Medicare Parts C and D Universal Audit Guide

Attachment I-A – FA Universe Template .xlsx
Rejected Claims_FormularyAdmin

HICN

1 of 1

Cardholder ID

CMS Contract ID

NDC 11 (no
CMS Plan ID hyphens)

Date of
Service

Date of
Rejection

Claim
Quantity

Claim Days
Supply

Patient
Residence

Pharmacy
Service Type

CMS Part D Defined
Qualified Facility

Compound
Code

Reject Code Pharmacy
Message 1
1

Reject Code Pharmacy
Message 2
2

Reject Code Pharmacy
3
Message 3

***Sponsor must provide ALL pharmacy messaging, not limited to the number of fields in
this template. Please insert columns as necessary.***