Medicare Parts C and D Universal Audit Guide

ATTACHMENT I-B
Formulary Administration Description of Documentation Required Sample
Case File Minimum Documentation Required
_________________________________________________________________
Purpose: To provide to the sponsor organization the minimum required documentation that will
be requested by CMS during live sample review as part of audit activities.
Instructions: The sponsor must include all documentation detailed below for each sample case.
Sponsor may include additional documentation not requested, including but not limited to a
narrative summary of the case, to provide additional detail or clarity. Sponsor must mark each
element on the screen print or provide a sample case as legend. The screenshots must be
provided to CMS via a Microsoft® Word or PDF document. The sponsor must provide a legend
that directs CMS to the requested information on the screenshot. At a minimum, the first shot of
each screen type must clearly indicate where the requested information resides on the screen.
This key is optional on subsequent screenshots of the same type.
Beneficiary information – The following information must be inserted into the document
prior to the specific screenshots. The information needs to be listed only once for each
beneficiary:
o Beneficiary Name
o HICN
o Cardholder or member ID
o CMS Contract ID
o CMS Plan Benefit Package (PBP) number
o Effective date of enrollment
Rejected claim information – The information below must be documented in screenshots
related to the specific claim rejection. Multiple screenshots may be requested during the
audit if there are other applicable rejections.
o NDC
o Drug name, strength, dosage form, route of administration
o Quantity
o Days supply
o Date of service
o Date and time of rejection
o Rejection code and messaging to pharmacy
o DAW code
o Pharmacy NPI
o Whether prior authorization was used to process the claim. If an authorization was
used, a screenshot that documents the level (e.g. GPI-6) and duration of the
authorization.
o The comment log associated with the rejected claim
o A history of all CY 2013 rejected claims for the same drug (brand name, dosage
form, route of administration)
o A history of all October – December 2012 and CY 2013 paid claims for the same
drug (brand name, dosage form, route of administration)

Page 1 of 2

ATTACHMENT I-B
Formulary Administration Description of Documentation Required Sample
Case File Minimum Documentation Required
_________________________________________________________________
Paid claim information – The following must be provided via screenshots for any paid
claims for the drug subsequent to the claim rejection:
o NDC
o Drug name, strength, dosage form, route of administration
o Quantity
o Days supply
o Date of service
o Date and time of paid claim
o DAW code
o Pharmacy NPI
o Whether prior authorization was used to process the claim. If an authorization was
used, a screenshot that documents the level (e.g. GPI-6) and duration of the
authorization.
o Claim payment information including beneficiary pay amount, LIS amount and
sponsor’s responsibility.

Page 2 of 2