Technical Specifications Document (Contract Year 2014)

Medicare Part C Plan Reporting Requirements

Technical Specifications Document

Contract Year 2014

Effective Date: January 1, 2014

Prepared by:

Centers for Medicare & Medicaid Services

Center for Medicare

Medicare Drug Benefit and C&D Data Group

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Background and Introduction

CMS has authority to establish reporting requirements for Medicare Advantage Organizations (MAOs) as described in 42CFR §422.516 (a). Pursuant to that authority, each MAO must have an effective procedure to develop, compile, evaluate, and report information to CMS in the time and manner that CMS requires. Additional regulatory support for the Medicare Part C Reporting Requirements is also found in the Final Rule entitled “Medicare Program; Revisions to the Medicare Advantage and Prescription Drug Program” (CMS 4131-F), and in the interim final rule (CMS 4138-IFC).

This document provides a description of the reporting sections,¹ reporting timeframes and deadlines, and specific data elements for each reporting section.

The technical specifications contained in this document should be used to develop a common understanding of the data, to assist organizations in preparing and submitting datasets, to ensure a high level of accuracy in the data reported to CMS, and to reduce the need for organizations to correct and resubmit data.

Each Part C Reporting Requirement reporting section of this document has the following information presented in a standardized way for ease of use:

1. Data element definitions - details for each data element reported to CMS.

2. Notes - additional clarifications to a reporting section derived from the responses to comments received under the OMB clearance process.

3. Reminder: Underlined passages indicate updates, and/or new information.

General Information

Organizations for which these specifications apply are required to collect these data. Reporting will vary depending on the plan type and reporting section. Most reporting sections will be reported annually, only one will be reported twice per year.

Reporting Part C Data: The information here should be used (unless otherwise indicated, or instructed by CMS) for reporting from this point forward.

The following data elements listed directly below are considered proprietary, and CMS considers these as not subject to public disclosure under provisions of the Freedom of Information Act (FOIA):*

• Employer DBA and Legal Name, Employer Address, Employer Tax Identification Numbers (Employer Group Sponsors)

*Under FOIA, Plans may need to independently provide justification for protecting these data if a FOIA request is submitted.

In order to provide guidance to Part C sponsors on the actual process of entering reporting requirements data into the Health Plan Management System, a separate Health Plan Management System (HPMS) Plan Reporting Module (PRM) User Guide may be found on the PRM start page.

Exclusions from Reporting

National PACE plans and 1833 cost plans are excluded from reporting all Part C Reporting Requirements reporting sections.

Suspended from Reporting:

Reporting section # 1 Benefit Utilization;

Reporting section # 2 Procedure Frequency;

Reporting section # 4 Provider Network Adequacy;

Reporting section #10 Agent Compensation Structure;

Reporting section #11 Agent Training and Testing; and

Major Changes from CY 2013 Technical Specifications

Reporting Section # 5 (Grievances), Reporting Section # 6 (Organization Determinations/Reconsiderations), and Reporting Section #12 (Plan Oversight of Agents) are significantly upgraded to accommodate user needs for data trending, policy development, auditing, and compliance monitoring. Reporting Section #3 (Serious Reportable Adverse Events) will be altered due to the availability of encounter data. Only 4 of the original 21 SRAEs will be reported via the Part C Reporting Requirements. The remaining SRAEs will be available from encounter data and will no longer be part of these Part C reporting requirements.

Timely Submission of Data

Data submissions are due by 11:59 p.m. Pacific time on the date of the reporting deadline. CMS expects that data are accurate on the date they are submitted. Data submitted after the given reporting period deadline shall be considered late and may not be incorporated within CMS data analyses and reporting. Only data reflecting a good faith effort by an organization to provide accurate responses to Part C reporting requirements will be counted as data submitted in a timely manner.

If a plan terminates before or at the end of its contract year (CY), it is not required to report and/or have its data validated for that CY.

Organizations failing to submit data, or submitting data late and/or inaccurately will receive compliance notices from CMS.

Correction of Previously Submitted Data / Resubmission Requests

If previously submitted data are incorrect, Part C Sponsors should request the opportunity to correct and resubmit data. Corrections of previously submitted data are appropriate if they are due to an error made at the date of the original submission, or as otherwise indicated by CMS. Once a reporting deadline has passed, organizations that need to correct data must submit a formal request to resubmit data via the HPMS Plan Reporting Module. Resubmission requests may only be submitted after the original reporting deadline has expired. In order to accommodate data validation activities, data corrections may only be submitted until March 31^st following the last quarter or end of year reporting deadline. CMS reserves the right to establish deadlines after which no further corrections may be submitted. Detailed instructions on resubmissions may be found on the starter page of the HPMS Plan Reporting Module User Guide.

Due Date Extension Requests

Generally speaking, CMS does not grant extensions to reporting deadlines, as these have been established and published well in advance. It is our expectation that organizations do their best with the information provided in the most current version of the Technical Specifications to prepare the data to be submitted in a timely fashion. Any assumptions that organizations may make in order to submit data timely should be fully documented and defensible under audit. CMS will consider appropriate “Resubmission Requests” through the Plan Reporting Module (PRM).

Periodic Updates to the Technical Specifications

If CMS, through questions raised by plans, clarifies the prior technical specifications for a data element, CMS requires that plans incorporate this change for the entire reporting period.

CMS has established the following email address for the purpose of collecting all questions regarding the Part C Technical Specifications: [email protected]. Plans should be aware that immediate responses to individual questions may not always be possible given the volume of email this box receives. CMS recommends that plans first refer to the current Medicare Part C Reporting Requirements Technical Specifications for answers or, when appropriate, contact the HPMS help desk: 1-800-220-2028 or email: [email protected] .

Reporting Requirement Reporting Sections List

The following summary table provides an overview of the parameters around each of the current Part C reporting requirements reporting sections.

Reporting Section	Organization Types Required to Report	Report Freq./ Level	Report Period (s)	Data Due date (s)
1. Benefit Utilization		Suspended
2. Procedure Frequency		Suspended
3. Serious Reportable Adverse Events (“Never Events” only) Revised. Report only October – December events for 2014 using ICD-10.	CCP, PFFS, MMP, MSA (includes all 800 series plans) , Employer/Union Direct Contract	1/year Contract	10/1/2014 – 12/31/2014	2/28 of following year
4. Provider Network Adequacy		Suspended
5. Grievances (Revised)	CCP, PFFS, 1876 Cost, MMP, MSA (includes all 800 series plans) , Employer/Union Direct Contract	1/Year Contract	1/1-3/31 4/1-6/30 7/1-9/30 10/1-12/31 (2/28 reporting will include each quarter)	2/28 of following year
6. Organization Determinations/ Reconsiderations (Revised)	CCP, PFFS, 1876 Cost, MMP, MSA (includes all 800 series plans) , Employer/Union Direct Contract	1/Year Contract	1/1-3/31 4/1-6/30 7/1-9/30 10/1-12/31 (2/28 reporting will include each quarter)	2/28 of following year
7. Employer Group Plan Sponsors	CCP, PFFS, 1876 Cost, MSA (includes 800 series plans and any individual plans sold to employer groups), Employer/Union Direct Contract	1/year PBP	1/1 - 12/31	2/28 of following year Validation unnecessary—using for monitoring only

Reporting Section	Organization Types Required to Report	Report Freq./ Level	Report Period (s)	Data Due date (s)
8. PFFS Plan Enrollment Verification Calls	PFFS (800-series plans should NOT report)	1/year PBP	1/1-12/31	2/28 of following year Validation unnecessary—using for monitoring only
9. PFFS Provider Payment Dispute Resolution Process	PFFS (includes all 800 series plans), Employer/Union Direct Contract	1/year PBP	1/1-12/31	2/28 of following year Validation unnecessary—using for monitoring only
10. Agent Compensation Structure		Suspended
11. Agent Training and Testing		Suspended
12. Plan Oversight of Agents		Revised
13. Special Need Plans (SNP) Care Management	Local, CCP, Regional CCP,RFB Local CCP with SNPs. Includes 800 series plans.	1/Year PBP	1/1-12/31	2/28 of following year
14. Enrollment/Disenrollment	1876 cost plans with no Part D only.*	2/Year Contract	1/1-6/30 7/112/31	8/31 2/28 of following year

* MA-only. MA-PDs and PDPs report under Part D. MSA and chronic care excluded.

Reporting Sections

1. Benefit Utilization (SUSPENDED)

2. Procedure Frequency (SUSPENDED)

Data elements reported under this measure are:

3. Serious Reportable Adverse Events (SRAE)

Reporting section	Organization Types Required to Report	Report Freq./ Level	Report Period (s)	Data Due date (s)
3. Serious Reportable Adverse Events (“Never Events” only) Revised. Report only October – December events for 2014 using ICD-10.	01 – Local CCP 02 - MSA 03 – RFB PFFS 04 - PFFS 05 - MMP 11 – Regional CCP 14 – ED-PFFS 15 – RFB Local CCP Organizations should include all 800 series plans. Employer/Union Direct Contracts should also report this reporting section, regardless of organization type.	1/year Contract	10/1/14 -12/31/14	2/28 of following year

Notes

This reporting section requires direct data entry into HPMS.

Total Surgeries

Inclusions: Surgeries are defined as the number of discharges accompanied by UB Revenue code 036X.

Exclusions: Maternity-related discharges (HEDIS-like method).

Never Events:

#3 Serious Reportable Adverse Events (Hospital-Acquired Conditions (HACs))

Report “Never Events” only (these events will be reported as previously but coding will be in ICD-10, effective October 1, 2014). Do not report for 1/1/2014 – 9/30/2014.

1. Surgery performed on the wrong body part. (140.7)

2. Surgery performed on the wrong patient. (140.8)

3. Wrong surgical procedure performed on a patient. (140.6)

4. Intraoperative or immediate death in an ASA class I patient.

Notes

This reporting section requires direct data entry into HPMS.

Only inpatient claims are to be used in identifying never events.

Adverse health conditions present upon admission should be excluded from this reporting section.

4. PROVIDER NETWORK ADEQUACY (SUSPENDED)

5. Grievances

Reporting section	Organization Types Required to Report	Report Freq./ Level	Report Period (s)	Data Due date (s)
5. Grievances	01 – Local CCP 02 - MSA 03 – RFB PFFS 04 - PFFS 05 – MMP 06 – 1876 Cost 11 – Regional CCP 14 – ED-PFFS 15 – RFB Local CCP Organizations should include all 800 series plans. Employer/Union Direct Contracts should also report this reporting section, regardless of organization type.	1/Year Contract	1/1-3/31 4/1-6/30 7/1-9/30 10/1-12/31 (2/28 reporting will include each quarter)	2/28 of following year

The data elements to be reported under this reporting section are:

The data elements to be reported under this reporting section are:

Grievance Category	Total number of Grievances		Number of grievances in which timely notification was given
Total Grievances	(5.1)		(5.12)
Number of Expedited Grievances	(5.2)		(5.13)
Enrollment/Disenrollment	(5.3)		(5.14)
Benefit Package Grievances	(5.4)		(5.15)
Access Grievances	(5.5)		(5.16)
Marketing Grievances	(5.6)		(5.17)
Customer Service Grievances	(5.7)		(5.18)
Organization determination and reconsideration process grievances	(5.8)		(5.19)
Quality Of Care Grievances	(5.9)		(5.20)
Grievances related to “CMS Issues”	(5.10)		(5.21)
Other Grievances	(5.11)		(5.22)

* Timely notification of grievances means grievances for which the member is notified of decision according to the following timelines:

For standard grievances: no later than 30 days after receipt of grievance.

For standard grievances with an extension taken: no later than 44 days after receipt of grievance.

For expedited grievances: no later than 24 hours after receipt of grievance.

Notes

This reporting section requires direct data entry into HPMS.

For an explanation of Medicare Part C grievance procedures, refer to CMS regulations and guidance:  42 CFR Part 422, Subpart M, and Chapter 13 of the Medicare Managed Care Manual, and the CMS website: http://www.cms.gov/MMCAG/. For an explanation of grievance procedures for MMPs, refer to the State-specific Memorandum of Understanding.

CMS requires plans to use one of eighteen categories described in this section to report grievances to CMS (Elements 5.1 – 5.18). For purposes of Reporting Section 5:

• A grievance is defined in Chapter 13 of the Medicare Managed Care Manual as “Any complaint or dispute, other than an organization determination, expressing dissatisfaction with the manner in which a Medicare health plan or delegated entity provides health care services, regardless of whether any remedial action can be taken. An enrollee or their representative may make the complaint or dispute, either orally or in writing, to a Medicare health plan, provider, or facility. An expedited grievance may also include a complaint that a Medicare health plan refused to expedite an organization determination or reconsideration, or invoked an extension to an organization determination or reconsideration time frame. In addition, grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item. Grievance issues may also include complaints that a covered health service procedure or item during a course of treatment did not meet accepted standards for delivery of health care.”

• For Part C reporting, grievances are defined as those grievances completed (i.e., plan has notified enrollee of its decision) during the reporting period, regardless of when the request was received; and include grievances filed by the enrollee or his or her representative.

The category, “Grievances Related to CMS Issues” involves grievances that primarily involve complaints concerning CMS’ policies, processes, or operations; the grievance is not directed against the health plan or providers. The new grievance category is meant to identify those grievances that are due to CMS issues, and are related to issues outside of the Plan's direct control. This same type of categorization is used in the Complaint Tracking Module (CTM) and allows CMS to exclude those grievances that are outside of the Plan’s direct control, from the total number of grievances filed against the contract.

Reporting Inclusions:

Report:

• Only those grievances processed in accordance with the plan grievance procedures outlined in 42 CFR Part 422, Subpart M (i.e., Part C grievances).

• Report grievances involving multiple issues under each applicable category.

• Report grievances if the member is ineligible on the date of the call to the plan but was eligible previously.

Reporting Exclusions:

Do not report:

• Enrollee complaints only made through the CMS Complaints Tracking Module (CTM). CTM complaints are addressed through a process that is separate and distinct from the plan’s procedures for handling enrollee grievances.  Therefore, plans should not report their CTM records to CMS as their grievance logs. 

• Withdrawn grievances.

• Enrollee grievances processed in accordance with the grievance procedures described under 42 C.F.R., Part 423, Subpart M (i.e., Part D grievances).

Additional Guidance

• If an enrollee 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.

• If an enrollee 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.

• For MA-PD contracts: Include only grievances that apply to the Part C benefit. (If a clear distinction cannot be made for an MA-PD, cases are reported as Part C grievances.)

• For additional details concerning Reporting Section 5 reporting requirements, see Appendix 3: FAQs: Reporting Sections 5 & 6.

6. Organization Determinations/Reconsiderations

Reporting section	Organization Types Required to Report	Report Freq./ Level	Report Period (s)	Data Due date (s)
6. Organization Determinations/ Reconsiderations	01 – Local CCP 02 - MSA 03 – RFB PFFS 04 - PFFS 05 – MMP 06 – 1876 Cost 11 – Regional CCP 14 – ED-PFFS 15 – RFB Local CCP Organizations should include all 800 series plans. Employer/Union Direct Contracts should also report this reporting section, regardless of organization type.	1/Year Contract	1/1-3/31 4/1-6/30 7/1-9/30 10/1-12/31 (2/28 reporting will include each quarter)	2/28 of following year

Element Number	Data Elements for Organization Determinations/Reconsiderations
6.1	Total Number of Organization Determinations Made in Reporting Time Period Above
6.2	Of the Total Number of Organization Determinations in 6.1, Number Processed Timely
6.3	Number of Organization Determinations – Fully Favorable (Services)
6.4	Number of Organization Determinations – Fully Favorable (Claims)
6.5	Number of Organization Determinations – Partially Favorable (Services)
6.6	Number of Organization Determinations – Partially Favorable (Claims)
6.7	Number of Organization Determinations – Adverse (Services)
6.8	Number of Organization Determinations – Adverse (Claims)
6.9	Number of Requests for Organization Determinations - Withdrawn
6.10	Total number of Reconsiderations Made in Reporting Time Period Above
6.11	Of the Total Number of Reconsiderations in 6.11, Number Processed Timely
6.12	Number of Reconsiderations – Fully Favorable (Services)
6.13	Number of Reconsiderations – Fully Favorable (Claims)
6.14	Number of Reconsiderations – Partially Favorable (Services)
6.15	Number of Reconsiderations – Partially Favorable (Claims)
6.16	Number of Reconsiderations – Adverse (Services)
6.17	Number of Reconsiderations – Adverse (Claims)
6.18	Number of Requests for Reconsiderations - Withdrawn
6.19	Total number of reopened (revised) decisions, for any reason, in Time Period Above
	For each case that was reopened, the following information will be uploaded in a data file:
6.20	Contract Number
6.21	Plan ID
6.22	Case ID
6.23	Date of original disposition
6.24	Original disposition (Fully Favorable; Partially Favorable or Adverse)
6.25	Case level (Organization Determination or Reconsideration)
6.26	Date case was reopened
6.27	Reason(s) for reopening (Clerical Error, New and Material Evidence, or Other)
6.28	Date of reopening disposition (revised decision)
6.29	Reopening disposition (Fully Favorable; Partially Favorable or Adverse)

Notes

This reporting section requires direct data entry into HPMS.

For an explanation of Part C organization determination and reconsideration procedures, refer to CMS regulations and guidance: 42 CFR Part 422, Subpart M, and Chapter 13 of the Medicare Managed Care Manual, and the CMS website: http://www.cms.gov/MMCAG/.

All plan types listed in the table at the beginning of this section are required to report: organization determinations and reconsiderations, as described in this guidance, regardless of whether the request was filed by an enrollee, the enrollee’s representative, a physician or a non-contract provider who signed a Waiver of Liability. 

For instances when the organization approves an initial request for an item or service (e.g., physical therapy services) and the organization approves a separate additional request to extend or continue coverage of the same item or service, include the decision to extend or continue coverage of the same item or service as another, separate, fully favorable organization determination.

CMS requires plans to report requests for organization determinations and reconsiderations submitted to the plan. For purposes of Reporting Section 6:

• An organization determination is a plan’s response to a request for coverage (payment or provision) of an item or service – including auto-adjudicated claims, prior authorization requests, and requests to continue previously authorized ongoing courses of treatment. It includes requests from both contract and non-contract providers.

• A reconsideration is a plan’s review of an adverse or partially favorable organization determination.

• A Fully Favorable decision means an item or service was covered in whole.

• A Partially Favorable decision means an item or service was partially covered. For example, if a claim has multiple line items, some of which were paid and some of which were denied, it would be considered partially favorable. Also, if a pre-service request for 10 therapy services was processed, but only 5 were authorized, this would be considered partially favorable.

• An Adverse decision means an item or service was denied in whole.

• In contrast to claims (payment decisions), service authorizations include all service-related decisions, including pre-authorizations, concurrent authorizations and post-authorizations.

• “Services” refers to appeals of MA organization denials of requests for services and “claims” refers to denials of payments for services.

• A reopening is a remedial action taken to change a final determination or decision even though the determination or decision was correct based on the evidence of record.

• A withdrawn organization determination or reconsideration is one that is withdrawn upon the enrollee’s request, but excludes appeals that the organization forwards to the IRE for dismissal.

If a provider (e.g., a physician) declines to provide coverage an enrollee has requested or offers alternative services, the provider is making a treatment decision, not an organization determination on behalf of the plan. In this situation, if the enrollee disagrees with the provider’s decision, and still wishes to obtain coverage of the service or item, the enrollee must contact the Medicare health plan to request an organization determination or the provider may request the organization determination on the enrollee’s behalf.

Reporting Inclusions:

Organization Determinations:

• All fully favorable payment (claims) and service-related organization determinations for contract and non-contract providers/suppliers.

• All Part B drug claims processed and paid by the plan’s PBM should be reported under the Organization Determinations and Reconsiderations report for Part C.

• All partially favorable payment (claims) and service-related organization determination for contract and non-contract providers/suppliers.

• All adverse payment (claims) and service-related organization determinations for contract and non-contract providers/suppliers.

• Report denials based on exhaustion of Medicare benefits.

Reconsiderations:

• All fully favorable payment (claims) and service-related reconsideration determinations for contract and non-contract providers/suppliers.

• All partially favorable payment (claims) and service-related reconsideration determinations for contract and non-contract providers/suppliers.

• All adverse payment (claims) and service-related reconsideration determinations for contract and non-contract providers/suppliers.

Additional Guidance

Report:

Completed organization determinations and reconsiderations (i.e., plan has notified enrollee of its decision concerning a requested item or service or adjudicated a claim) during the reporting period, regardless of when the request was received. Plans are only to report the coverage determination or reconsideration requests as described in this section and processed in accordance with the organization determination and reconsideration procedures described under 42 C.F.R. Part 422, Subpart M.

Claims with multiple line items at the “summary level.”

• A request for payment as a separate and distinct organization determination, even if a pre-service request for that same item or service was also processed.

• A denial of Medicare payment for item or service as either partially favorable or adverse, regardless of whether Medicaid payment ultimately is provided, in whole or in part, for that item or service.

Do not report:

• Withdrawals and dismissals. .

• Independent Review Entity (IRE) decisions.

• Duplicate payment requests concerning the same service or item.

• Payment requests returned to a provider/supplier in which a substantive decision (fully favorable, partially favorable or adverse) has not been made–  e.g., payment requests or forms are incomplete, invalid or do not meet the requirements for a Medicare claim (e.g., due to a clerical error).

• A Quality Improvement Organization (QIO) review of an individual’s request to continue Medicare-covered services (e.g., a SNF stay) and any related claims/requests to pay for continued coverage based on such QIO decision.

• Enrollee complaints only made through the CMS Complaints Tracking Module (CTM).

NOTE: For purposes of this current reporting effort, plans are not required to distinguish

between standard and expedited organization determinations or standard and expedited

reconsiderations.

For additional details concerning the Reporting Section 6 reporting requirements, see Appendix 3: FAQs: Reporting Sections 5 & 6.

7. Employer Group Plan Sponsors

Reporting section	Organization Types Required to Report	Report Freq./ Level	Report Period (s)	Data Due date (s)
7. Employer Group Plan Sponsors	01 – Local CCP 02 - MSA 04 - PFFS 06 – 1876 Cost 11 – Regional CCP 14 – ED-PFFS Organizations should include all 800 series plans and any individual plans sold to employer groups. Employer/Union Direct Contracts should also report this reporting section, regardless of organization type.	1/year PBP	1/1 - 12/31	2/28 of following year

Data elements reported under this reporting section are:

Element Number	Data Elements for Employer Group Plan Sponsors
7.1	Employer Legal Name
7.2	Employer DBA Name
7.3	Employer Federal Tax ID
7.4	Employer Address
7.5	Type of Group Sponsor (employer, union, trustees of a fund)
7.6	Organization Type (State Government, Local Government, Publicly Traded Organization, Privately Held Corporation, Non-Profit, Church Group, Other)
7.7	Type of Contract (insured, ASO, other)
7.8	Is this a calendar year plan? (Y (yes) or N (no))
7.9	If data element 7.8 is no, provide non-calendar year start date.
7.10	Current/Anticipated Enrollment

Notes

This reporting section is an HPMS upload. The full record layout for this upload is available as Appendix 2 to this document.

All employer groups who have an arrangement in place with the Part C Organization for any portion of the reporting period should be included in the file upload, regardless of enrollment. In this case, plans should use the date they have an arrangement in place with the employer group to identify the reporting year. For employer groups maintaining multiple addresses with your organization, please report the address from which the employer manages the human resources/health benefits.

Federal Tax ID is a required field in the file upload. Organizations should work with their employer groups to collect this information directly. Alternatively, there are several commercially available lookup services that may be used to locate this number.

Data Element 7.7 refers to the type of contract your organization holds with the employer group that binds you to offer benefits to their retirees.

For Data Element 7.10, the enrollment to be reported should be as of the last day of the reporting period and should include all enrollments from the particular employer group into the specific plan benefit package (PBP) noted. (If an employer group canceled mid-way through the reporting period, they would still appear on the listing but would show zero enrollments.)

The employer organization type is based on how plan sponsors file their taxes.

For organizations that provide coverage to private market employer groups and which are subject to Mandatory Insurer Reporting (MIR) of Medicare Secondary Payer data, CMS permits these organizations to use the employer address and tax ID information submitted via the MIR to also satisfy CMS’ Part C reporting and validation requirements.   However, this does not imply that if the organization has already submitted this information to CMS for some other purpose, they do not have to resubmit it to us again for the purposes of the Part C reporting requirements.

8. Provider Fee-For-Service ((PFFS) Plan Enrollment Verification Calls; Monitoring Purposes Only

– Validation of this reporting section is not required because these data will be initially used only for monitoring.

Reporting section	Organization Types Required to Report	Report Freq./ Level	Report Period (s)	Data Due date (s)
8. PFFS Plan Enrollment Verification Calls	03 – RFB PFFS 04 – PFFS 800-series plans should NOT report	1/year PBP	1/1-12/31	2/28 of following year

Data elements to be reported under this reporting section are:

Element Number	Data Elements for PFFS Plan Enrollment Verification Calls
8.1	Number of times the plan reached the prospective enrollee with the first call of up to three required attempts in reporting period
8.2	Number of follow-up educational letters sent in reporting period
8.3	Number of enrollments in reporting period

Notes

This reporting section requires direct data entry into HPMS.

Note that this does not apply to group PFFS coverage. Also, this reporting section only pertains to calls made to individual enrollees.

Plans should tie the reported elements to enrollment effective dates.  For example, report for 2013 all those calls and follow-up letters linked to 2013 effective enrollments—including those done in late 2012 for 2013 enrollments.  Any enrollment requests received in 2012 (for 2013 effective dates) and calls/letters associated with them would be reported in the 2013 reporting period--not in the 2012 reporting period. Otherwise, the reported elements for this reporting section would not connect for “Annual Coordinated Election Period” (AEP) enrollments. 

9. PFFS Provider Payment Dispute Resolution Process; monitoring purposes only

–Validation of this reporting section is not required because these data will initially be used only for monitoring.

Reporting section	Organization Types Required to Report	Report Freq./ Level	Report Period (s)	Data Due date (s)
9. PFFS Provider Payment Dispute Resolution Process	03 – RFB PFFS 04 - PFFS 14 – ED-PFFS	1/year PBP	1/1-12/31	2/28 of following year

Data elements reported under this reporting section are:

Element Number	Data Elements for PFFS Provider Payment Dispute Resolution Process
9.1	Number of provider payment denials overturned in favor of provider upon appeal
9.2	Number of provider payment appeals
9.3	Number of provider payment appeals resolved in greater than 60 days

Notes

This reporting section requires direct data entry into HPMS.

This reporting section must be reported by all PFFS plans, regardless of whether or not they have a network attached.

This reporting requirement seeks to capture only provider payment disputes which include any decisions where there is a dispute that the payment amount made by the MA PFFS Plan to deemed providers is less than the payment amount that would have been paid under the MA PFFS Plan’s terms and conditions, or the amount paid to non-contracted providers is less than would have been paid under original Medicare (including balance billing).

10. Agent Compensation Structure – SUSPENDED

11. Agent Training and Testing – SUSPENDED

12. Plan Oversight of Agents –

Reporting section	Organization Types Required to Report	Report Freq./ Level	Report Period (s)	Data Due date (s)
12. PLAN OVERSIGHT OF AGENTS	1876 cost plans, local Coordinated Care Plans (Local CCP), Medicare Savings Accounts (MSA), Provider Fee-For-Service plans (PFFS), and Regional Coordinated Care Plans (Regional CCP).*	1/year Contract	1/1-12/31	2/28 of following year

* Sponsors of stand-alone prescription drug plans, which do not also have MA-PD plans, already report these data as part of the Part D reporting requirements and are, therefore, exempt from this Part C reporting section. Employer/union group plans and 800 series plans are also exempt from this reporting section.

  Sponsors are required to comply with State requests for information about the performance of licensed agents or brokers as part of a state investigation into the individual’s conduct. Plans are responsible for monitoring the conduct of their agents. While the states oversee agent licensing, CMS will monitor agent complaints to determine if Sponsors are investigating identified complaints and imposing disciplinary actions as well as reporting poor conduct to the state.

Complaints include both complaints from the Complaint Tracking Module (CTM) and other complaints or grievances made directly to the Sponsor. Complaints may result in various disciplinary actions, ranging from verbal warning to termination of employment or contract.

Reporting timeline:

	YTD
Reporting Period	January 1 - December 31
Data due to CMS/HPMS	February 28

Data elements to be uploaded at the Contract level:

1. Agent/Broker:

For each agent that received compensation (including commission and salary) in the reporting period (initial enrollments and renewal payments received), indicate:

1. Contract Number.

2. Agent/Broker Type (Captive, Employed, Independent, None).

3. Agent/Broker Last Name.

4. Agent/Broker First Name.

5. Agent/Broker Middle Initial.

6. Agent/Broker State Licensed. For agents licensed in multiple states, complete a row for each state in which the agent is licensed.

7. Agent/Broker National Producer Number (NPN).

8. Plan Assigned Agent/Broker Identification Number.

9. Agent/Broker Current License Effective Date.

10. Agent/Broker Appointment Date.

11. Agent/Broker Training Completion Date.

12. Agent/Broker Testing Completion Date.

13. In aggregate, the number of Agent/Broker complaints for the reporting period. If multiple lines are needed for an agent (licensed in more than one state) only fill out this data element for the first line. For example, if an agent has four complaints and is licensed in Florida and Georgia, all four complaints should be listed under the Florida line.

14. In aggregate, the number of Agent/Broker disciplinary actions taken in the reporting period (related to Marketing). Examples of disciplinary actions include: retraining, verbal or written warnings, suspension, termination, etc. If multiple lines are needed for an agent (licensed in more than one state) only fill out this data element for the first line. For example, if an agent has received two disciplinary actions and is licensed in Florida and Georgia, both actions should be listed under the Florida line.

15. At agent/broker level, Agent/Broker Termination Date (if applicable).

16. At agent/broker level, Termination for Cause? (Y(yes) or N (no)).

17. Third-party Marketing Organization (TMO)/Field Marketing Organization Name(FMO), if applicable.

18. The number of new enrollments in the reporting period. If more than one line is filled out because of agent being licensed in multiple states, please put enrollments in by state.

2. New Enrollments:

For all new enrollments (initial or renewal) during the reporting period for which an Agent/Broker is associated (includes instances where the agent/broker was assigned after the enrollment was initiated), indicate:

1. Contract Number.

2. Plan Beneficiary Package (PBP) Number.

3. Beneficiary Last Name.

4. Beneficiary First Name.

5. Beneficiary Middle Initial.

6. Beneficiary HICN or RRB Number.

7. Agent/Broker Last Name.

8. Agent/Broker First Name.

9. Agent/Broker Middle Initial.

10. Agent/Broker National Producer Number (NPN).

11. Plan Assigned Agent/Broker Identification Number.

12. Enrollment Mechanism. (Plan/Plan Representative Online; CMS Online Enrollment Center; Plan Call Center; 1-800-MEDICARE; Paper Application; Auto-Assigned/Facilitated; Other).

13. Enrollment Application Date.

14. Enrollment Effective Date.

15. The number of Agent/Broker complaints filed by the beneficiary in the reporting period.

16. Of the number reported in O, the number of Marketing related complaints.

13. Special Needs Plans (SNPs) Care Management

Reporting section	Organization Types Required to Report	Report Freq./ Level	Report Period (s)	Data Due date (s)
13. SNPS Care Management	SNP PBPs under the following types: 01 – Local CCP 11 – Regional CCP 15 – RFB Local CCP Organizations should exclude 800 series plans if they are SNPs.	1/Year PBP	1/1-12/31	2/28 of following year

Data elements reported under this reporting section are:

Element Number	Data Element	Inclusions	Exclusions
13.1	Number of new enrollees.	New enrollees are defined with respect to the "90-day rule." The initial health risk assessment is expected to be completed within 90 days of enrollment which must be continuous for that period. The member could have initially enrolled as early as 90 days prior to the measurement year (enrolled as early as 10/3 of the previous year) and would still be eligible in the current measurement year as of 1/1 if no initial HRA had been performed prior to 1/1. For the purposes of this reporting, members enrolled continuously for more than 90 days in the same plan without receiving an initial HRA are no longer reported as eligible for an initial HRA in the same plan but are reported as eligible for a “reassessment HRA” in that same plan. If a member disenrolls from one plan and enrolls in another plan, that member is reported as eligible for an initial HRA anytime during the initial period of 90 days from enrollment date.	Members with a documented initial HRA under that plan prior to the measurement year.
13.2	Number of enrollees eligible for an annual health risk reassessment (HRA)	Report all members in the same health plan who reached the threshold of 365 days of continuous enrollment after their last HRA in that health plan at some point of time within the measurement year or received a reassessment HRA in that plan within the 365 day timeframe as required.	Enrollees who did not reach a threshold of continuous enrollment in the same health plan for at least 365 days after their last HRA and did not receive a reassessment HRA in that plan within the 365 day timeframe as required.
13.3	Number of initial HRAs performed on new enrollees.	Initial HRAs performed on new enrollees (as defined above in data element 13.1) within 90 days of enrollment. The HRA must have occurred between 1/1and 12/31 of the measurement year.	Initial HRAs on new enrollees as defined in data element 13.1 that were not performed during the time period of 1/1 and 12/31 of the measurement year.
13.4	Number of annual reassessments performed.	Number of annual reassessments performed on enrollees eligible for a reassessment (during the measurement year as defined in element 13.2 above). Includes all measurement year HRA reassessments performed within 365 days of last HRA on eligible enrollees. If an HRA is completed for the first time for a beneficiary between the 91st and 365th day of continuous enrollment, count this as an “annual reassessment.” Future annual reassessments would be on a 365 day cycle, only counted if they occur within 365 days of the last reassessment.	HRA reassessments not performed between 1/1and 12/31 of the measurement year.

Notes:

This reporting section requires direct data entry into HPMS.

For Data Elements 13.3 and 13.4, CMS requires only completed assessments. This reporting section excludes cancelled enrollments.² If an enrollee has multiple reassessments within the 90-day or the 365 day time periods, just report one HRA for the 90-day period and/or one reassessment within the 365 day time period.

If eligibility records received after completion of the health assessment retroactively indicate the member was never enrolled in the plan (even when doing the HRA), do not count this beneficiary as a new enrollee or count the HRA.

The 90-day rule applies to initial health risk assessments (HRAs) for new enrollees and current enrollees who do not have a documented health risk assessment within 90 days of enrollment. Current enrollees with documented health risk assessments must have an annual reassessment no later than one year (365 days) after their last documented health risk assessment.

The date the HRA is completed by the sponsoring organization is the completed date of the HRA.

If a beneficiary enrolls and is mailed an HRA in December 2013, and the HRA is completed in 2014 (within 90 days of enrollment), count this beneficiary as a new enrollee in 2014 with an HRA completed in calendar 2014.

.

Questions have arisen regarding how to report data elements in this reporting section when members disenroll and then re-enroll, either in the same plan or a different plan (different organization or sponsor). When a member disenrolls from one plan and re-enrolls into another plan (a different sponsor or organization), the member should be counted as a “new enrollee” for the purposes of Part C reporting. If the enrollee received a pre-assessment health risk assessment from the same organization within 90 days prior to the enrollment in the new PBP, the member is not a “new enrollee” for the purposes of this Part C reporting requirement. However, if the pre-assessment health risk assessment occurred greater than 90 days while enrolled in the “old PBP but prior to enrollment in the “new PBP,” the member should be considered as a “new enrollee” in the “new PBP.” The table below provides guidance for the case in which a member disenrolls and then re-enrolls in the same plan.

A health risk assessment can be reported before an individualized care plan (ICP) is completed.

Please note that these technical specifications pertain to Part C reporting only and are not a statement of policy relating to special needs plan care management. For more information, refer to Chapter 16b of the Medicare Managed Care Manual (Section 90.8 Health Risk Assessment), which was issued and became effective on May 20, 2011.

	Additional Reporting Guidance for SNPs Care Management Reporting Section: Member Disenrolls/Re-Enrolls in Same Plan
Data Element	Health Risk Assessment (HRA) Status
	Initial HRA Performed prior to Disenrollment	Initial HRA not Performed prior to disenrollment	Reassessment Performed prior to Disenrollment	Reassessment not Performed prior to Disenrollment but Initial HRA Performed
13.1 (# New Enrollees)		Count as new enrollee beginning day of re-enrollment
13.2 (# Eligible for Reassessment)	Count as eligible for reassessment beginning on day of re-enrollment		Count as eligible for reassessment HRA beginning on day of re-enrollment.	Count as eligible for reassessment HRA beginning on day of re-enrollment.
13.3 (# Initial HRAs Performed within 90 Days of Enrollment)		HRA must occur within 90 days of enrollment to count for this data element.
13.4 (# Reassessments Performed within 365 day of last HRA)	Reassessment HRA must be performed within 365 days of re-enrollment to count for this data element.	Count reassessment HRAs performed within 365 days of the initial HRA (if initial HRA is performed within 90 days of re-enrollment) or within 365 days of the date of initial enrollment (if initial HRA is not performed within 90 days of re-enrollment) .	Reassessment HRA must be performed within 365 days of re-enrollment to count for this data element.	Reassessment HRA must be performed within 365 days of re-enrollment to count for this data element.

14. Enrollment and Disenrollment

Reporting section	Organization Types Required to Report*	Report Freq./ Level	Report Period (s)	Data Due date (s)
14. Enrollment and Disenrollment	All stand-alone MAOs (MA, no Part D) 1876 Cost Plans with no Part D	2/Year Contract	1/1-6/30 7/1 – 12/31	8/31 2/28 of following year

* For other organization types, please report this reporting section under the appropriate section in the Part D reporting requirements. For example, MA-PDs should report in Part D for this reporting section, listed as a “section” in Part D.

For Part C reporting:

For Part C reporting, all stand-alone MAOs (MA, no Part D) are to report this reporting section as well as 1876 cost plans with no Part D. For other organization types, please report this reporting section under the appropriate section in the Part D reporting requirements. For example, MA-PDs should report in Part D for this reporting section, listed as a “section” in Part D.

CMS provides guidance for MAOs and Part D sponsors’ processing of enrollment and disenrollment requests.

Both Chapter 2 of the Medicare Managed Care Manual and Chapter 3 of the Medicare Prescription Drug Manual outline the enrollment and disenrollment periods (Section 30) enrollment (Section 40) and disenrollment procedures (Section 50) for all Medicare health and prescription drug plans.

CMS will collect data on the elements for these requirements, which are otherwise not available to CMS, in order to evaluate the sponsor’s processing of enrollment and disenrollment requests in accordance with CMS requirements. For example, while there are a number of factors that result in an individual’s eligibility for a Special Enrollment Period (SEP), sponsors are currently unable to specify each of these factors when submitting enrollment transactions. Sponsor’s reporting of data regarding SEP reasons for which a code is not currently available will further assist CMS in ensuring sponsors are providing support to beneficiaries, while complying with CMS policies.

Data elements 1.A-1.O must include all enrollments (code 61 transactions). Disenrollments must not be included in Section 1 Enrollment.

Section 2: Disenrollment must include all voluntary disenrollment transactions.

Reporting Timeline:

Reporting Period	January 1 – June 30	July 1-December 31
Data Due to CMS	August 31	February 28 of next year

Data elements to be entered into the HPMS at the Contract level:  

1. Enrollment:

1. The total number of enrollment requests received in the specified time period. (data element 14.1).

2. Of the total reported in A, the number of enrollment requests complete at the time of initial receipt (i.e. required no additional information from applicant or his/her authorized representative). (data element 14.2)

3. Of the total reported in A, the number of enrollment requests that required requests for additional information. (data element 14.3)

4. Of the total reported in A, the number of enrollment requests denied due to the Sponsor’s determination of the applicant’s ineligibility to elect the plan (e.g. individual not having a valid enrollment period). (data element 14.4)

5. Of the total reported in C, the number of incomplete enrollment requests received that are completed within established timeframes. (data element 14.5)

6. Of the total reported in C, the number of enrollment requests denied due to the applicant or his/her authorized representative not providing information to complete the enrollment request within established timeframes. (data element 14.6)

7. Of the total reported in A, the number of paper enrollment requests received. (data element 14.7)

8. Of the total reported in A, the number of telephonic enrollment requests received (if offered). (data element 14.8)

9. Of the total reported in A, the number of internet enrollment requests received via plan website (if offered). (data element 14.9)

10. Of the total reported in A, the number of Online Enrollment Center (OEC) enrollment requests received. (data element 14.10)

11. For stand-alone prescription drug plans (PDPs) only: Of the total reported in A, the number of enrollment requests effectuated by sales persons (as defined in Chapter 3 of the Medicare Managed Care Manual). (This does not apply to Part C or 1876 cost plans.)

12. Of the number reported in A, the number of enrollment transactions submitted using the SEP Election Period code "S" related to creditable coverage.

13. Of the number reported in A, the number of enrollment transactions submitted using the SEP Election Period code "S" related to credible coverage. (This does not apply to Part C or 1876 cost plans.)

14. For stand-alone prescription drug plans (PDPs) only: Of the number reported in A, the number of enrollment transactions submitted using the SEP Election Period code “S” related to SPAP (This does not apply to Part C or 1876 cost plans.)

15. Of the number reported in A, the number of enrollment transactions submitted using the SEP Election Period Code “S” for individuals affected by a contract nonrenewal, plan termination or service area reduction. (data element 14.11)

2. Disenrollment:

1. The total number of voluntary disenrollment requests received in the specified time period. (data element 14.12)

2. Of the total reported in A, the number of disenrollment requests complete at the time of initial receipt (i.e. required no additional information from enrollee or his/her authorized representative). (data element 14.13)

3. Of the total reported in A, the number of disenrollment requests denied by the Sponsor for any reason. (data element 14.14)

Appendix 1: Employer Group Plan Sponsor Upload File Format

Required File Format = ASCII File - Tab Delimited

Do not include a header record

Filename extension should be “.TXT”

There can be multiple records per plan.

Field Name	Field Type	Field Length	Field Description	Sample Field Value(s)
Contract_ Number	CHAR Required	5 Exactly	Provide the CMS issued contract number being offered to the Employer Group Plan Sponsor. (Note: The system shall validate the contract number is valid.)	H1234
Plan_ID	NUM Required	3 Exactly	Provide the ID (with leading zeros as appropriate) of the Plan Benefit Package (PBP) being offered to the Employer Group Plan Sponsor. (Note: This is a numeric field only. The system shall validate the plan ID is valid.)	801 or 001
Employer_Legal_Name	CHAR Required	150	Provide the legal name of the Employer Group Plan Sponsor.	United Parcel Service
Employer_DBA_Name	CHAR Optional	150	If applicable provide the doing business as (DBA) name of the Employer Group Plan Sponsor.	United Parcel Service Employees Association
Employer_Federal_Tax_ID	NUM Required	20	Provide the federal tax ID of the Employer Group Plan Sponsor. (Note: This is a numeric field only.)	<numeric>
Employer_Street_Address	CHAR Required	150	Provide the street address of the Employer Group Plan Sponsor headquarters.	1212 North Luther Street
Employer_City_Address	CHAR Required	75	Provide the city in which the Employer Group Plan Sponsor headquarters is located.	Wichita
Employer_ State_Address	CHAR Required	2	Provide the state abbreviation in which the Employer Group Plan Sponsor headquarters is located. (Note: The system shall validate the state abbreviation is appropriate.)	MO
Employer_Zip_Address	NUM Required	10	Provide the Employer Group Plan Sponsor headquarters’ zip code. (Note: This is a numeric field only.)	22203
Employer_Sponsor_Type	NUM Required	1	Indicate the Employer Group Plan Sponsor Type; acceptable values provided as sample. (Note: This is a numeric field only. The system shall validate the value is 1 through 3.)	1=Employer 2=Union 3=Trustees of a Fund
Employer_Organization_Type	NUM Required	1	Indicate the Employer Group Plan Organization Type; acceptable values provided as sample. (Note: This is a numeric field only. The system shall validate the value is 1 through 7.)	1=State Government 2=Local Government 3=Publicly Traded Corp. 4=Privately Held Corp. 5=Non-Profit 6=Church Group 7=Other
Employer_Contract_Type	NUM Required	1	Indicate the Employer Group Plan Contract Type; acceptable values provided as sample. (Note: This is a numeric field only. The system shall validate the value is 1 through 3.)	1=Insured 2=ASO 3=Other
Employer_Start_Date	NUM Required	6	Provide the month and year when the Employer Group Plan Sponsor started (or will start). The format is MMYYYY, so the sample is intended to depict June 2008 (062008). (Note: This is a numeric field only. The system shall validate that the month is a value of 01 to 12.)	062008
Employer Enrollment	NUM Required	7	Provide the current (or anticipated) enrollment for the Employer Group Plan Sponsor. (Note: This is a numeric field only. Do not include commas.)	9999999

Appendix 2: FAQs: Reporting Sections 5 & 6:

Grievances, Organization Determinations, & Reconsiderations

	PLAN INQUIRIES	CMS RESPONSES
	Should plans report informal complaints as Grievances under the Part C reporting requirements? For example: During the course of a home visit, a member expresses dissatisfaction regarding a particular issue.  The member does not contact the plan directly to file a complaint, but the plan representative determines the member is not happy and logs the issue for Quality Improvement tracking.	Plans are to report any grievances filed directly with the plan and processed in accordance with the plan grievance procedures outlined under 42 CFR Part 422, Subpart M. Plans are not to report complaints made to providers, such as the complaint in the example provided, that are not filed with the plan.
	Should plans report all Dual Eligible member grievances to CMS?	No. Plans are only to report Dual Eligible member grievances processed in accordance with the plan grievance procedures outlined under 42 CFR Part 422, Subpart M. For example, plans will not report grievances filed under the state Medicaid process, but not filed with the plan and addressed under the plan’s Subpart M grievance process.
	Is a plan to report a grievance, organization determination or reconsideration to CMS when the plan makes the final decision or when the request is received?	Plans are to report grievances, organization determinations and reconsiderations that were completed (i.e., plan has notified enrollee of its decision or provided or paid for a service, if applicable) during the reporting period, regardless of when the request was received.
	Are plans to report only those organization determinations defined under 42 C.F.R. 422.566?	CMS requires plans to report requests for payment and services, as described in the Part C Technical Specifications, Reporting section 6. Plans are to report requests for payment and services consistent with CMS regulations at 42 C.F.R. Part 422, Subpart M as “organization determinations” – i.e., a relatively broader category of requests for coverage For example, plans are to include adjudicated claims in the reportable data for Organization Determinations.
	We are seeking information on how we should report pre-service requests and claims requests for this category. Do you want fully favorable, partially favorable, and adverse for both pre-service requests and claims requests?	Yes. Plans are to report fully favorable, partially favorable, and adverse pre-service and claims requests (organization determinations and reconsiderations).
	If we have a prior authorization request and a claim for the same service -- is that considered a duplicate or should we report both?	Plans are to report both a prior authorization request and a claim for the same service; this is not considered a duplicate.
	Is a request for a predetermination to be counted as an organization determination?  Does it matter who requests the predetermination – contracted provider, non-contracted provider or member?  If so, should they also be counted as partially and fully unfavorable?	Organization determinations include a request for a pre-service (“predetermination”) decision submitted to the plan, regardless of who makes the pre-service request – e.g., a contracted provider, non-contracted provider or member. Plans are to report partially favorable, adverse and fully favorable pre-service organization determinations.
	Should plans report determinations made by delegated entities or only decisions that are made directly by the plan – e.g., should plans report decisions made by contracted radiology or dental groups?	Yes. Plans are to report decisions made by delegated entities – such as an external, contracted entity responsible for organization determinations (e.g., claims processing and pre-service decisions) or reconsiderations.
	The Tech Specs advise plans to exclude certain duplicate/edits when reporting on the claim denial requirement.  Is the intent to exclude duplicates or is it to exclude "billing" errors or both?  For example, if a claim is denied because the provider didn’t submit the claim with the required modifier, should that be excluded from the count?	Plans are to report organization determinations where a substantive decision (fully favorable, partially favorable, and adverse) has been made. Plans should exclude duplicate claim submissions (e.g., a request for payment concerning the same service) and claims returned to a provider/supplier due to error (e.g., claim submissions or forms that are incomplete, invalid or do not meet the requirements for a Medicare claim).
	Do we have to include lab claims for this reporting section? Do we need to report the ones which involve no pre-service as well as the ones that involve pre-service?	Yes. Plans are to report lab claims. Even in the absence of a pre-service request, a request for payment (claim) is a reportable organization determination.
	Enrollee is hospitalized for heart surgery, no prior authorization is required and the claim is paid timely in accordance with full benefit coverage. Our reading of the Medicare Managed Care Manual reveals that the organization is only required to notify the enrollee of Partially Favorable or Adverse decisions.  There is no requirement to notify enrollees of Fully Favorable decisions.  Is this an organization determination?	Prior authorization is not required to consider a decision an organization determination. A submitted claim is a request for an organization determination. All paid claims are reportable (fully favorable) organization determinations. Timeframe and notification requirements for Fully Favorable determinations are described under 42 C.F.R 422.568(b) and (c). Written notice is required for Partially Favorable, and Adverse determinations.
	Enrollee obtains a rhinoplasty for purely cosmetic reasons, which is a clear exclusion on the policy. Enrollee and provider both know this is likely not covered but they submit the claim.  Claim is denied as an exclusion/ non-covered service.  Neither the enrollee nor the provider pursues it any further. Is this an organization determination?	The plan is to report this denial as an organization determination. A request for payment (claim) is a reportable organization determination.
	Enrollee is out of area and in need of urgent care. Provider is out of area / network.  The enrollee calls plan and requests a coverage determination for this service.  Health Plan approves use of out of area services.  Claim is submitted and paid in full.   Is this counted as one event (i.e., pre-auth and claim not counted as two events)?	In this example, both the pre-service decision and claim are counted as two, separate fully favorable organization determinations. A claim submitted for payment is an organization determination request. Claims paid in full are reportable (fully favorable) organization determinations.
	When an organization determination is extended into the future does that extension count in the reporting of org determinations (e.g. on-going approval for services approved in the initial decision)?	Yes. Plans generally are to count an initial request for an organization determination (request for an ongoing course of treatment) as separate from any additional requests to extend the coverage. For example, plans are to count an initial approved request for physical therapy services as one organization determination. If the plan, later, approves a subsequent request to continue the ongoing services, the plan should count the decision to extend physical therapy services as another, separate organization determination.
	Our interpretation is that the term “contracted provider” means “contracted with the health plan” not “contracted with Medicare”.	Yes. For purposes of Part C Reporting Section 6 reporting requirements, “contracted provider” means “contracted with the health plan” not “contracted” (or participating) with Medicare.”
	When we make an adverse determination that is sent to the QIO for review and later our adverse determination is overturned, should we count and report the initial Adverse determination that goes to the QIO? We understand that QIO determinations are excluded from our reporting.	Yes. Regardless of whether a QIO overturns an Adverse organization determination, plans are to report the initial adverse or partially favorable organization determination.
	Should cases forwarded to the Part C IRE be counted once in the reporting section, i.e., as the Partially Favorable or adverse decision prior to sending to the IRE?	When a plan upholds its adverse or partially favorable organization determination at the reconsideration level, the plan generally must report both the adverse or partially favorable organization determination and reconsideration. Exceptions: Plans are not to report: 1.) Withdrawn or dismissed cases, or 2.) QIO determinations concerning an inpatient hospital, skilled nursing facility, home health and comprehensive outpatient rehabilitation facility services terminations.
	Should supplemental benefit data be excluded from the Part C Reporting?	As described in this guidance, a plan’s response to a request for coverage (payment or provision) of an item or service is a reportable organization determination. Thus, requests for coverage of a supplemental benefit (e.g., a non-Medicare covered item/service) are reportable under this effort.

Appendix 3: Agent/Broker (A/B) File

Agent/Broker/TMO Information

A/B Type

A/B Last Name

A/B First Name

A/B MI

State

A/B National Producer Number (NPN)

Plan Assigned A/B ID Number

License Date

Appointment Date

Training Completion Date

Testing Completion Date

# of A/B Complaints

# of Disciplinary Actions taken?

Termination Date (if applicable)

Termination for Cause? (Y/N)

TMO/ FMO Name/ ID

# of New Enrollments

Read Me
Variable	Description	Allowable Values
Agent/Broker (A/B) Type	The type of agent/broker used for each beneficiary enrollment.	Captive, Employed, Independent, None
Agent/Broker (A/B) Last Name	If the enrollment was facilitated by an agent/broker or one was assigned after enrollment, provide the last name of the agent/broker.	Last Name
Agent/Broker (A/B) First Name	If the enrollment was facilitated by an agent/broker or one was assigned after enrollment, provide the first name of the agent/broker (optional).	First Name
Agent/Broker (A/B) Middle Initial	If the enrollment was facilitated by an agent/broker or one was assigned after enrollment, provide the middle initial of the agent/broker.	MI
State	Indicate the State where agent/broker is licensed.	State Postal Code
Agent/Broker (A/B) National Producer Number (NPN)	The number assigned to the agent/broker in the National Insurance Producer Registry (NIPR).
Plan Assigned Agent/Broker (A/B) Identification Number	The unique identification number assigned to the agent/broker by the plan.
Agent/Broker Licensed Date	Indicate the agent/broker current license date.	MM/DD/YYYY
Agent/Broker Appointment Date	Indicate the current agent/broker appointment date.	MM/DD/YYYY
Agent/Broker Training Completion Date	Indicate date that agent/broker has completed all annual training requirements.	MM/DD/YYYY
Agent/Broker Testing Completion Date	Indicate date that agent/broker completed all of the annual testing requirements with a passing score.	MM/DD/YYYY
# Agent/Broker Complaints	Indicate number of complaints against the agent.	0, 1, 2, …
# of Disciplinary Actions Taken	Indicate the number of disciplinary actions taken related to marketing. Examples of disciplinary actions include: retraining, verbal or written warnings, suspension, termination, etc.	0, 1, 2, …
Termination Date	If the agent/broker was terminated during the year, indicate the date of termination	MM/DD/YYYY
Termination for cause? Y/N	Enter Yes if the agent/broker was terminated for cause. Enter No if the agent/broker was terminated for another reason.	Yes or No
TMO/FMO Name	The name of the associated Third-party Marketing Organization (TMO)/Field Marketing Organization (FMO), if applicable.
# of New Enrollments	Indicate number of new enrollments generated by this agent/broker for the reporting period.

Instructions:

For agents licensed in multiple states, complete a row for each state in which the agent is licensed.

Fill out for every agent who received compensation in the reporting period (initial enrollments and renewal payments received).

1 The term “measure” has been replaced with the term “reporting section” effective 2013.

2 A cancelled enrollment is one that never becomes effective as in the following example:

An individual submits an enrollment request to enroll in Plan A on March 25th for an effective date of April 1st. Then, on March 30th, the individual contacts Plan A and submits a request to cancel the enrollment. Plan A cancels the enrollment request per our instructions in Chapter 2, and the enrollment never becomes effective.”