflects Data Element 7.3
the employer’s headquarters address.
[Data Element 7.4].
MSC-6
MSC-6: The organization’s “Organization Type” data field accurately reflects Data Element 7.4
data based on how the organization files its taxes.
[Data Element 7.6]
MSC-7
MSC-7: The organization’s “Type of Contract” data field accurately captures Data Element 7.5
the type of contract that the organization holds with the employer group
that binds it to offer benefits to group retirees.
[Data Element 7.7]
MSC-8
Data Element 7.6
MSC-8: The organization’s “Employer Plan Year Start Date” data field
accurately reflects the month and year in which the employer’s benefit year
begins.
[Data Element 7.8]
Review Results:
MSC-9
MSC-9: The organization accurately calculates the number of currently
enrolled members, including the following criteria:
Data Element 7.7
Review Results:
MSC-9a: Includes all enrollments from a particular employer group into
the specific PBP.
[Data Element 7.9]
Data Element 7.8
Review Results:
MSC-9b: Includes all members that are enrolled in the employer group
plan as of the last day of the reporting period.
[Data Element 7.9]
Data Element 7.9
Review Results:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Review Results:
MSC-9c: Enrollment number for contracts that were cancelled during the
reporting period is reported as zero.
[Data Element 7.9]
3
3.a
Organization implements appropriate policies and procedures for data submission, including the following:
Data Sources:
Data elements are accurately entered into the HPMS tool and entries match corresponding source
documents.
DRAFT – Meets Section 508 Compliance Standards
2
Findings Data Collection Form: Employer Group Plan Sponsors (Part C)
2.7 Employer Group Plan Sponsors (Part C)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Employer Group Plan Sponsors (Part C)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
3.b
MSC-4
Standard/Sub-standard Description
Data files are properly uploaded into HPMS according to any HPMS templates provided.
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Applicable Measure-Specific Criteria:
MSC-4: Organization accurately identifies data on each employer group plan and uploads it into the
HPMS submission tool, including the following criteria:
MSC-4a: Includes the following information for each plan benefit package reported: Employer Legal
Name; Employer DBA Name; Employer Federal Tax ID; Employer Address; Type of Group Sponsor
(employer, union, trustees of a fund); Organization Type (State Government, Local Government,
Publicly Traded Organization, Privately Held Corporation, Non-Profit, Church Group, Other); Type of
Contract (insured, ASO, other); Employer Plan Year Start Date; and Current Enrollment.
[Data Elements 7.1–7.9]
MSC-4b: Follows the specified file format provided by CMS in the Part C Reporting Requirements
Technical Specifications Document (Appendix 6).
[Data Elements 7.1–7.9]
3.c
4
All source, intermediate, and final stage data sets relied upon to enter data into HPMS are archived.
Organization implements appropriate policies and procedures for periodic data system updates (e.g.,
changes in enrollment, provider/pharmacy status, claims adjustments).
Review Results:
Data Sources:
Review Results:
5
Organization implements appropriate policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).
Data Sources:
Review Results:
6
7
If organization’s data systems underwent any changes during the reporting period (e.g., as a result of a
merger, acquisition, or upgrade): Organization provided documentation on the data system changes and,
upon review, there were no issues that significantly impacted data reported.
Data Sources:
If data collection, validation, and/or reporting for this data measure is delegated to another entity:
Organization regularly monitors the quality and timeliness of the data collected, validated, and/or reported
by the delegated entity or first tier/ downstream contractor.
Data Sources:
DRAFT – Meets Section 508 Compliance Standards
Review Results:
Review Results:
3
Findings Data Collection Form: Plan Oversight of Agents (Part C)
2.8 Plan Oversight of Agents (Part C)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Plan Oversight of Agents (Part C)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
1
Standard/Sub-standard Description
A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved data
queries, file layouts, process flows) indicates that all source documents accurately capture required data
fields and are properly documented.
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
1.a
Source documents and output are properly secured so that source documents can be retrieved at any
time to validate the information submitted to CMS via HPMS.
Review Results:
1.b
Source documents create all required data fields for reporting requirements.
Review Results:
1.c
Source documents are error-free (e.g., programming code and spreadsheet formulas have no messages
or warnings indicating errors).
Review Results:
1.d
All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID, rather
than Field1 and maintain the same field name across data sets).
Review Results:
1.e
Data file locations are referenced correctly.
Review Results:
1.f
If used, macros are properly documented.
Review Results:
1.g
Source documents are clearly and adequately documented.
Review Results:
1.h
Titles and footnotes on reports and tables are accurate.
Review Results:
1.i
Version control of source documents is appropriately applied.
Review Results:
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.
2.a
The appropriate date range(s) for the reporting period(s) is captured.
MSC-1
2.b
2.c
2.d
Review Results:
Review Results:
Organization properly assigns data to the applicable CMS contract.
Appropriate deadlines are met for reporting data (e.g., quarterly).
MSC-3
Data Sources:
Organization reports data based on the required reporting period of 1/1 through 12/31.
Data are assigned at the applicable level (e.g., plan benefit package or contract level).
MSC-2
Findings:
Select "Y" or "N"
from Sections in
White Only
Review Results:
Organization meets deadline for reporting annual data to CMS by 2/28.
Terms used are properly defined per CMS regulations, guidance and Reporting Requirements Technical
Specifications.
DRAFT – Meets Section 508 Compliance Standards
1
Findings Data Collection Form: Plan Oversight of Agents (Part C)
2.8 Plan Oversight of Agents (Part C)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Plan Oversight of Agents (Part C)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
2.e
MSC-4
Standard/Sub-standard Description
The number of expected counts (e.g., number of members, claims,
Data Element 12.1
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.
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Applicable Measure-Specific Criteria:
MSC-4: Organization accurately calculates the total number of agents who
are licensed to sell on behalf of the contract during the applicable reporting
period, including the following criteria:
MSC-4a: Includes all direct employees of the organization who are
licensed to sell on behalf of the contract.
[Data Element 12.1]
Data Element 12.2
MSC-4b: Includes all licensed agents who are under a contractual
agreement to sell on behalf of the contract, regardless of whether or not
the agent was actively selling during the reporting period.
[Data Element 12.1]
MSC-5
Review Results:
MSC-5: Organization accurately calculates the number of agents
investigated based on complaints, including the following criteria:
MSC-5a: Includes all investigations that were completed during the
applicable reporting period, regardless of when the complaint was
received.
[Data Element 12.2]
MSC-5b: Includes investigations based on complaints filed directly with
the organization as well as those from the HPMS Complaint Tracking
Module (CTM).
[Data Element 12.2]
MSC-5c: Includes all investigations based on complaints against an agent Data Element 12.3
under the applicable plan contract. If a complaint cannot be tied to a
specific contract, then the complaint is included under all contracts that
the agent is licensed to sell.
[Data Element 12.2]
Review Results:
MSC-5d: The number calculated for Data Element 12.2 is a subset of the
total number of agents calculated for Data Element 12.1.
[Data Element 12.2]
MSC-6
MSC-6: Organization accurately calculates the number of agents receiving
disciplinary action resulting from a complaint filed against an agent,
including the following criteria:
MSC-6a: Includes all disciplinary actions that were taken during the
applicable reporting period, regardless of when the complaint was
received.
[Data Element 12.3]
MSC-6b: Includes any disciplinary action taken by the organization,
including manager-coaching, documented verbal warning, re-training,
documented corrective action plan, suspension, termination of
employment/contract, and short-term revocation.
[Data Element 12.3]
MSC-6c: Includes disciplinary actions based on complaints filed directly
with the organization as well as those from the HPMS Complaint
Tracking Module (CTM).
[Data Element 12.3]
Data Element 12.4
DRAFT – Meets Section 508 Compliance Standards
Review Results:
2
Findings Data Collection Form: Plan Oversight of Agents (Part C)
2.8 Plan Oversight of Agents (Part C)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Plan Oversight of Agents (Part C)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Standard/Sub-standard Description
MSC-6d: Includes all disciplinary actions based on complaints against an
agent under the applicable plan contract. If a complaint cannot be tied
to a specific contract, then the disciplinary action is included under all
contracts that the agent is licensed to sell.
[Data Element 12.3]
Data Sources and Review Results:
Enter
review results and/or data sources
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
MSC-6e: The number calculated for Data Element 12.3 is a subset of the
total number of agents calculated for Data Element 12.1.
[Data Element 12.3]
MSC-7
MSC-7: Organization accurately calculates the number of complaints filed
against an agent that the organization reported to the governing State,
including the following criteria [Note to reviewer : If organization does not
voluntarily report complaints against a contracted agent to the State, then it
is appropriate to report a zero for this data element.]:
MSC-7a: Includes all complaints against a contracted agent received and Data Element 12.5
reported to the State during the applicable reporting period.
[Data Element 12.4]
Review Results:
MSC-7b: Includes only complaints that are filed directly with the
organization (e.g., excludes all complaints that are only forwarded to the
organization from the CMS Complaint Tracking Module (CTM) and not
filed directly with the organization).
[Data Element 12.4]
MSC-7c: Includes all complaints against an agent and reported to the
governing State under the applicable plan contract. If a complaint that is
reported to the governing State cannot be tied to a specific contract,
then the complaint is included under all contracts that the agent is
licensed to sell.
[Data Element 12.4]
MSC-8
MSC-8: Organization accurately calculates the number of agents whose
selling privileges were revoked by the organization based on conduct or
discipline, including the following criteria:
[Data Element 12.5]
MSC-8a: Includes all revocations initiated during the applicable reporting
period, regardless of when the conduct causing the revocation occurred.
[Data Element 12.5]
MSC-8b: The number calculated for Data Element 12.5 is a subset of the Data Element 12.6
total number of agents calculated for Data Element 12.1.
[Data Element 12.5]
MSC-9
Review Results:
MSC-9: Organization accurately calculates the number of “agent assisted
enrollments” during the applicable reporting period, including the following
criteria:
MSC-9a: Includes all agent assisted enrollments that became effective
during the reporting period.
[Data Element 12.6]
MSC-9b: Defines “agent assisted enrollments” as enrollments where the
member used a licensed agent that is compensated (employee or
independent) to complete the enrollment process (e.g., includes
enrollments completed through a call center staffed by licensed agents,
in person sales appointments, and public sales meetings where a
licensed agent collects enrollment forms).
[Data Element 12.6]
DRAFT – Meets Section 508 Compliance Standards
3
Findings Data Collection Form: Plan Oversight of Agents (Part C)
2.8 Plan Oversight of Agents (Part C)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Plan Oversight of Agents (Part C)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Data Sources and Review Results:
Enter
review results and/or data sources
Standard/Sub-standard Description
MSC-9c: Includes agent assisted enrollments from both the individual
and group enrollment process.
[Data Element 12.6]
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
MSC-9d: Includes enrollments that are as a direct result of the
participation of the group of agents reported in Data Element 12.1.
[Data Element 12.6]
3
3.a
Organization implements appropriate policies and procedures for data submission, including the following:
Data elements are accurately entered into the HPMS tool and entries match Data Element 12.1
corresponding source documents.
Review Results:
Data Element 12.2
Review Results:
Data Element 12.3
Review Results:
Data Element 12.4
Review Results:
Data Element 12.5
Review Results:
Data Element 12.6
Review Results:
3.b
Data files are properly uploaded into HPMS according to any HPMS templates provided.
3.c
All source, intermediate, and final stage data sets relied upon to enter data into HPMS are archived.
4
Data Sources:
Organization implements appropriate policies and procedures for periodic data system updates (e.g.,
changes in enrollment, provider/pharmacy status, claims adjustments).
Review Results:
Data Sources:
Review Results:
5
Organization implements appropriate policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).
Data Sources:
Review Results:
6
7
If organization’s data systems underwent any changes during the reporting period (e.g., as a result of a
merger, acquisition, or upgrade): Organization provided documentation on the data system changes and,
upon review, there were no issues that significantly impacted data reported.
Data Sources:
If data collection, validation, and/or reporting for this data measure is delegated to another entity:
Organization regularly monitors the quality and timeliness of the data collected, validated, and/or reported
by the delegated entity or first tier/ downstream contractor.
Data Sources:
DRAFT – Meets Section 508 Compliance Standards
Review Results:
Review Results:
4
Findings Data Collection Form: Special Needs Plans (SNPs) Care Management
2.9 Special Needs Plans (SNPs) Care Management
Organization Name:
Contract Number:
Data Measure:
Special Needs Plans (SNPs) Care Management
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
1
Standard/Sub-standard Description
A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved data
queries, file layouts, process flows) indicates that all source documents accurately capture required data
fields and are properly documented.
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
1.a
Source documents and output are properly secured so that source documents can be retrieved at any
time to validate the information submitted to CMS via HPMS.
Review Results:
1.b
Source documents create all required data fields for reporting requirements.
Review Results:
1.c
Source documents are error-free (e.g., programming code and spreadsheet formulas have no messages
or warnings indicating errors).
Review Results:
1.d
All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID, rather
than Field1 and maintain the same field name across data sets).
Review Results:
1.e
Data file locations are referenced correctly.
Review Results:
1.f
If used, macros are properly documented.
Review Results:
1.g
Source documents are clearly and adequately documented.
Review Results:
1.h
Titles and footnotes on reports and tables are accurate.
Review Results:
1.i
Version control of source documents is appropriately applied.
Review Results:
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.
2.a
The appropriate date range(s) for the reporting period(s) is captured.
MSC-1
2.b
2.c
2.d
Review Results:
Review Results:
Organization properly assigns data to the applicable CMS contract and plan benefit package.
Appropriate deadlines are met for reporting data (e.g., quarterly).
MSC-3
Data Sources:
Organization reports data based on the required reporting period of 1/1 through 12/31.
Data are assigned at the applicable level (e.g., plan benefit package or contract level).
MSC-2
Findings:
Select "Y" or "N"
from Sections in
White Only
Review Results:
Organization meets deadline for reporting annual data to CMS by 5/31.
Terms used are properly defined per CMS regulations, guidance and Reporting Requirements Technical
Specifications.
DRAFT – Meets Section 508 Compliance Standards
1
Findings Data Collection Form: Special Needs Plans (SNPs) Care Management
2.9 Special Needs Plans (SNPs) Care Management
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Special Needs Plans (SNPs) Care Management
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
2.e
MSC-4
Standard/Sub-standard Description
The number of expected counts (e.g., number of members, claims,
Data Element 13.1
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.
Applicable Measure-Specific Criteria:
MSC-4: Organization accurately calculates the number of new members,
including the following criteria:
MSC-4a: Includes all members whose effective date of enrollment
occurred during the reporting period.
[Data Element 13.1]
MSC-5
MSC-6
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Data Element 13.2
Review Results:
MSC-6: Organization accurately calculates the number of initial assessments Data Element 13.3
performed on new members, including the following criteria [Note to
reviewer : CMS has not identified a standard tool that SNPs must use to
complete initial and annual health risk assessments. The information will
not be captured by designated CPT or ICD-9 Procedure codes. Reviewer
should confirm that the SNP maintained documentation for each reported
assessment. ]:
Review Results:
MSC-5: Organization accurately calculates the number of existing members
who were eligible for a reassessment during the reporting period.
[Data Element 13.2]
MSC-6a: Includes all initial assessments that were completed with a date
of service that occurs within the reporting period.
[Data Element 13.3]
MSC-6b: The number of initial assessments calculated for Data Element
13.3 is a subset of number of new members calculated for Data Element
13.1.
[Data Element 13.3]
MSC-7
MSC-7: Organization accurately calculates the number of annual
Data Element 13.4
reassessments performed on members eligible for a reassessment,
including the following criteria [Note to reviewer : CMS has not identified a
standard tool that SNPs must use to complete initial and annual health risk
assessments. The information will not be captured by designated CPT or
ICD-9 Procedure codes. Reviewer should confirm that the SNP maintained
documentation for each reported assessment. ]:
DRAFT – Meets Section 508 Compliance Standards
Review Results:
2
Findings Data Collection Form: Special Needs Plans (SNPs) Care Management
2.9 Special Needs Plans (SNPs) Care Management
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Special Needs Plans (SNPs) Care Management
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Data Sources and Review Results:
Enter
review results and/or data sources
Standard/Sub-standard Description
MSC-7a: Includes all annual reassessments that were completed with a
date of service that occurs within the reporting period.
[Data Element 13.4]
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
MSC-7b: The number of annual reassessments calculated for Data
Element 13.4 is a subset of number of eligible members calculated for
Data Element 13.2.
[Data Element 13.4]
3
3.a
Organization implements appropriate policies and procedures for data submission, including the following:
Data elements are accurately entered into the HPMS tool and entries match Data Element 13.1
corresponding source documents.
Review Results:
Data Element 13.2
Review Results:
Data Element 13.3
Review Results:
Data Element 13.4
Review Results:
3.b
Data files are properly uploaded into HPMS according to any HPMS templates provided.
3.c
All source, intermediate, and final stage data sets relied upon to enter data into HPMS are archived.
4
Data Sources:
Organization implements appropriate policies and procedures for periodic data system updates (e.g.,
changes in enrollment, provider/pharmacy status, claims adjustments).
Review Results:
Data Sources:
Review Results:
5
Organization implements appropriate policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).
Data Sources:
Review Results:
6
7
If organization’s data systems underwent any changes during the reporting period (e.g., as a result of a
merger, acquisition, or upgrade): Organization provided documentation on the data system changes and,
upon review, there were no issues that significantly impacted data reported.
Data Sources:
If data collection, validation, and/or reporting for this data measure is delegated to another entity:
Organization regularly monitors the quality and timeliness of the data collected, validated, and/or reported
by the delegated entity or first tier/ downstream contractor.
Data Sources:
DRAFT – Meets Section 508 Compliance Standards
Review Results:
Review Results:
3
Findings Data Collection Form: Retail, Home Infusion, and Long Term Care Pharmacy Accesss (Part D)
3.1 Retail, Home Infusion, and Long Term Care Pharmacy Accesss (Part D)
Organization Name:
Contract Number:
Data Measure:
Retail, Home Infusion, and Long Term Care Pharmacy Accesss (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
1
Standard/Sub-standard Description
A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved data
queries, file layouts, process flows) indicates that all source documents accurately capture required data
fields and are properly documented.
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
1.a
Source documents and output are properly secured so that source documents can be retrieved at any
time to validate the information submitted to CMS via HPMS.
Review Results:
1.b
Source documents create all required data fields for reporting requirements.
Review Results:
1.c
Source documents are error-free (e.g., programming code and spreadsheet formulas have no messages
or warnings indicating errors).
Review Results:
1.d
All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID, rather
than Field1 and maintain the same field name across data sets).
Review Results:
1.e
Data file locations are referenced correctly.
Review Results:
1.f
If used, macros are properly documented.
Review Results:
1.g
Source documents are clearly and adequately documented.
Review Results:
1.h
Titles and footnotes on reports and tables are accurate.
Review Results:
1.i
Version control of source documents is appropriately applied.
Review Results:
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.
2.a
The appropriate date range(s) for the reporting period(s) is captured.
MSC-1
2.b
Data Sources:
Review Results:
Organization reports data based on the required reporting periods of 1/1 through 3/31 (Data
Elements A and B) and 1/1 through 12/31 (Data Elements C and D) [Note to reviewer : All
criteria that reference Data Element C are applicable only to contracts that own and operate
their own pharmacies and received a CMS waiver of the any willing pharmacy requirement for
the reporting period. All criteria that reference Data Element D are applicable only to
contracts that own and operate their own retail pharmacies and received a CMS waiver of the
retail pharmacy convenient access standards for the reporting period.]
Data are assigned at the applicable level (e.g., plan benefit package or contract level).
MSC-2
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Review Results:
Organization properly assigns data to the applicable CMS contract number (Data Elements A
and B) and plan benefit package (Data Elements C and D) [Note to reviewer : All criteria that
reference Data Element C are applicable only to contracts that own and operate their own
pharmacies and received a CMS waiver of the any willing pharmacy requirement for the
reporting period. All criteria that reference Data Element D are applicable only to contracts
that own and operate their own retail pharmacies and received a CMS waiver of the retail
pharmacy convenient access standards for the reporting period.]
DRAFT – Meets Section 508 Compliance Standards
1
Findings Data Collection Form: Retail, Home Infusion, and Long Term Care Pharmacy Accesss (Part D)
3.1 Retail, Home Infusion, and Long Term Care Pharmacy Accesss (Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Retail, Home Infusion, and Long Term Care Pharmacy Accesss (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
2.c
MSC-3
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Standard/Sub-standard Description
Appropriate deadlines are met for reporting data (e.g., quarterly).
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Organization meets deadlines for reporting data to CMS by 5/31 (Data Elements A and B) and
by 2/28 (Data Elements C and D) [Note to reviewer : All criteria that reference Data Element C
are applicable only to contracts that own and operate their own pharmacies and received a
CMS waiver of the any willing pharmacy requirement for the reporting period. All criteria that
reference Data Element D are applicable only to contracts that own and operate their own
retail pharmacies and received a CMS waiver of the retail pharmacy convenient access
standards for the reporting period.]
2.d
Terms used are properly defined per CMS regulations, guidance and Reporting Requirements Technical
Specifications.
2.e
Data Element A1
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.
Review Results:
Applicable Measure-Specific Criteria:
MSC-5
MSC-5: Organization accurately calculates retail pharmacy access
percentages, including the following criteria:
MSC-5a: Uses either the Quest Analytics Suite™ or GeoNetworks®
software or another alternative method that has been approved by CMS
to calculate the ratios.
[Data Elements A1-A3]
Data Element A2
Review Results:
MSC-5f: Calculates the ratios by service area for local MA-PDs, Employer Data Element A3
Group “800 Series Only” contracts, Employer/Union Direct contracts, and
Part D sponsors that offer both individual plans and “800 series” plans.
[Data Element A1-A3]
Review Results:
MSC-5b: Uses the CMS reference file that provides counts of Medicare
beneficiaries by state, region, and zip code for the appropriate year.
[Data Elements A1-A3]
MSC-5c: Bases the calculated ratios on the “total Medicare beneficiary
count” and not plan member counts.
[Data Elements A1-A3]
MSC-5d: Bases the calculated ratios on pharmacies that are contracted in
the network as of the last day of the reporting period.
[Data Elements A1-A3]
MSC-5e: Calculates the ratios by state for PDPs and RPPOs.
[Data Elements A1-A3]
MSC-6
MSC-6: Organization accurately calculates the number of contracted retail
pharmacies in the contract’s service area, including the following criteria:
MSC-6a: Includes only pharmacies that are contracted in the network as
of the last day of the reporting period.
[Data Element A4]
DRAFT – Meets Section 508 Compliance Standards
2
Findings Data Collection Form: Retail, Home Infusion, and Long Term Care Pharmacy Accesss (Part D)
3.1 Retail, Home Infusion, and Long Term Care Pharmacy Accesss (Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Retail, Home Infusion, and Long Term Care Pharmacy Accesss (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
MSC-6c: Includes the number of contracted retail pharmacies by state
for PDPs and RPPOs, and by service area for local MA-PDs.
[Data Elements A4]
MSC-7
Data Sources and Review Results:
Enter
review results and/or data sources
Standard/Sub-standard Description
MSC-6b: Includes only retail pharmacies.
[Data Element A4]
Data Element A4
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Review Results:
MSC-7: Organization accurately calculates data for each home infusion
network pharmacy and uploads it into the HPMS submission tool, including
the following criteria:
MSC-7a: Includes only pharmacies that are contracted in the network as
of the last day of the reporting period.
[Data Element B1]
MSC-7b: Includes only home infusion pharmacies.
[Data Element B1]
MSC-7c: For the States_Licensed field, includes all states in the contract’s
service area [Note to reviewer: A contract with both individual
contracts in particular states and 800 series plans with national coverage Data Element B1
will be required to report data only for the states in the individual
contract’s service area. If a contract only includes 800 series plans, it will
be required to report data for all states.]
[Data Element B1]
MSC-8
Review Results:
MSC-8: Organization accurately calculates data for each long-term care
(LTC) pharmacy and uploads it into the HPMS submission tool, including the
following criteria:
MSC-8a: Includes only pharmacies that are contracted in the network as
of the last day of the reporting period.
[Data Element B2]
Data Element B2
Review Results:
MSC-8b: Includes only long-term care pharmacies.
[Data Element B2]
MSC-8c: For the States_Licensed field, includes all states in the
contract’s service area. [Note to reviewer : A contract with both
individual contracts in particular states and 800 series plans with national
coverage will be required to report data only for the states in the
individual contract’s service area. If a contract only includes 800 series
plans, it will be required to report data for all states.]
[Data Element B2]
MSC-9
Data Element C1
MSC-9: Organization accurately calculates the number of prescriptions
provided, including the following criteria [Note to reviewer : All criteria that
reference Data Element C are applicable only to contracts that own and
operate their own pharmacies and received a CMS waiver of the any willing
pharmacy requirement for the reporting period.]:
DRAFT – Meets Section 508 Compliance Standards
Review Results:
3
Findings Data Collection Form: Retail, Home Infusion, and Long Term Care Pharmacy Accesss (Part D)
3.1 Retail, Home Infusion, and Long Term Care Pharmacy Accesss (Part D)
Organization Name:
Contract Number:
Data Measure:
Retail, Home Infusion, and Long Term Care Pharmacy Accesss (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Standard/Sub-standard Description
MSC-9a: For Data Element C1: Includes only pharmacy claims with dates
of service within the reporting period that are identified as provided by a
pharmacy that is owned and operated by the plan.
[Data Element C1]
MSC-9b: For Data Element C2: Includes all pharmacy claims with dates of
service within the reporting period. [Note to reviewer : All criteria that
reference Data Element C are applicable only to contracts that own and
operate their own pharmacies and received a CMS waiver of the any
willing pharmacy requirement for the reporting period.]
Data Element C2
[Data Element C2]
Data Sources and Review Results:
Enter
review results and/or data sources
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Review Results:
MSC-9c: Number calculated for Data Element C1 is a subset of the
number of prescriptions provided at all pharmacies calculated for Data
Element C2 [Note to reviewer : All criteria that reference Data Elements
C1-C2 are applicable only to contracts that own and operate their own
pharmacies and received a CMS waiver of the any willing pharmacy
requirement for the reporting period.]
[Data Element C1]
MSC-10
MSC-10: Organization accurately calculates the number of prescriptions
provided by retail pharmacies, including the following criteria:
Data Element D1
MSC-10a: For Data Element D1: Includes only pharmacy claims with
dates of service within the reporting period that are identified as
provided by a retail pharmacy that is owned and operated by the plan
[Note to reviewer : All criteria that reference Data Elements D1-D2 are
applicable only to contracts that own and operate their own pharmacies
and received a CMS waiver of the retail pharmacy convenient access
standards for the reporting period.]
[Data Element D1]
Review Results:
MSC-10b:For Data Element D2: Includes all retail pharmacy claims with
dates of service within the reporting period.
[Note to reviewer : All criteria that reference Data Elements D1-D2 are
applicable only to contracts that own and operate their own pharmacies
and received a CMS waiver of the retail pharmacy convenient access
standards for the reporting period.]
[Data Element D2]
Data Element D2
MSC-10c: Number calculated for Data Element D1 is a subset of the
number of prescriptions provided at all retail pharmacies calculated for
Data Element D2 [Note to reviewer : All criteria that reference Data
Elements D1-D2 are applicable only to contracts that own and operate
their own pharmacies and received a CMS waiver of the retail pharmacy
convenient access standards for the reporting period.]
[Data Element D2]
3
Organization implements appropriate policies and procedures for data submission, including the following:
DRAFT – Meets Section 508 Compliance Standards
Review Results:
Data Sources:
4
Findings Data Collection Form: Retail, Home Infusion, and Long Term Care Pharmacy Accesss (Part D)
3.1 Retail, Home Infusion, and Long Term Care Pharmacy Accesss (Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Retail, Home Infusion, and Long Term Care Pharmacy Accesss (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
3.a
Standard/Sub-standard Description
Data elements are accurately entered into the HPMS tool and entries match Data Element A1
corresponding source documents.
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Data Element A2
Review Results:
Data Element A3
Review Results:
Data Element A4
Review Results:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Data Element B1
Data Element B2
3.b
Data Element C1
Review Results:
Data Element C2
Review Results:
Data Element D1
Review Results:
Data Element D2
Review Results:
Data files are properly uploaded into HPMS according to any HPMS templates provided.
Review Results:
Applicable Measure-Specific Criteria:
MSC-7
MSC-7: Organization accurately calculates data for each home infusion network pharmacy and uploads
it into the HPMS submission tool, including the following criteria:
MSC-7d: Follows the specified file format provided by CMS in the Part D Reporting Requirements
Technical Specifications Document.
[Data Element B1]
MSC-8
MSC-8: Organization accurately calculates data for each long-term care (LTC) pharmacy and uploads it
into the HPMS submission tool, including the following criteria:
MSC-8d: Follows the specified file format provided by CMS in the Part D Reporting Requirements
Technical Specifications Document.
[Data Element B2]
3.c
All source, intermediate, and final stage data sets relied upon to enter data into HPMS are archived.
MSC-4
4
Review Results:
Applicable Measure-Specific Criteria:
MSC-4: Organization maintains appropriate documentation to support submitted pharmacy access data
elements (e.g., Geo-Access reports).
Organization implements appropriate policies and procedures for periodic data system updates (e.g.,
changes in enrollment, provider/pharmacy status, claims adjustments).
Data Sources:
Review Results:
5
Organization implements appropriate policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).
Data Sources:
Review Results:
6
7
If organization’s data systems underwent any changes during the reporting period (e.g., as a result of a
merger, acquisition, or upgrade): Organization provided documentation on the data system changes and,
upon review, there were no issues that significantly impacted data reported.
Data Sources:
If data collection, validation, and/or reporting for this data measure is delegated to another entity:
Organization regularly monitors the quality and timeliness of the data collected, validated, and/or reported
by the delegated entity or first tier/ downstream contractor.
Data Sources:
DRAFT – Meets Section 508 Compliance Standards
Review Results:
Review Results:
5
Findings Data Collection Form: Medication Therapy Management Programs (Part D)
3.2 Medication Therapy Management Programs (Part D)
Organization Name:
Contract Number:
Data Measure:
Medication Therapy Management Programs (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
1
Standard/Sub-standard Description
A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved data
queries, file layouts, process flows) indicates that all source documents accurately capture required data
fields and are properly documented.
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
1.a
Source documents and output are properly secured so that source documents can be retrieved at any
time to validate the information submitted to CMS via HPMS.
Review Results:
1.b
Source documents create all required data fields for reporting requirements.
Review Results:
1.c
Source documents are error-free (e.g., programming code and spreadsheet formulas have no messages
or warnings indicating errors).
Review Results:
1.d
All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID, rather
than Field1 and maintain the same field name across data sets).
Review Results:
1.e
Data file locations are referenced correctly.
Review Results:
1.f
If used, macros are properly documented.
Review Results:
1.g
Source documents are clearly and adequately documented.
Review Results:
1.h
Titles and footnotes on reports and tables are accurate.
Review Results:
1.i
Version control of source documents is appropriately applied.
Review Results:
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.
2.a
The appropriate date range(s) for the reporting period(s) is captured.
MSC-1
2.b
2.c
2.d
Review Results:
Review Results:
Organization properly assigns data to the applicable CMS contract.
Appropriate deadlines are met for reporting data (e.g., quarterly).
MSC-3
Data Sources:
Organization reports data based on the required reporting period of 1/1 through 12/31.
Data are assigned at the applicable level (e.g., plan benefit package or contract level).
MSC-2
Findings:
Select "Y" or "N"
from Sections in
White Only
Review Results:
Organization meets deadline for reporting annual data to CMS by 2/28.
Terms used are properly defined per CMS regulations, guidance and Reporting Requirements Technical
Specifications.
DRAFT – Meets Section 508 Compliance Standards
1
Findings Data Collection Form: Medication Therapy Management Programs (Part D)
3.2 Medication Therapy Management Programs (Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Medication Therapy Management Programs (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
2.e
MSC-4
Standard/Sub-standard Description
The number of expected counts (e.g., number of members, claims,
Data Element A
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.
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Applicable Measure-Specific Criteria:
MSC-4: Organization accurately calculates the number of members
identified to be eligible and auto-enrolled in the MTMP, including the
following criteria:
MSC-4a: Properly identifies members who met the eligibility criteria
during the reporting period.
[Data Element A]
Data Element B
Review Results:
MSC-4b: Includes continuing MTMP members as well as members who
were newly identified and auto-enrolled in the MTMP at any time during
the reporting period.
[Data Element A]
MSC-5
MSC-5: Organization accurately calculates the number of members who
opted-out of enrollment in the MTMP, including:
MSC-5a: Properly identifies members with a date of MTMP opt-out that
occurs within the reporting period.
[Data Element B]
MSC-5b: The number calculated for Data Element B is a subset of the
number of members identified as eligible for and auto-enrolled in MTMP
calculated for Data Element A.
Data Element C
[Data Element B]
MSC-6
Review Results:
MSC-6: Organization accurately calculates the number of members who
opted-out of MTMP enrollment by reason for opt-out, including the
following criteria:
MSC-6a: Properly sorts the total number of members who opted-out of
MTMP by each of the following opt-out reasons: death, disenrollment,
request by member, other reason.
[Data Elements C-F]
MSC-6b: Each number calculated for Data Elements C through F is a
subset of the total number of members who opted out of MTMP
enrollment calculated for Data Element B.
[Data Elements C-F]
MSC-6c: The sum of the numbers calculated for Data Elements C
through F is equal to the total number of members who opted out of
MTMP enrollment calculated for Data Element B.
[Data Elements C-F]
MSC-7
Data Element D
Review Results:
Data Element E
Review Results:
MSC-7: Organization accurately calculates the total prescription cost of all
covered Part D medications on a per MTMP member per month basis,
including the following criteria:
MSC-7a: Rounding the currency value to the nearest dollar.
[Data Element G]
MSC-7b: The numerator is the sum of gross drug cost, which equals
Ingredient Cost Paid + Dispensing Fee + Sales Tax
[Data Element G]
MSC-7c: The numerator includes the costs of covered Part D
prescriptions dispensed in the reporting period.
[Data Element G]
DRAFT – Meets Section 508 Compliance Standards
2
Findings Data Collection Form: Medication Therapy Management Programs (Part D)
3.2 Medication Therapy Management Programs (Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Medication Therapy Management Programs (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Data Sources and Review Results:
Enter
review results and/or data sources
Standard/Sub-standard Description
MSC-7d: The numerator includes both MTMP member cost sharing and
Part D paid costs.
[Data Element G]
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
MSC-7e: The denominator is the total number of member months the
member was enrolled in the Part D contract during the reporting period,
not only the months the member was enrolled in the MTMP.
[Data Element G]
MSC-8
MSC-8: Organization accurately calculates the number of covered Part D
prescriptions on a per MTMP member per month basis to a 30-day
equivalent, including the following criteria:
Data Element F
Review Results:
MSC-9: Organization accurately calculates the number of MTMP members Data Element G
offered a comprehensive medication review, including the following criteria:
Review Results:
MSC-8a: The numerator is the sum of the days supply of all covered Part
D prescriptions dispensed for all members enrolled in MTMP as of the
last day of the reporting period divided by 30.
[Data Element H]
MSC-8b: The denominator is the total number of member months the
member was enrolled in the Part D contract during the reporting period,
not only the months the member was enrolled in MTMP.
[Data Element H]
MSC-9
MSC-9a: Includes all MTMP members with a date of offer of a
comprehensive medication review that occurs within the reporting
period.
[Data Element I]
MSC-9b: The number calculated for Data Element I should be a subset of
the number of members identified to be eligible and auto-enrolled in the
MTMP calculated for Data Element A.
[Data Element I]
MSC-10
MSC-10: Organization correctly calculates the number of MTMP members
who received a comprehensive medication review, including the following
criteria:
Data Element H
Review Results:
Data Element I
Review Results:
MSC-10a: Includes all MTMP members with a comprehensive medication
review with date of service that occurs within the reporting period.
[Data Element J]
MSC-10b: The number calculated for Data Element J should be a subset
of the number of members offered a comprehensive medication review
calculated for Data Element I.
[Data Element J]
MSC-11
MSC-11: Organization accurately identifies data on MTMP participation for
each member identified as being eligible for the MTMP and uploads it into
the HPMS submission tool, including the following criteria:
MSC-11a: Each of the data elements requested in Section II is based on
the same members counted for Data Element A.
MSC-11b: For Section II (g): Properly identifies whether each member
was a resident in a long-term care facility for the entire time s/he was
enrolled in the MTMP or on the date the member opted-out of MTMP
enrollment.
DRAFT – Meets Section 508 Compliance Standards
3
Findings Data Collection Form: Medication Therapy Management Programs (Part D)
3.2 Medication Therapy Management Programs (Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Medication Therapy Management Programs (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Data Sources and Review Results:
Enter
review results and/or data sources
Standard/Sub-standard Description
MSC-11c: For Section II (i): The date of MTMP opt-out, if applicable, is
completed for the same members counted for Data Element B.
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
MSC-11d: For Section II (j): The reason participant opted-out of the
MTMP is completed for every member with a date of opt-out completed,
and is completed for the same members counted for Data Elements C
through F.
MSC-12
MSC-12: Organization accurately calculates data on MTMP interventions for Data Element J
each member identified as being eligible for the MTMP and uploads it into
the HPMS submission tool, including the following criteria:
Review Results:
MSC-12a: For Section II (k): Properly identifies whether each member
received a comprehensive medication review during the reporting
period, and completes this field for the same members counted for Data
Element J.
MSC-12b: For Section II (l): The date of comprehensive medication
review, if applicable, occurs within the reporting period, is completed for
every member with a “Y” entered for Section II (k).
MSC-12c: For Section II (m): Includes all targeted medication reviews
within the reporting period for each applicable member.
MSC-12d: For Section II (n): Includes all prescriber interventions within
the reporting period for each applicable member.
Section II
MSC-12e: For Section II (o): Includes all changes to drug therapy made
as a result of MTMP interventions within the reporting period for each
applicable member (includes dosage changes, therapeutic or generic
substitutions, and discontinuation of therapy).
3
3.a
3.b
Organization implements appropriate policies and procedures for data submission, including the following:
Data Sources:
Data elements are accurately entered into the HPMS tool and entries match Data Element A
corresponding source documents.
Review Results:
Data Element B
Review Results:
Data Element C
Review Results:
Data Element D
Review Results:
Data Element E
Review Results:
Data Element F
Review Results:
Data Element G
Review Results:
Data Element H
Review Results:
Data Element I
Review Results:
Data Element J
Review Results:
Data files are properly uploaded into HPMS according to any HPMS templates provided.
DRAFT – Meets Section 508 Compliance Standards
Review Results:
4
Findings Data Collection Form: Medication Therapy Management Programs (Part D)
3.2 Medication Therapy Management Programs (Part D)
Organization Name:
Contract Number:
Data Measure:
Medication Therapy Management Programs (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
3.c
4
Standard/Sub-standard Description
All source, intermediate, and final stage data sets relied upon to enter data into HPMS are archived.
Organization implements appropriate policies and procedures for periodic data system updates (e.g.,
changes in enrollment, provider/pharmacy status, claims adjustments).
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Data Sources:
Review Results:
5
Organization implements appropriate policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).
Data Sources:
Review Results:
6
7
If organization’s data systems underwent any changes during the reporting period (e.g., as a result of a
merger, acquisition, or upgrade): Organization provided documentation on the data system changes and,
upon review, there were no issues that significantly impacted data reported.
Data Sources:
If data collection, validation, and/or reporting for this data measure is delegated to another entity:
Organization regularly monitors the quality and timeliness of the data collected, validated, and/or reported
by the delegated entity or first tier/ downstream contractor.
Data Sources:
DRAFT – Meets Section 508 Compliance Standards
Review Results:
Review Results:
5
Findings Data Collection Form: Grievances (Part D)
3.3 Grievances (Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Grievances (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
1
Standard/Sub-standard Description
A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved data
queries, file layouts, process flows) indicates that all source documents accurately capture required data
fields and are properly documented.
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
1.a
Source documents and output are properly secured so that source documents can be retrieved at any
time to validate the information submitted to CMS via HPMS.
Review Results:
1.b
Source documents create all required data fields for reporting requirements.
Review Results:
1.c
Source documents are error-free (e.g., programming code and spreadsheet formulas have no messages
or warnings indicating errors).
Review Results:
1.d
All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID, rather
than Field1 and maintain the same field name across data sets).
Review Results:
1.e
Data file locations are referenced correctly.
Review Results:
1.f
If used, macros are properly documented.
Review Results:
1.g
Source documents are clearly and adequately documented.
Review Results:
1.h
Titles and footnotes on reports and tables are accurate.
Review Results:
1.i
Version control of source documents is appropriately applied.
Review Results:
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.
2.a
The appropriate date range(s) for the reporting period(s) is captured.
MSC-1
2.b
2.c
2.d
Review Results:
Review Results:
Organization meets deadlines for reporting quarterly data to CMS by 5/15, 8/15, 11/15, and
2/15.
Terms used are properly defined per CMS regulations, guidance and Reporting Requirements Technical
Specifications.
MSC-4
Review Results:
Organization properly assigns data to the applicable CMS contract and plan benefit package.
Appropriate deadlines are met for reporting data (e.g., quarterly).
MSC-3
Data Sources:
Organization reports data based on the required reporting periods of 1/1 through 3/31, 4/1
through 6/30, 7/1 through 9/30, and 10/1 through 12/31.
Data are assigned at the applicable level (e.g., plan benefit package or contract level).
MSC-2
Findings:
"N"
Select "Y" or "N"
from Sections in
White Only
Review Results:
Organization properly defines the term “Grievance” in accordance with 42 CFR §423.564 and
the Prescription Drug Benefit Manual Chapter 18, Sections 10.1 and 20.2. Requests for
coverage determinations, exceptions, or redeterminations are not categorized as grievances.
DRAFT – Meets Section 508 Compliance Standards
1
Findings Data Collection Form: Grievances (Part D)
3.3 Grievances (Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Grievances (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
2.e
MSC-5
Standard/Sub-standard Description
The number of expected counts (e.g., number of members, claims, grievances, Data Element A
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.
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
MSC-5: Organization accurately calculates the number of members who filed a
grievance, including the following criteria:
MSC-5a: Includes all members who filed a grievance with a date of receipt that
occurs during the reporting period.
[Data Elements A-B]
MSC-5b: Properly sorts by member’s low-income subsidy (LIS) eligibility status
as of the date the quarterly Part D grievance data is reported to CMS.
[Data Elements A-B]
MSC-6
MSC-6: Organization accurately calculates the total number of grievances,
including the following criteria:
MSC-6a: Includes all grievances that were received during the reporting period,
regardless of when the grievance was completed (i.e., organization notified
member of its decision).
Data Element B
[Data Elements C-D]
Review Results:
MSC-6b: If a grievance contains multiple issues filed by a single complainant,
each issue is calculated as a separate grievance.
[Data Elements C-D]
MSC-6c: If a beneficiary files a grievance and then files a subsequent grievance
on the same issue prior to the organization’s decision or deadline for decision
notification (whichever is earlier), then the issue is counted as one grievance.
[Data Elements C-D]
MSC-6d: If a beneficiary files a grievance and then files a subsequent grievance
on the same issue after the organization’s decision or deadline for decision
notification (whichever is earlier), then the issue is counted as a separate
grievance.
[Data Elements C-D]
MSC-6e: Includes all methods of grievance receipt (e.g., telephone, letter, fax,
in-person).
[Data Elements C-D]
MSC-6f: Includes all grievances regardless of who filed the grievance (e.g.,
member or appointed representative).
[Data Elements C-D]
Data Element C
Review Results:
MSC-6g: Includes only grievances that are filed directly with the organization
(e.g., excludes all complaints that are received by 1-800 Medicare or are only
forwarded to the organization from the CMS Complaint Tracking Module (CTM)
and not filed directly with the organization).
[Data Elements C-D]
MSC-6h: For MA-PD contracts : Includes only grievances that apply to the Part
D benefit. If a clear distinction cannot be made for an MA-PD, cases are
calculated as Part C grievances.
[Data Elements C-D]
DRAFT – Meets Section 508 Compliance Standards
2
Findings Data Collection Form: Grievances (Part D)
3.3 Grievances (Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Grievances (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
MSC-7
MSC-8
Data Sources and Review Results:
Enter
review results and/or data sources
Standard/Sub-standard Description
MSC-7: Organization accurately sorts all grievances received during the
reporting period according to the member’s LIS eligibility status on the date the
grievance was received.
[Data Element C]
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
MSC-8: Organization accurately calculates the number of grievances which the
Part D sponsor provided timely notification of the decision, including the
following criteria:
MSC-8a: Includes only grievances for which the member is notified of decision
according to the following timelines:
i. For standard grievances: no later than 30 days after receipt of grievance.
ii. For standard grievances with an extension taken: no later than 44 days after
receipt of grievance.
Data Element D
iii. For expedited grievances: no later than 24 hours after receipt of grievance.
[Data Elements C-D]
Review Results:
MSC-8b: Each number calculated is a subset of the total number of grievances
received for the applicable beneficiary status and category.
[Data Elements C-D]
MSC-9
MSC-9: Organization accurately calculates the number of grievances by
category, including the following criteria:
MSC-9a: Properly sorts the total number of grievances by grievance category:
Enrollment/Plan Benefits/Pharmacy Access; Customer Service; and Coverage
determinations/Exceptions/Appeals Process (which includes expedited
grievances (e.g., untimely decisions) and any grievance about the exceptions
and appeals process).
[Data Element D]
MSC-9b: Assigns all additional categories tracked by organization that are not
listed above as Other.
[Data Element D]
3
3.a
Organization implements appropriate policies and procedures for data submission, including the following:
Data elements are accurately entered into the HPMS tool and entries match Data Element A
corresponding source documents.
Review Results:
Data Element B
Review Results:
Data Element C
Review Results:
Data Element D
Review Results:
3.b
Data files are properly uploaded into HPMS according to any HPMS templates provided.
3.c
All source, intermediate, and final stage data sets relied upon to enter data into HPMS are archived.
4
Data Sources:
Organization implements appropriate policies and procedures for periodic data system updates (e.g.,
changes in enrollment, provider/pharmacy status, claims adjustments).
Review Results:
Data Sources:
Review Results:
5
Organization implements appropriate policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).
Data Sources:
Review Results:
DRAFT – Meets Section 508 Compliance Standards
3
Findings Data Collection Form: Grievances (Part D)
3.3 Grievances (Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Grievances (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
6
7
Standard/Sub-standard Description
If organization’s data systems underwent any changes during the reporting period (e.g., as a result of a
merger, acquisition, or upgrade): Organization provided documentation on the data system changes and,
upon review, there were no issues that significantly impacted data reported.
If data collection, validation, and/or reporting for this data measure is delegated to another entity:
Organization regularly monitors the quality and timeliness of the data collected, validated, and/or reported
by the delegated entity or first tier/ downstream contractor.
DRAFT – Meets Section 508 Compliance Standards
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Review Results:
Data Sources:
Review Results:
4
Findings Data Collection Form: Coverage Determinations and Exceptions (Part D)
3.4 Coverage Determinations and Exceptions (Part D)
Organization Name:
Contract Number:
Data Measure:
Coverage Determinations and Exceptions (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
1
Standard/Sub-standard Description
A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved data
queries, file layouts, process flows) indicates that all source documents accurately capture required data
fields and are properly documented.
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
1.a
Source documents and output are properly secured so that source documents can be retrieved at any
time to validate the information submitted to CMS via HPMS.
Review Results:
1.b
Source documents create all required data fields for reporting requirements.
Review Results:
1.c
Source documents are error-free (e.g., programming code and spreadsheet formulas have no messages
or warnings indicating errors).
Review Results:
1.d
All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID, rather
than Field1 and maintain the same field name across data sets).
Review Results:
1.e
Data file locations are referenced correctly.
Review Results:
1.f
If used, macros are properly documented.
Review Results:
1.g
Source documents are clearly and adequately documented.
Review Results:
1.h
Titles and footnotes on reports and tables are accurate.
Review Results:
1.i
Version control of source documents is appropriately applied.
Review Results:
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.
2.a
The appropriate date range(s) for the reporting period(s) is captured.
MSC-1
2.b
2.c
2.d
Review Results:
Review Results:
Organization meets deadlines for reporting quarterly data to CMS by 5/15, 8/15, 11/15, and
2/15.
Terms used are properly defined per CMS regulations, guidance and Reporting Requirements Technical
Specifications.
MSC-4
Review Results:
Organization properly assigns data to the applicable CMS contract and plan benefit package.
Appropriate deadlines are met for reporting data (e.g., quarterly).
MSC-3
Data Sources:
Organization reports data based on the required reporting periods of 1/1 through 3/31, 4/1
through 6/30, 7/1 through 9/30, and 10/1 through 12/31.
Data are assigned at the applicable level (e.g., plan benefit package or contract level).
MSC-2
Findings:
Select "Y" or "N"
from Sections in
White Only
Review Results:
Organization properly determines whether a request is subject to the coverage
determinations or the exceptions process in accordance with the Prescription Drug Benefit
Manual Chapter 18, Section 30.1.
DRAFT – Meets Section 508 Compliance Standards
1
Findings Data Collection Form: Coverage Determinations and Exceptions (Part D)
3.4 Coverage Determinations and Exceptions (Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Coverage Determinations and Exceptions (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
2.e
MSC-5
Standard/Sub-standard Description
The number of expected counts (e.g., number of members, claims,
Data Element A
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.
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Applicable Measure-Specific Criteria:
MSC-5: Organization accurately calculates the number of pharmacy
transactions, including the following criteria:
MSC-5a: Includes pharmacy transactions with dates of service within the
reporting period.
[Data Element A]
Data Element B
Review Results:
MSC-5b: Includes in-network and out-of-network transactions.
[Data Element A]
MSC-5c: Includes transactions with a final disposition of reversed.
[Data Element A]
MSC-5d: Excludes pharmacy transactions for enhanced alternative drugs.
[Data Element A]
MSC-6
MSC-6: Organization accurately calculates the number of pharmacy
transactions rejected due to formulary restrictions, including the following
criteria:
Data Element C
Review Results:
Data Element D
Review Results:
Data Element E
Review Results:
MSC-6a: Includes rejections due to non-formulary status, prior
authorization (PA) requirements, step therapy and quantity limits.
[Data Element B]
MSC-6b: Excludes rejections due to early refill requests.
[Data Element B]
MSC-6c: Number calculated for Data Element B is a subset of the number
of pharmacy transactions calculated for Data Element A.
[Data Element B]
MSC-7
MSC-7: Organization accurately calculates the number of coverage
determinations and exceptions (Part D only), including the following criteria:
MSC-7a: Includes all coverage determinations/exceptions with a date of
receipt that occurs during the reporting period, regardless of when the
final decision was made.
[Data Elements C-J]
MSC-7b: Includes all methods of receipt (e.g., telephone, letter, fax, inperson).
[Data Elements C-J]
MSC-7c: Includes all coverage determinations/exceptions regardless of
who filed the request (e.g., beneficiary, appointed representative, or
prescribing physician).
[Data Elements C-J]
MSC-7d: Includes coverage determinations/exceptions from delegated
entities.
[Data Elements C-J]
DRAFT – Meets Section 508 Compliance Standards
2
Findings Data Collection Form: Coverage Determinations and Exceptions (Part D)
3.4 Coverage Determinations and Exceptions (Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Coverage Determinations and Exceptions (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Data Sources and Review Results:
Enter
review results and/or data sources
Standard/Sub-standard Description
MSC-7e: Includes both standard and expedited coverage
determinations/exceptions.
[Data Elements C-J]
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
MSC-7f: Excludes coverage determinations/exceptions that were
forwarded to the IRE because the organization failed to make a timely
decision on a standard or expedited request.
[Data Elements C-J]
MSC-8
MSC-8: Organization accurately calculates the total number of PAs
requested and approved, including the following criteria:
MSC-8a: Includes all requests for a decision on whether a member has,
or has not, satisfied a PA requirement.
[Data Element C]
Data Element F
Review Results:
MSC-8d: Number calculated for approved requests (Data Element D) is a
subset of the number of requests calculated for Data Element C.
[Data Element D]
Data Element G
Review Results:
MSC-8b: Includes requests that relate to Part B versus Part D coverage.
[Data Element C]
MSC-8c: Includes all favorable decisions on requests for PAs.
[Data Element D]
MSC-9
MSC-9: Organization accurately calculates the number of exceptions to the
organization’s utilization management (UM) tools (PAs, quantity limits, step
therapy requirements) requested and approved, including the following
criteria:
MSC-9a: Includes all requests for a decision where a member/prescribing
physician is seeking an exception to a PA or other UM requirement (e.g.,
a physician indicates that the member would suffer adverse effects if he
or she were required to satisfy the PA requirement).
[Data Element E]
MSC-9b: Includes all favorable decisions on requests for exceptions to
the organization’s UM tools.
[Data Element F]
Data Element H
Review Results:
Data Element I
Review Results:
MSC-9c: Number calculated for approved requests (Data Element F) is a
subset of the number of decisions calculated for Data Element E.
[Data Element F]
MSC-10
MSC-10: Organization accurately calculates the number of tier exceptions
requested and approved, including the following criteria:
MSC-10a: Includes all requests for a decision on whether to permit a
member to obtain a non-preferred drug at the more favorable costsharing terms applicable to drugs in the preferred tier.
[Data Element G]
MSC-10b: Includes all favorable decisions on requests for tier exceptions.
[Data Element H]
DRAFT – Meets Section 508 Compliance Standards
3
Findings Data Collection Form: Coverage Determinations and Exceptions (Part D)
3.4 Coverage Determinations and Exceptions (Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Coverage Determinations and Exceptions (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
MSC-11
Data Sources and Review Results:
Enter
review results and/or data sources
Standard/Sub-standard Description
MSC-10c: Number calculated for approved requests (Data Element H) is
a subset of the number of requests calculated for Data Element G.
[Data Element H]
Applicable Measure-Specific Criteria:
MSC-11: Organization accurately calculates the number of exceptions for
non-formulary medications requested and approved, including the following Data Element J
criteria:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Review Results:
MSC-11a: Includes all requests for a decision on whether to permit a
member to obtain a Part D drug that is not included on the formulary.
[Data Element I]
MSC-11b: Includes all favorable decisions on requests for non-formulary
medications.
[Data Element J]
MSC-11c: Number calculated for approved requests (Data Element J) is a
subset of the number of requests calculated for Data Element I.
[Data Element J]
3
3.a
Organization implements appropriate policies and procedures for data submission, including the following:
Data elements are accurately entered into the HPMS tool and entries match Data Element A
corresponding source documents.
Review Results:
Data Element B
Review Results:
Data Element C
Review Results:
Data Element D
Review Results:
Data Element E
Review Results:
Data Element F
Review Results:
Data Element G
Review Results:
Data Element H
Review Results:
Data Element I
Review Results:
Data Element J
Review Results:
3.b
Data files are properly uploaded into HPMS according to any HPMS templates provided.
3.c
All source, intermediate, and final stage data sets relied upon to enter data into HPMS are archived.
4
Data Sources:
Organization implements appropriate policies and procedures for periodic data system updates (e.g.,
changes in enrollment, provider/pharmacy status, claims adjustments).
Review Results:
Data Sources:
Review Results:
5
Organization implements appropriate policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).
Data Sources:
Review Results:
6
If organization’s data systems underwent any changes during the reporting period (e.g., as a result of a
merger, acquisition, or upgrade): Organization provided documentation on the data system changes and,
upon review, there were no issues that significantly impacted data reported.
DRAFT – Meets Section 508 Compliance Standards
Data Sources:
Review Results:
4
Findings Data Collection Form: Coverage Determinations and Exceptions (Part D)
3.4 Coverage Determinations and Exceptions (Part D)
Organization Name:
Contract Number:
Data Measure:
Coverage Determinations and Exceptions (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
7
Standard/Sub-standard Description
If data collection, validation, and/or reporting for this data measure is delegated to another entity:
Organization regularly monitors the quality and timeliness of the data collected, validated, and/or reported
by the delegated entity or first tier/ downstream contractor.
DRAFT – Meets Section 508 Compliance Standards
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Review Results:
5
Findings Data Collection Form: Appeals
3.5 Appeals
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Appeals
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cific
Name of Reviewer:
1
Standard/Sub-standard Description
A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved data
queries, file layouts, process flows) indicates that all source documents accurately capture required data
fields and are properly documented.
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
1.a
Source documents and output are properly secured so that source documents can be retrieved at any
time to validate the information submitted to CMS via HPMS.
Review Results:
1.b
Source documents create all required data fields for reporting requirements.
Review Results:
1.c
Source documents are error-free (e.g., programming code and spreadsheet formulas have no messages
or warnings indicating errors).
Review Results:
1.d
All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID, rather
than Field1 and maintain the same field name across data sets).
Review Results:
1.e
Data file locations are referenced correctly.
Review Results:
1.f
If used, macros are properly documented.
Review Results:
1.g
Source documents are clearly and adequately documented.
Review Results:
1.h
Titles and footnotes on reports and tables are accurate.
Review Results:
1.i
Version control of source documents is appropriately applied.
Review Results:
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.
2.a
The appropriate date range(s) for the reporting period(s) is captured.
MSC-1
2.b
2.c
2.d
Review Results:
Review Results:
Organization meets deadlines for reporting quarterly data to CMS by 5/15, 8/15, 11/15, and
2/15.
Terms used are properly defined per CMS regulations, guidance and Reporting Requirements Technical
Specifications.
MSC-4
Review Results:
Organization properly assigns data to the applicable CMS contract and plan benefit package.
Appropriate deadlines are met for reporting data (e.g., quarterly).
MSC-3
Data Sources:
Organization reports data based on the required reporting periods of 1/1 through 3/31, 4/1
through 6/30, 7/1 through 9/30, and 10/1 through 12/31.
Data are assigned at the applicable level (e.g., plan benefit package or contract level).
MSC-2
Findings:
Select "Y" or "N"
from Sections in
White Only
Review Results:
Organization properly defines the term “Appeal” in accordance with Title 1, Part 423, Subpart
M §423.560 and the Prescription Drug Benefit Manual Chapter 18, Section 10.1.
DRAFT – Meets Section 508 Compliance Standards
1
Findings Data Collection Form: Appeals
3.5 Appeals
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Appeals
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cific
Name of Reviewer:
2.e
MSC-5
Standard/Sub-standard Description
The number of expected counts (e.g., number of members, claims,
Data Element A
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.
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Applicable Measure-Specific Criteria:
MSC-5: Organization accurately calculates the total number of
redeterminations (Part D only), including the following criteria:
MSC-5a: Includes all redeterminations with a date of final decision that
occurs during the reporting period, regardless of when the request for
redetermination was received.
[Data Element A]
MSC-5b: Includes all reviews of partially favorable and adverse coverage Data Element B
determinations.
[Data Element A]
Review Results:
MSC-5c: Includes both standard and expedited redeterminations.
[Data Element A]
MSC-5d: Includes all methods of receipt (e.g., telephone, letter, fax, inperson).
[Data Element A]
MSC-5e: Includes all redeterminations regardless of who filed the
request (e.g., member, appointed representative, or prescribing
physician).
[Data Element A]
MSC-5f: Excludes dismissals or withdrawals.
[Data Element A]
MSC-5g: Excludes IRE decisions, as they are considered to be the second Data Element C
level of appeal.
[Data Element A]
MSC-6
Review Results:
MSC-6: Organization accurately calculates the number of redeterminations
by final decision, including the following criteria:
MSC-6a: Properly sorts the total number of redeterminations by final
decision: Full Reversal (e.g., fully favorable decision reversing the original
coverage determination) and Partial Reversal (e.g., denial with a “part”
that has been approved).
[Data Elements B and C]
MSC-6b: Each number calculated for Data Elements B and C is a subset of
the total number of redeterminations calculated for Data Element A.
[Data Elements B and C]
3
3.a
3.b
Organization implements appropriate policies and procedures for data submission, including the following:
Data Sources:
Data elements are accurately entered into the HPMS tool and entries match Data Element A
corresponding source documents.
Review Results:
Data Element B
Review Results:
Data Element C
Review Results:
Data files are properly uploaded into HPMS according to any HPMS templates provided.
DRAFT – Meets Section 508 Compliance Standards
2
Findings Data Collection Form: Appeals
3.5 Appeals
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Appeals
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cific
Name of Reviewer:
3.c
4
Standard/Sub-standard Description
All source, intermediate, and final stage data sets relied upon to enter data into HPMS are archived.
Organization implements appropriate policies and procedures for periodic data system updates (e.g.,
changes in enrollment, provider/pharmacy status, claims adjustments).
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Data Sources:
Review Results:
5
Organization implements appropriate policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).
Data Sources:
Review Results:
6
7
If organization’s data systems underwent any changes during the reporting period (e.g., as a result of a
merger, acquisition, or upgrade): Organization provided documentation on the data system changes and,
upon review, there were no issues that significantly impacted data reported.
Data Sources:
If data collection, validation, and/or reporting for this data measure is delegated to another entity:
Organization regularly monitors the quality and timeliness of the data collected, validated, and/or reported
by the delegated entity or first tier/ downstream contractor.
Data Sources:
DRAFT – Meets Section 508 Compliance Standards
Review Results:
Review Results:
3
Findings Data Collection Form: Long Term Care Utilization (Part D)
3.6 Long Term Care Utilization (Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Long Term Care Utilization (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
ea
Cr sure
ite -S
ria pe
ID cific
Name of Reviewer:
Standard/ Substandard ID
1
Standard/Sub-standard Description
A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved data
queries, file layouts, process flows) indicates that all source documents accurately capture required data
fields and are properly documented.
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
1.a
Source documents and output are properly secured so that source documents can be retrieved at any
time to validate the information submitted to CMS via HPMS.
Review Results:
1.b
Source documents create all required data fields for reporting requirements.
Review Results:
1.c
Source documents are error-free (e.g., programming code and spreadsheet formulas have no messages
or warnings indicating errors).
Review Results:
1.d
All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID, rather
than Field1 and maintain the same field name across data sets).
Review Results:
1.e
Data file locations are referenced correctly.
Review Results:
1.f
If used, macros are properly documented.
Review Results:
1.g
Source documents are clearly and adequately documented.
Review Results:
1.h
Titles and footnotes on reports and tables are accurate.
Review Results:
1.i
Version control of source documents is appropriately applied.
Review Results:
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.
2
2.a
The appropriate date range(s) for the reporting period(s) is captured.
MSC-1
2.b
2.c
2.d
Review Results:
Review Results:
Organization properly assigns data to the applicable CMS contract.
Appropriate deadlines are met for reporting data (e.g., quarterly).
MSC-3
Data Sources:
Organization reports data based on the required reporting period of 1/1 through 12/31.
Data are assigned at the applicable level (e.g., plan benefit package or contract level).
MSC-2
Findings:
Select "Y" or "N"
from Sections in
White Only
Review Results:
Organization meets deadlines for reporting quarterly data to CMS by 6/30.
Terms used are properly defined per CMS regulations, guidance and Reporting Requirements Technical
Specifications.
DRAFT – Meets Section 508 Compliance Standards
1
Findings Data Collection Form: Long Term Care Utilization (Part D)
3.6 Long Term Care Utilization (Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Long Term Care Utilization (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
ea
Cr sure
ite -S
ria pe
ID cific
Name of Reviewer:
Standard/ Substandard ID
2.e
MSC-4
Standard/Sub-standard Description
The number of expected counts (e.g., number of members, claims,
Data Element A
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.
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Findings:
Select "Y"
Y" or "N"
N"
from Sections in
White Only
Applicable Measure-Specific Criteria:
MSC-4: Organization accurately calculates the number of network LTC
pharmacies in the service area, including the following criteria:
MSC-4a: Includes the number of contracted LTC pharmacies by state for
PDPs and RPPOs, and by service area for MA-PDs.
[Data Element A]
MSC-4b: Includes only LTC pharmacies that are contracted as of the last
day of the reporting period.
[Data Element A]
MSC-4c: Includes LTC pharmacies that do not have utilization.
[Data Element A]
MSC-5
MSC-5: Organization accurately calculates the number of network retail
pharmacies in the service area, including:
MSC-5a: Includes the number of contracted retail pharmacies by state
for PDPs and regional for PPOs, and by service area for local MA-PDs.
[Data Element B]
Data Element B
Review Results:
Data Element C
Review Results:
MSC-5b: Includes only retail pharmacies that are contracted as of the
last day of the reporting period.
[Data Element B]
MSC-5c: Includes LTC pharmacies that do not have utilization.
[Data Element B]
MSC-6
MSC-6: Organization accurately calculates the total number of members in
LTC facilities for whom Part D drugs have been provided, including the
following criteria:
MSC-6a: Counts each member only once in each reporting period.
[Data Element C]
MSC-6b: Includes only members with covered Part D drug claims with
dates of service within the reporting period.
[Data Element C]
MSC-6c: Includes only members who resided in a long-term care facility
on the date of service for that Part D drug at the time the Part D claim
for that member was processed. [Note to reviewer : Claims with location
code 03 or the LTI report may be used to identify applicable members.
Claims with location code 07 should not be included.]
[Data Element C]
MSC-7
MSC-7: Organization accurately identifies the following data for each
network LTC pharmacy in the service area and uploads it into the HPMS
submission tool:
MSC-7a: LTC pharmacy name, LTC pharmacy NPI, contract entity name
of LTC pharmacy, chain code of LTC pharmacy
[Data Element D: a-d]
DRAFT – Meets Section 508 Compliance Standards
2
Findings Data Collection Form: Long Term Care Utilization (Part D)
3.6 Long Term Care Utilization (Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Long Term Care Utilization (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
ea
Cr sure
ite -S
ria pe
ID cific
Name of Reviewer:
Standard/ Substandard ID
MSC-8
Data Sources and Review Results:
Enter
review results and/or data sources
Standard/Sub-standard Description
MSC-7b: Includes all LTC pharmacies that were active in the network for
one or more days in the reporting period.
[Data Element D: a-d]
Findings:
Select "Y"
Y" or "N"
N"
from Sections in
White Only
MSC-8: Organization accurately calculates the number of 31-day equivalent
prescriptions dispensed for each network LTC pharmacy in the service area
and uploads it into the HPMS submission tool, including the following
criteria:
MSC-8a: Sums days supply of all covered Part D prescriptions dispensed
and divides this by 31 days.
[Data Element D: e-f]
MSC-8b: Performs the calculations separately for formulary prescriptions
and non-formulary prescriptions.
[Data Element D: e-f]
MSC-8c: Includes only covered Part D drug claims with dates of service
within the reporting period.
[Data Element D: e-f]
MSC-9
Data Element D
Review Results:
MSC-9: Organization accurately calculates prescription costs for each
network LTC pharmacy in the service area and uploads it into the HPMS
submission tool, including the following criteria:
MSC-9a: Prescription cost is the sum of the ingredient cost, dispensing
fee, and sales tax.
[Data Element D: g-h]
MSC-9b: Ingredient cost reflects Sponsor’s negotiated price.
[Data Element D: g-h]
MSC-9c: Performs the calculations separately for formulary prescriptions
and non-formulary prescriptions.
[Data Element D: g-h]
MSC-9d: Includes only covered Part D drug claims with dates of service
within the reporting period.
[Data Element D: g-h]
MSC-10
MSC-10: Organization accurately calculates the number of 30-day
equivalent prescriptions dispensed for each network retail pharmacy in the
service area, including the following criteria:
MSC-10a: Sums days supply of all covered Part D prescriptions dispensed Data Element E a
and divides this by 30 days.
[Data Element E: a-b]
Review Results:
MSC-10b: Performs the calculations separately for formulary
prescriptions and non-formulary prescriptions.
[Data Element E: a-b]
MSC-10c: Includes only covered Part D drug claims with dates of service Data Element E b
within the reporting period.
[Data Element E: a-b]
MSC-11
Review Results:
MSC-11: Organization accurately calculates prescription costs for all
network retail pharmacies in the service area, including the following
criteria:
MSC-11a: Prescription cost is the sum of the ingredient cost, dispensing
fee, and sales tax.
[Data Element E: c-d]
Data Element E c
DRAFT – Meets Section 508 Compliance Standards
Review Results:
3
Findings Data Collection Form: Long Term Care Utilization (Part D)
3.6 Long Term Care Utilization (Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Long Term Care Utilization (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
ea
Cr sure
ite -S
ria pe
ID cific
Name of Reviewer:
Standard/ Substandard ID
Data Sources and Review Results:
Enter
review results and/or data sources
Standard/Sub-standard Description
MSC-11b: Ingredient cost reflects Sponsor’s negotiated price.
[Data Element E: c-d]
MSC-11c: Performs the calculations separately for formulary
prescriptions and non-formulary prescriptions.
[Data Element E: c-d]
Data Element E d
Findings:
Select "Y"
Y" or "N"
N"
from Sections in
White Only
Review Results:
MSC-11d: Includes only covered Part D drug claims with dates of service
within the reporting period.
[Data Element E: c-d]
3
3.a
Organization implements appropriate policies and procedures for data submission, including the following:
Data Sources:
Data elements are accurately entered into the HPMS tool and entries match Data Element A
corresponding source documents.
Review Results:
Data Element B
Review Results:
Data Element C
Review Results:
Data Element D
Data Element E a
Review Results:
Data Element E b
Review Results:
Data Element E c
Review Results:
Data Element E d
Review Results:
3.b
Data files are properly uploaded into HPMS according to any HPMS templates provided.
Review Results:
3.c
All source, intermediate, and final stage data sets relied upon to enter data into HPMS are archived.
Review Results:
4
Organization implements appropriate policies and procedures for periodic data system updates (e.g.,
changes in enrollment, provider/pharmacy status, claims adjustments).
Data Sources:
Review Results:
5
Organization implements appropriate policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).
Data Sources:
Review Results:
6
7
If organization’s data systems underwent any changes during the reporting period (e.g., as a result of a
merger, acquisition, or upgrade): Organization provided documentation on the data system changes and,
upon review, there were no issues that significantly impacted data reported.
Data Sources:
Review Results:
If data collection, validation, and/or reporting for this data measure is delegated to another entity:
Data Sources:
Organization regularly monitors the quality and timeliness of the data collected, validated, and/or reported
by the delegated entity or first tier/ downstream contractor.
Review Results:
DRAFT – Meets Section 508 Compliance Standards
4
Findings Data Collection Form: Employer/Union-Sponsored Group Health Plan Sponsors (Part D)
3.7 Employer/Union-Sponsored Group Health Plan Sponsors (Part D)
Organization Name:
Contract Number:
Data Measure:
Employer/Union-Sponsored Group Health Plan Sponsors (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
ea
Cr sure
ite -S
ria pe
ID cific
Name of Reviewer:
Standard/ Substandard ID
1
Standard/Sub-standard Description
A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved data
queries, file layouts, process flows) indicates that all source documents accurately capture required data
fields and are properly documented.
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
1.a
Source documents and output are properly secured so that source documents can be retrieved at any
time to validate the information submitted to CMS via HPMS.
Review Results:
1.b
Source documents create all required data fields for reporting requirements.
Review Results:
1.c
Source documents are error-free (e.g., programming code and spreadsheet formulas have no messages
or warnings indicating errors).
Review Results:
1.d
All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID, rather
than Field1 and maintain the same field name across data sets).
Review Results:
1.e
Data file locations are referenced correctly.
Review Results:
1.f
If used, macros are properly documented.
Review Results:
1.g
Source documents are clearly and adequately documented.
Review Results:
1.h
Titles and footnotes on reports and tables are accurate.
Review Results:
1.i
Version control of source documents is appropriately applied.
Review Results:
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.
2
2.a
The appropriate date range(s) for the reporting period(s) is captured.
MSC-1
2.b
2.c
2.d
Review Results:
Review Results:
Organization properly assigns data to the applicable CMS contract or plan benefit package.
Appropriate deadlines are met for reporting data (e.g., quarterly).
MSC-3
Data Sources:
Organization reports data based on the required reporting periods of 1/1 through 12/31.
Data are assigned at the applicable level (e.g., plan benefit package or contract level).
MSC-2
Findings:
Select "Y" or "N"
from Sections in
White Only
Review Results:
Organization meets deadlines for reporting quarterly data to CMS by 2/28.
Terms used are properly defined per CMS regulations, guidance and Reporting Requirements Technical
Specifications.
DRAFT – Meets Section 508 Compliance Standards
1
Findings Data Collection Form: Employer/Union-Sponsored Group Health Plan Sponsors (Part D)
3.7 Employer/Union-Sponsored Group Health Plan Sponsors (Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Employer/Union-Sponsored Group Health Plan Sponsors (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
ea
Cr sure
ite -S
ria pe
ID cific
Name of Reviewer:
Standard/ Substandard ID
2.e
Standard/Sub-standard Description
Data Element A
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
Data Element B
control of reported data elements is appropriately applied; QA
checks/thresholds are applied to detect outlier or erroneous data prior to
data submission.
Data Sources and Review Results:
Enter
review results and/or data sources
MSC-5
Applicable Measure-Specific Criteria:MSC-5:
The organization’s “Employer Address” data field accurately reflects the
employer’s headquarters address.
[Data Element D]
MSC-6
MSC-6: The organization’s “Organization Type” data field accurately reflects Data Element D
data based on how the organization files its taxes.
[Data Element F]
MSC-7
MSC-7: The organization’s “Type of Contract” data field accurately captures Data Element E
the type of contract that the organization holds with the employer group
that binds it to offer benefits to group retirees.
[Data Element G]
MSC-8
Data Element F
MSC-8: The organization’s “Employer Plan Year Start Date” data field
accurately reflects the month and year in which the employer’s benefit year
begins.
[Data Element H]
Review Results:
MSC-9
MSC-9: The organization accurately calculates the number of currently
enrolled members, including the following criteria:
Data Element G
Review Results:
MSC-9a: Includes all enrollments from a particular employer group into
the specific PBP.
[Data Element I]
Data Element H
Review Results:
MSC-9b: Includes all members that are enrolled in the employer group
plan as of the last day of the reporting period.
[Data Element I]
Data Element I
Review Results:
Findings:
Select "Y"
Y" or "N"
N"
from Sections in
White Only
Data Element C
Review Results:
MSC-9c: Enrollment number for contracts that were cancelled during the
reporting period is reported as zero.
[Data Element I]
3
Organization implements appropriate policies and procedures for data submission, including the following:
3.a
Data Sources:
Data elements are accurately entered into the HPMS tool and entries match corresponding source
documents.
3.b
Data files are properly uploaded into HPMS according to any HPMS templates provided.
MSC-4
Review Results:
Applicable Measure-Specific Criteria:
MSC-4: Organization accurately identifies data on each employer/union-sponsored group health plan
and uploads it into the HPMS submission tool, including the following criteria:
MSC-4a: Includes the following information for each plan benefit package reported: Employer Legal
Name; Employer DBA Name; Employer Federal Tax ID; Employer Address; Type of Group Sponsor
(employer, union, trustees of a fund); Organization Type (State Government, Local Government,
Publicly Traded Organization, Privately Held Corporation, Non-Profit, Church Group, Other); Type of
Contract (insured, ASO, other); Employer Plan Year Start Date; and Current/Anticipated Enrollment.
[Data Elements A – I]
MSC-4b: Follows the specified file format provided by CMS in the Part D Reporting Requirements
Technical Specifications Document.
[Data Elements A – I]
3.c
All source, intermediate, and final stage data sets relied upon to enter data into HPMS are archived.
DRAFT – Meets Section 508 Compliance Standards
Review Results:
2
Findings Data Collection Form: Employer/Union-Sponsored Group Health Plan Sponsors (Part D)
3.7 Employer/Union-Sponsored Group Health Plan Sponsors (Part D)
Organization Name:
Contract Number:
Data Measure:
Employer/Union-Sponsored Group Health Plan Sponsors (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
ea
Cr sure
ite -S
ria pe
ID cific
Name of Reviewer:
Standard/ Substandard ID
4
Standard/Sub-standard Description
Organization implements appropriate policies and procedures for periodic data system updates (e.g.,
changes in enrollment, provider/pharmacy status, claims adjustments).
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
Findings:
Select "Y"
Y" or "N"
N"
from Sections in
White Only
Review Results:
5
Organization implements appropriate policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).
Data Sources:
Review Results:
6
7
If organization’s data systems underwent any changes during the reporting period (e.g., as a result of a
merger, acquisition, or upgrade): Organization provided documentation on the data system changes and,
upon review, there were no issues that significantly impacted data reported.
Data Sources:
Review Results:
If data collection, validation, and/or reporting for this data measure is delegated to another entity:
Data Sources:
Organization regularly monitors the quality and timeliness of the data collected, validated, and/or reported
by the delegated entity or first tier/ downstream contractor.
Review Results:
DRAFT – Meets Section 508 Compliance Standards
3
Findings Data Collection Form: Plan Oversight of Agents (Part D)
3.8 Plan Oversight of Agents(Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Plan Oversight of Agents (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
1
Standard/Sub-standard Description
A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved data
queries, file layouts, process flows) indicates that all source documents accurately capture required data
fields and are properly documented.
Data Sources and Review Results:
Enter
review results and/or data sources
Data Sources:
1.a
Source documents and output are properly secured so that source documents can be retrieved at any
time to validate the information submitted to CMS via HPMS.
Review Results:
1.b
Source documents create all required data fields for reporting requirements.
Review Results:
1.c
Source documents are error-free (e.g., programming code and spreadsheet formulas have no messages
or warnings indicating errors).
Review Results:
1.d
All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID, rather
than Field1 and maintain the same field name across data sets).
Review Results:
1.e
Data file locations are referenced correctly.
Review Results:
1.f
If used, macros are properly documented.
Review Results:
1.g
Source documents are clearly and adequately documented.
Review Results:
1.h
Titles and footnotes on reports and tables are accurate.
Review Results:
1.i
Version control of source documents is appropriately applied.
Review Results:
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.
2.a
The appropriate date range(s) for the reporting period(s) is captured.
MSC-1
2.b
2.c
2.d
Review Results:
Review Results:
Organization properly assigns data to the applicable CMS contract.
Appropriate deadlines are met for reporting data (e.g., quarterly).
MSC-3
Data Sources:
Organization reports data based on the required reporting periods of 1/1 through 12/31.
Data are assigned at the applicable level (e.g., plan benefit package or contract level).
MSC-2
Findings:
Select "Y" or "N"
from Sections in
White Only
Review Results:
Organization meets deadlines for reporting quarterly data to CMS by 2/28.
Terms used are properly defined per CMS regulations, guidance and Reporting Requirements Technical
Specifications.
DRAFT – Meets Section 508 Compliance Standards
1
Findings Data Collection Form: Plan Oversight of Agents (Part D)
3.8 Plan Oversight of Agents(Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Plan Oversight of Agents (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
2.e
MSC-4
Standard/Sub-standard Description
Data Element A
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.
Data Sources and Review Results:
Enter
review results and/or data sources
Review Results:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
Applicable Measure-Specific Criteria:
MSC-4: Organization accurately calculates the total number of agents who
are licensed to sell on behalf of the contract during the applicable reporting
period, including the following criteria:
MSC-4a: Includes all direct employees of the Part D sponsor who are
licensed to sell on behalf of the contract.
[Data Element A]
MSC-4b: Includes all licensed agents who are under a contractual
agreement to sell on behalf of the contract, regardless of whether or not
the agent was actively selling during the reporting period.
[Data Element A]
MSC-5
MSC-5: Organization accurately calculates the number of agents
investigated based on complaints, including the following criteria:
Data Element B
Review Results:
Data Element C
Review Results:
MSC-5a: Includes all investigations that were completed during the
applicable reporting period, regardless of when the complaint was
received.
[Data Element B]
MSC-5b: Includes investigations based on complaints filed directly with
the organization as well as those from the HPMS Complaint Tracking
Module (CTM).
[Data Element B]
MSC-5c: Includes all investigations based on complaints against an agent
under the applicable contract. If a complaint cannot be tied to a specific
contract, then the complaint is included under all contracts that the
agent is licensed to sell.
[Data Element B]
MSC-5d: The number calculated for Data Element B is a subset of the
total number of agents calculated for Data Element A.
[Data Element B]
MSC-6
MSC-6: Organization accurately calculates the number of agents receiving
disciplinary action resulting from a complaint filed against an agent,
including the following criteria:
MSC-6a: Includes all disciplinary actions that were taken during the
applicable reporting period, regardless of when the complaint was
received.
[Data Element C]
MSC-6b: Includes any disciplinary action taken by the Part D sponsor,
including manager-coaching, documented verbal warning, re-training,
documented corrective action plan, suspension, termination of
employment/contract, and short-term revocation.
[Data Element C]
MSC-6c: Includes disciplinary actions based on complaints filed directly
with the organization as well as those from the HPMS Complaint
Tracking Module (CTM).
[Data Element C]
DRAFT – Meets Section 508 Compliance Standards
2
Findings Data Collection Form: Plan Oversight of Agents (Part D)
3.8 Plan Oversight of Agents(Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Plan Oversight of Agents (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ Substandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Standard/Sub-standard Description
MSC-6d: Includes all disciplinary actions based on complaints against an
agent under the applicable contract. If a complaint cannot be tied to a
specific contract, then the disciplinary action is included under all
contracts that the agent is licensed to sell.
[Data Element C]
Data Sources and Review Results:
Enter
review results and/or data sources
Data Element D
Review Results:
MSC-7b:Includes only complaints that are filed directly with the
organization (e.g., excludes all complaints that are only forwarded to the
organization from the CMS Complaint Tracking Module (CTM) and not
Data Element E
filed directly with the organization).
[Data Element D]
Review Results:
Findings:
Select "Y" or "N"
"N"
from Sections in
White Only
MSC-6e: The number calculated for Data Element C is a subset of the
total number of agents calculated for Data Element B.
[Data Element C]
MSC-7
MSC-7: Organization accurately calculates the number of complaints filed
against an agent that the Part D sponsor reported to the governing State,
including the following criteria [Note to reviewer : If organization does not
voluntarily report complaints against a contracted agent to the State, then it
is appropriate to report a zero for Data Element D.]:
MSC-7a: Includes all complaints against a contracted agent received and
reported to the State during the applicable reporting period.
[Data Element D]
MSC-7c: Includes all complaints against an agent and reported to the
governing State under the applicable plan contract. If a complaint that is
reported to the governing State cannot be tied to a specific contract,
then the complaint is included under all contracts that the agent is
licensed to sell.
[Data Element D]
MSC-8
MSC-8: Organization accurately calculates the number of agents whose
selling privileges were revoked by the organization based on conduct or
discipline, including the following criteria:
MSC-8a:Includes all revocations initiated during the applicable reporting
period, regardless of when the conduct causing the revocation occurred.
[Data Element E]
MSC-8b: The number calculated for Data Element E is a subset of the
total number of agents calculated for Data Element A.
[Data Element E]
MSC-9
Data Element F
Review Results:
MSC-9: Organization accurately calculates the number of “agent assisted
enrollments” during the applicable reporting period, including the following
criteria:
MSC-9a: Includes all agent assisted enrollments that became effective
during the reporting period.
[Data Element F]
MSC-9b: Defines “agent assisted enrollments” as enrollments where the
member used a licensed agent that is compensated (employee or
independent) to complete the enrollment process (e.g., includes
enrollments completed through a call center staffed by licensed agents,
in person sales appointments, and public sales meetings where a
licensed agent collects enrollment forms).
[Data Element F]
DRAFT – Meets Section 508 Compliance Standards
3
Findings Data Collection Form: Plan Oversight of Agents (Part D)
3.8 Plan Oversight of Agents(Part D)
Instructions for each Standard or Sub-standard:
1) In the "Data Sources and Review Results:" column, enter the
review results and/or data sources used for each standard or substandard
2) In the "Findings" column, select "Y" if the requirements for the
standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met,
select "N".
Organization Name:
Contract Number:
Data Measure:
Plan Oversight of Agents (Part D)
Last Updated:
MM/DD/YYYY
Date of Site Visit:
Last name, First name
Name of Peer Reviewer:
Last name, First name
M
Standard/ SSububstandard ID
ea
Cr sure
it e - S
ria pe
ID cifi
c
Name of Reviewer:
Data Sources and Review Results:
Enter
review results and/or data sources
Standard/Sub-standard Description
MSC-9c: Includes agent assisted enrollments from both the individual
and group enrollment process.
[Data Element F]
Findings:
Select "Y" or "N"
from Sections in
White Only
MSC-9d: Includes enrollments that are as a direct result of the
participation of the group of agents reported in Data Element A.
[Data Element F]
3
3.a
3.b
3.c
4
Organization implements appropriate policies and procedures for data submission, including the following:
Data Sources:
Data elements are accurately entered into the HPMS tool and entries match Data Element A
corresponding source documents.
Review Results:
Data Element B
Review Results:
Data Element C
Review Results:
Data Element D
Review Results:
Data Element E
Review Results:
Data Element F
Review Results:
Data files are properly uploaded into HPMS according to any HPMS templates provided.
All source, intermediate, and final stage data sets relied upon to enter data into HPMS are archived.
Organization implements appropriate policies and procedures for periodic data system updates (e.g.,
changes in enrollment, provider/pharmacy status, claims adjustments).
Review Results:
Data Sources:
Review Results:
5
Organization implements appropriate policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).
Data Sources:
Review Results:
6
7
If organization’s data systems underwent any changes during the reporting period (e.g., as a result of a
merger, acquisition, or upgrade): Organization provided documentation on the data system changes and,
upon review, there were no issues that significantly impacted data reported.
If data collection, validation, and/or reporting for this data measure is delegated to another entity:
Organization regularly monitors the quality and timeliness of the data collected, validated, and/or reported
by the delegated entity or first tier/ downstream contractor.
DRAFT – Meets Section 508 Compliance Standards
Data Sources:
Review Results:
Data Sources:
Review Results:
4
| File Type | application/pdf |
| File Title | Medicare Part C and Part D Measure |
| Subject | Findings Data Collection Form for Data Validation Contractors |
| Author | Centers for Medicare & Medicaid Services |
| File Modified | 2010-08-26 |
| File Created | 2010-08-26 |