Medicare Parts C and D Universal Audit Guide

Attachment X-A

Universe Instructions: The sponsor must submit an Excel file for each universe. The specif
Pre-Audit Universe Tab 1: All Enrollments Effectuated by Agents/Brokers Effective [Octo
Format: Microsoft Excel
Contract PBP
number number

Plan type Agent/Broker Agent/Broker Agent/Broker
(HMO, Last Name
First Name
NPN
PFFS,
PDP)

Agent/Broker
Company Name
or Field
Marketing
Organization
(FMO) Name

Attachment X-A

fic list of elements that must be included for each case in the universe is noted below.
ber 1, 2012-March 1, 2013 or January 1, 2013-June 1, 2013]

Application
Signature
Date

Application Enrollment Beneficiary Beneficiary Beneficiary Beneficiary
Received
Effective
member
HICN
last name
first name
Date
Date
identification
number

Attachment X-A

Beneficiary Beneficiary
street address city

Beneficiary Beneficiary Cancellation date, Disenrollment
state
ZIP
if applicable
effective date,
if applicable

Attachment X-A

If the Beneficiary
Disenrolled,
indicate if rapid
disenrollment