Medicare Parts C and D Universal Audit Guide

ATTACHMENT X
Outbound Enrollment Verification (OEV)
Audit Process and Universe Request
Purpose: To evaluate Medicare Advantage Organizations’ and Prescription Drug Plans’
compliance with requirements relating to Outbound Enrollment Verification (OEV). CMS will
perform its audit activities using these instructions (unless otherwise noted).
I.

Required Universes
A. CMS requires the sponsor to pull the following two universes and submit them to
CMS:
1. Enrollments Effectuated by Agents/Brokers: For audits conducted between
January 1 and June 30, 2013, provide all enrollments effectuated by all
agents/brokers with enrollment effective dates of October 1, 2012 through March
1, 2013. For audits conducted between July 1 and December 31, 2013, provide all
enrollments effectuated by all agents/brokers with enrollment effective dates of
January 1 through June 1, 2013. If a beneficiary in the universe disenrolled or
cancelled from the plan, include the disenrollment or cancellation date. Sponsors
should identify those disenrollments that qualify as a rapid disenrollment
(disenrollment within 90 days of enrollment date).
Submit Universe 1 using Attachment X-A (Universe 1) in Excel format (files
may be submitted in CSV or text format if the file is too large for Excel).
2. Agents/Brokers who Sold Sponsor’s Contract Year 2012 and 2013 MA and/or
Part D Products: Indicate whether the agents/brokers were captive, employed, or
independent and whether they sold on behalf of the sponsor for 2012, 2013, or
both.
Submit Universe 2 using Attachment X-A (Universe 2) in Excel format (files
may be submitted in CSV or text format if the file is too large for Excel).

II.

Assessment of Outbound Enrollment Verification (OEV)
A. Sample Selection: CMS will select a targeted sample of 30 cases from the universes
above.
B. Obtain Evidence: CMS will obtain documentation of the OEV process from the
sponsor for the identified enrollees, including the following:
1. Evidence that calls were made, i.e., recordings, transcripts, call logs or other
documentation of the substance of completed OEV calls;
2. Copies of CMS approved OEV letters sent, where required;
3. Copy of CMS approved OEV call script; and
4. Other evidence, as needed, that demonstrates compliance with OEV requirements
for each case selected.
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ATTACHMENT X
Outbound Enrollment Verification (OEV)
Audit Process and Universe Request
C. Apply Compliance Standard To Each Case: Apply the following test to each of the 30
cases. OEV calls will be reviewed to determine the following:
1. Verify through the review of supporting documentation that the first two call
attempts were made within 10 days of the receipt of the application.
2. Verify through the review of supporting documentation that all three call attempts
were made within 15 days of the receipt of the application.
3. In instances where the sponsor did not successfully reach the beneficiary on the
first or second attempt, verify that the sponsor sent a fully compliant enrollment
verification letter after the second attempt and completed a third call attempt
within 15 days of the receipt of the application.
4. Verify that the sponsor appropriately handled the beneficiary request (e.g.
cancellation).
D. Sample Case Results: CMS will test each of the 30 cases. If CMS requirements are
not met, a sample case fails and a condition (finding) is documented. If CMS
requirements are met, a sample case passes and no conditions (findings) are
documented.

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