Part C Medicare Advantage Reporting Requirements and Supporting Regulations in 42 CFR 422.516(a)

Medicare Part C Plan Reporting Requirements
Technical Specifications Document
Contract Year 2016

Effective Date: January 1, 2016

Version Date: August 2015

Prepared by:
Centers for Medicare & Medicaid Services
Center for Medicare
Medicare Drug Benefit and C&D Data Group

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Table of Contents
Background and Introduction

3

General Information

3

Reporting Requirements Reporting Sections List

5

Reporting Sections

9

Benefit Utilization (Suspended)

9

Procedure Frequency (Suspended)

9

Serious Reportable Adverse Events (Suspended)

9

Provider Network Adequacy (Suspended)

9

Grievances

9

Organization Determinations/Reconsiderations

13

Employer Group Plan Sponsors

20

Provider Fee-For-Service ((PFFS) Plan Enrollment Verification Calls

22

PFFS Provider Payment Dispute Resolution Process

23

Agent Compensation Structure (Suspended)

24

Agent Training and Testing (Suspended)

24

Sponsor Oversight of Agents

24

Special Needs Plan Care Management

27

Enrollment and Disenrollment

31

Rewards and Incentives Program (new)

34

Mid-Year Network Changes(new)

36

Appendix: FAQs: Reporting Sections 5 & 6

39

2

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).
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:
A. Data element definitions - details for each data element reported to CMS.
B. Notes - additional clarifications to a reporting section derived from the responses to
comments received under the OMB clearance process.
C. Reminder: Underlined passages indicate updates and/or new information from the
last version including draft versions.
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.
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), Agent/Broker Name, and Beneficiary Name.
*Under FOIA, Plans may need to provide independently justification for protecting these data if
a FOIA request is submitted.

1

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

3

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 # 3 Serious Reportable Adverse Events;
Reporting section # 4 Provider Network Adequacy;
Reporting section #10 Agent Compensation Structure;
Reporting section #11 Agent Training and Testing;
Major Changes from CY 2015 Technical Specifications
Two reporting sections Reporting Section # 6 (Organization Determinations/Reconsiderations),
and Reporting Section #14 (Enrollments/Disenrollments) were updated to include additional data
elements. In addition, three new reporting sections were added: Rewards and Incentives
Program, Mid-Year Network Changes, and Payments to Providers. Reporting Section # 12 Plan
Oversight of Agents was changed to Sponsor Oversight of Agents and the data due date was
changed to the first Monday in February of the following year. The dues dates for Grievances
and Employer Group Plan Sponsors were also changed to the first Monday in February. The due
dates for Enrollment/Disenrollment were changed to last Monday of August and February.

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.

4

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 31st
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 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] .

5

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
Organization
Report
Report
Data Due date
Section
Types Required
Freq./
Period (s)
(s)
to Report
Level
1. Benefit
Utilization
Suspended
2. Procedure
Frequency
3. Serious
Reportable
Adverse Events
4. Provider
Network
Adequacy
5. Grievances
(Revised)

Suspended
Suspended

Suspended

CCP, PFFS,
1876 Cost,
MMP, MSA,
Employer/Union
Direct Contract
(includes all 800
series plans)

1/Year
Contract

6. Organization
Determinations/
Reconsiderations
(Revised)

CCP, PFFS,
1876 Cost,
MMP, ,
Employer/Union
Direct Contract
MSA (includes
all 800 series
plans)

1/Year
Contract

7. Employer
Group Plan
Sponsors
8. PFFS Plan
Enrollment
Verification
Calls

1/year
PBP

1/1 - 12/31

PFFS

1/year
PBP

(800-series plans
should NOT
report)

1/1-3/31
4/1-6/30
7/1-9/30
10/1-12/31
(2/28 reporting
will include
each quarter)
1/1-3/31
4/1-6/30
7/1-9/30
10/1-12/31
(2/28 reporting
will include
each quarter)

1/1-12/31

First Monday of
February in
following year

Last Monday of
February in
following year

First Monday of
February in
following year
Last Monday
of February in
following year
Validation
unnecessary—
using for
monitoring only

6

Reporting
Section

Organization
Types Required
to Report

Report
Freq./

Reporting
Section

9. PFFS Provider
Payment Dispute
Resolution
Process

PFFS,
Employer/Union
Direct Contract
(includes all 800
series plans)

1/year
PBP

1/1-12/31

10. Agent
Compensation
Structure
11. Agent
Training and
Testing
12. Plan
Oversight of
Agents

13. Special Need
Plans (SNP)
Care
Management

14.
Enrollment/Dise
nrollment

Organization
Types
Required to
Report
Last Monday of
February in
following year
Validation
unnecessary—
using for
monitoring only

Suspended

Suspended

1876 cost plans, Revised
local
Coordinated
Care Plans
(Local CCP),
Medicare
Savings
Accounts
(MSA), Provider
Fee-For-Service
plans (PFFS),
and Regional
Coordinated
Care Plans
(Regional CCP).
Local, CCP,
1/Year
Regional CCP,
PBP
RFB Local CCP
with SNPs.
Includes 800
series plans.

1/1-12/31

First Monday of
February in
following year

1/1-12/31

Last Monday
of February in
following year

Only 1876 cost
plans with no
Part D.*

1/1-6/30
7/112/31

Last Monday
of August and
February
Validation
unnecessary—
using for
monitoring only

2/Year
Contract

7

Reporting
Section

Organization Types
Required to Report

Report
Freq./

Reporting
Section

15. Rewards and
Incentives

Local Coordinated
Care Plans (Local
CCP), Medicare
Savings Accounts
(MSA), Provider FeeFor-Service plans
(PFFS), and Regional
Coordinated Care Plans
(Regional CCP)
Regional CCP, Local
CCP, and RFB

1/Year

1/1-12/31

1/Year

1/1-12/31

16. Mid-Year
Network
Changes

Organization
Types
Required to
Report
Last Monday
of February in
following
year

Last Monday
of February in
following
year
17. Payments to
Regional CCP, Local
1/Year
04 – PFFS Last Monday
Providers
CCP, RFB, and PFFS
of February in
following
year
* MA-only. MA-PDs and PDPs report under Part D. MSA and chronic care excluded.

8

Reporting Sections
1. BENEFIT UTILIZATION (SUSPENDED)
2. PROCEDURE FREQUENCY (SUSPENDED)
3. SERIOUS REPORTABLE ADVERSE EVENTS
(SUSPENDED)
4. PROVIDER NETWORK ADEQUACY
(SUSPENDED)
5. GRIEVANCES
Reporting
section
5. Grievances

Organization Types
Required to Report
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.

Report
Freq./
Level
1/Year
Contract

Report
Data Due date (s)
Period
(s)
1/1-3/31 First Monday of
4/1-6/30 February in
7/1-9/30 following year
10/1­
12/31
(2/28
reporting
will
include
each
quarter)

Employer/Union Direct
Contracts should also
report this reporting
section, regardless of
organization type.

9

The data elements to be reported under this reporting section are:
Grievance Category
Total number Number of grievances in which
of Grievances timely notification* was given
Total Grievances
(5.1)
(5.2)
Number of Expedited Grievances
(5.3)
(5.4)
Enrollment/Disenrollment
(5.5)
(5.6)
Benefit Package Grievances
(5.7)
(5.8)
Access Grievances
(5.9)
(5.10)
Marketing Grievances
(5.11)
(5.12)
Customer Service Grievances
(5.13)
(5.14)
Organization determination and
(5.15)
(5.16)
reconsideration process
grievances
Quality Of Care Grievances
(5.17)
(5.18)
Grievances related to “CMS
(5.19)
(5.20)
Issues”
Other Grievances
(5.21)
(5.22)
* Timely notification of grievances means the member was notified according to the following
timelines:
• For standard grievances: no later than 30 calendar days after receipt of grievance.
• For standard grievances with an extension taken: no later than 44 calendar days after
receipt of grievance.
• For expedited grievances: no later than 24 hours after receipt of grievance.
Notes
This reporting section requires upload into HPMS.
In cases where a purported representative files a grievance on behalf of a beneficiary without an
Appointment of Representative (AOR) form, the timeliness calculation (“clock”) starts upon
receipt of the AOR form. This is a contrast to grievances filed by a beneficiary, in which cases
the clock starts upon receipt of the grievance.
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 22 categories described in this section to report grievances to
CMS (Elements 5.1 – 5.22). 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
10

representative may make the complaint or dispute, 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 period. 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 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.

11

•

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
•

See CY2014 Part C Plan Reporting Module for specific guidance concerning reporting
grievances.

•

Plans should validate that the total number of grievances is equal to the sum of the
total number of grievances for each category excluding expedited grievances.

•

Plans should validate that the total number of timely notifications is equal to the
sum of the total number of timely notifications for each category excluding
expedited grievances.
In cases where an extension is requested after the required decision making timeframe
has elapsed, the plan is to report the decision as non-timely. For example, Plan receives
grievance on 1/1/2014 at 04:00pm. An extension is requested at 1/31/2014 04:05pm.
Plan completes investigation and provides notification on 2/5/2014 04:00pm (35 calendar
days after receipt). This grievance is not considered timely for reporting as the decision
was rendered more than 30 calendar days after receipt.

•

•

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 the Part C
Reporting Module and Appendix 1: FAQs: Reporting Sections 5 & 6.

12

6. ORGANIZATION
DETERMINATIONS/RECONSIDERATIONS

Reporting
section
6. Organization
Determinations/
Reconsiderations

Organization Types
Required to Report
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.

Report
Freq./
Level
1/Year
Contract

Report
Data Due date (s)
Period
(s)
1/1-3/31 Last Monday of
4/1-6/30 February in
7/1-9/30 following year
10/1­
12/31
(2/28
reporting
will
include
each
quarter)

Employer/Union Direct
Contracts should also
report this reporting
section, regardless of
organization type.

13

Data elements for this reporting section are contained in Table 1. Two new data elements would
be added: data element 6.10, Number of Requests for Organization Determinations—Dismissals,
and data element 6.20, Number of Requests for Reconsiderations—Dismissals. These additions
will fill user needs for data on dismissals and make this reporting section more consistent with a
similar reporting section in Part D, Coverage Determinations and Redeterminations.
Table 1: Data Elements for Organization Determinations/Reconsiderations Reporting Section
Element
Number
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
6.10*
6.11
6.12
6.13
6.14
6.15
6.16
6.17
6.18
6.19
6.20*
6.21

6.22
6.23
6.24

Data Elements for Organization Determinations/Reconsiderations
Total Number of Organization Determinations Made in Reporting Time Period
Above
Of the Total Number of Organization Determinations in 6.1, Number Processed
Timely
Number of Organization Determinations – Fully Favorable (Services)
Number of Organization Determinations – Fully Favorable (Claims)
Number of Organization Determinations – Partially Favorable (Services)
Number of Organization Determinations – Partially Favorable (Claims)
Number of Organization Determinations – Adverse (Services)
Number of Organization Determinations – Adverse (Claims)
Number of Requests for Organization Determinations - Withdrawn
Number of Requests for Organization Determinations - Dismissals
Total number of Reconsiderations Made in Reporting Time Period Above
Of the Total Number of Reconsiderations in 6.10, Number Processed Timely
Number of Reconsiderations – Fully Favorable (Services)
Number of Reconsiderations – Fully Favorable (Claims)
Number of Reconsiderations – Partially Favorable (Services)
Number of Reconsiderations – Partially Favorable (Claims)
Number of Reconsiderations – Adverse (Services)
Number of Reconsiderations – Adverse (Claims)
Number of Requests for Reconsiderations - Withdrawn
Number of Requests for Reconsiderations - Dismissals
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:
Contract Number
Plan ID
Case ID
14

6.25
6.26
6.27
6.28
6.29
6.30
6.31

Date of original disposition
Original disposition (Fully Favorable; Partially Favorable or Adverse)
Case level (Organization Determination or Reconsideration)
Date case was reopened
Reason(s) for reopening (Clerical Error, New and Material Evidence, or Other)
Date of reopening disposition (revised decision)
Reopening disposition (Fully Favorable; Partially Favorable, Adverse or
Pending)
* Indicates new data element.

Notes
This reporting section requires both data entry and a file upload.
For an explanation of Part C organization determination, reconsideration, and reopenings
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 reconsideration procedures for MMPs,
refer to the State-specific Memorandum of Understanding.
All plan types listed in the table at the beginning of this section are required to report:
organization determinations, reconsiderations and reopenings, 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.
In cases where a purported representative files an appeal on behalf of a beneficiary without an
Appointment of Representative (AOR) form, the timeliness calculation (“clock”) starts upon
receipt of the AOR form. This is a contrast to appeals filed by a beneficiary, in which case the
clock starts upon receipt of the appeal.
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.
Plans are to report encounter data, whereby an encounter took place under a capitation
arrangement, as an organization determination. That is, we want plans to report capitated
providers’ encounters in lieu of actual claims data. All encounter data should be reported as
timely submissions.
Requests for Organization Determinations – Withdrawn (Element 6.9) should not be included in
the Total Number of Organization Determinations (Element 6.1).

15

Requests for Reconsiderations – Withdrawn (Element 6.19) should not be included in the Total
Number of Reconsiderations (Element 6.11).

If the Reopening Disposition (Element 6.31) is resolved (Fully Favorable, Partially Favorable, or
Adverse), the Date of Reopening Disposition (Element 6.30) is expected to fall in the quarter for
which the data is being reported.

CMS requires plans to report organization determinations and reconsiderations requests
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.

•

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 were 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 servicerelated decisions, including pre-authorizations, concurrent authorizations and postauthorizations.

•

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, upon request,
removed from the plan’s review process. This category excludes appeals that are
dismissed.

•

A dismissal is an action taken by a Medicare health plan when an organization
determination request or reconsideration request lacks required information or otherwise
does not meet CMS requirements to be considered a valid request. For example, an
individual requests reconsideration on behalf of an enrollee, but a properly executed
appointment of representative form has not been filed and there is no other documentation to
16

show that the individual is legally authorized to act on the enrollee’s behalf per the guidance
set forth in section 10.4.1 of Chapter 13. The plan must follow Chapter guidance prior to
issuing the dismissal

If a provider (e.g., a physician) declines to provide a service an enrollee has requested or offers
alternative service, 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 Inclusion
Organization Determinations:
•

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

•

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.

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.

Reopenings:
•

All Fully Favorable, Partially Favorable, Adverse or Pending Reopenings of Organization
Determinations and Reconsiderations, as described in the preceding sections.

17

Report:
• Completed organization determinations and reconsiderations (i.e., plan has notified
enrollee of its pre-service decision or adjudicated a claim) during the reporting period,
regardless of when the request was received. Plans are to report organization determination
or reconsideration where a substantive decision has been made, 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 and Chapter 13 of the Medicare
Managed Care Manual.
• All Part B drug claims processed and paid by the plan’s PBM are reported as organization
determinations or reconsiderations.
• Reopenings that are in a reopening status across multiple reporting periods are to be
reported in each applicable reporting period. For example, if a plan reopened an
organization determination on 3/15/2014 and sent the notice of the revised decision on
4/22/2014, that case should be reported as “pending” in the Q1 data file and then as
resolved in Q2 (either Fully Favorable, Partially Favorable or Adverse).
• 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.
• Report denials based on exhaustion of Medicare benefits.
•

In cases where an extension is requested after the required decision making timeframe has
elapsed, the plan is to report the decision as non-timely. For example, Plan receives
standard pre-service reconsideration request on 1/1/2014 at 04:00pm. An extension is
requested at 1/31/2014 04:05pm. Plan completes reconsideration and provides
notification on 2/5/2014 04:00pm (35 calendar days after receipt). This reconsideration is
not considered timely for reporting as the decision was rendered more than 30 calendar
days after receipt.

•

Dismissals

Do not report:

• Independent Review Entity (IRE) decisions.

18

• Reopenings requested or completed by the IRE, ALJ, and MAC.
• Concurrent reviews during hospitalization.
• Concurrent review of SNF, HHA or CORF care.
• 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
1: FAQs: Reporting Sections 5 & 6.

19

7. EMPLOYER GROUP PLAN SPONSORS
Reporting
section
7. Employer
Group Plan
Sponsors

Organization Types
Required to Report
01 – Local CCP
02 – MSA
04 – PFFS
06 – 1876 Cost
11 – Regional CCP
14 – ED-PFFS

Report
Freq./
Level
1/year
PBP

Report
Period (s)
1/1 ­
12/31

Data Due date
(s)
First Monday of
February in
following year

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.

Data elements reported under this reporting section are:
Element
Number
7.1
7.2
7.3
7.4
7.5
7.6
7.7
7.8
7.9
7.10

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

20

Notes
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, several commercially
available lookup services may be used to locate this number.
Data Element 7.7 refers to the type of contract the 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.

21

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
8. PFFS Plan
Enrollment
Verification
Calls

Organization Types
Required to Report
03 – RFB PFFS
04 – PFFS

Report
Freq./
Level
1/year
PBP

Report
Period
(s)
1/1­
12/31

Data Due date (s)

Last Monday of
February in
following year

800-series plans should
NOT report

Data elements to be reported under this reporting section are:
Element
Number
8.1
8.2
8.3

Data Elements for PFFS Plan Enrollment Verification Calls
Number of times the plan reached the prospective enrollee with the first call
of up to three required attempts in reporting period
Number of follow-up educational letters sent in reporting period
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
2016 all those calls and follow-up letters linked to 2016 effective enrollments—including those
done in late 2015 for 2016 enrollments. Any enrollment requests received in 2015 (for 2016
effective dates) and calls/letters associated with them would be reported in the 2016 reporting
period--not in the 2015 reporting period. Otherwise, the reported elements for this reporting
section would not connect for “Annual Coordinated Election Period” (AEP) enrollments.

22

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

9. PFFS Provider
Payment Dispute
Resolution
Process

03 – RFB PFFS
04 – PFFS
14 – ED-PFFS

Report
Freq./
Level
1/year
PBP

Report
Period
(s)
1/1­
12/31

Data Due date (s)

Last Monday of
February in
following year

Data elements reported under this reporting section are:
Element
Number
9.1
9.2
9.3

Data Elements for PFFS Provider Payment Dispute Resolution Process
Number of provider payment denials overturned in favor of provider upon
appeal
Number of provider payment appeals
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).

23

10. AGENT COMPENSATION STRUCTURE –
SUSPENDED

11. AGENT TRAINING AND TESTING –
SUSPENDED

12. SPONSOR OVERSIGHT OF AGENTS –
Reporting
section
12. SPONSOR
OVERSIGHT
OF AGENTS

Organization Types
Required to Report
1876 cost plans, local
Coordinated Care Plans
(Local CCP), Medicare
Savings Accounts
(MSA), Provider FeeFor-Service plans
(PFFS), and Regional
Coordinated Care Plans
(Regional CCP).*

Report
Freq./
Level
1/year
Contract

Report
Period
(s)
1/1­
12/31

Data Due date (s)

First Monday of
February in
following year

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. However,
CMS needs to monitor agent complaints to determine if Organizations are investigating
identified complaints and imposing disciplinary actions as well as reporting poor conduct to the
state. Therefore, Organizations must continue to monitor the conduct of their agents.
Complaints include both complaints from the Complaint Tracking Module (CTM) and other
complaints or grievances made directly to the Organization. Complaints may result in various
disciplinary actions, ranging from verbal warning to termination of employment or contract.
Reporting timeline:
Reporting Period

YTD
January 1 - December 31

Data due to CMS/HPMS

February 28

Data elements to be uploaded in two data files at the Contract level:
1. Agent/Broker:
For each agent/broker who earned compensation during the reporting period (initial enrollments
and renewal payments received) for members with an effective date of 1/1/2015-12/31/2015,
provide the information requested below. Enrollment applications received in 2014 for CY2015
effective dates are considered earned for CY2015 since the enrollment effective date is in
CY2015. For purposes of these reporting requirements compensation is defined as any payment
made to an agent/broker for purposes of enrolling beneficiaries into health plans for purposes of
the reporting requirement based on effective date, (e.g. commission, salary, bonuses, and
24

referrals) earned during in the reporting period (initial enrollments and renewal payments
received), indicate:
A.
Contract Number.
B.
Agent/Broker Type (Captive 2, Employed, Independent). 3
C.
Agent/Broker Last Name.
D.
Agent/Broker First Name.
E.
Agent/Broker Middle Initial.
F.
Agent/Broker State Licensed. For agents licensed in multiple states, complete a row for
each state in which the agent is licensed if they also earned compensation in that state.
G.
Agent/Broker National Producer Number (NPN).
H.
Organization Assigned Agent/Broker Identification Number.
I.
Agent/Broker Current License Effective/Renewal Date (if applicable). For “evergreen”
licenses, this would be the original license date. For other licenses, this would be the most recent
renewal date.
J.
Agent/Broker Appointment Date (if applicable). This date should be the most recent date
the agent becomes affiliated with the sponsor.
K.
Agent/Broker Training Completion Date for the previous contract year products.
L.
Agent/Broker Testing Completion Date for the previous contract year products.
M.
In aggregate, the number of Agent/Broker marketing complaints from any source for
reported during 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. For complaints that cannot be tied to a contract number, please put the aggregate
number of complaints into the first contract number.
N.
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.
O.
Agent/Broker Termination Date (if applicable).
P.
Termination for Cause? (Y (yes) or N (no)).
Q.
Third-party Marketing Organization (TMO)/Field Marketing Organization Name (FMO),
if applicable.
R.
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

A captive agent sells for one organization only but is not an employee of the organization.

3

*When a single agent/broker has multiple types (e.g., captive and employed) or has a gap in
appointment, please provide the type of “employment” that was most prevalent during the
reporting period.

25

2.

New Enrollments:
Important: Sponsors should not upload the POA New Enrollments level data file if they have
no new enrollees to report. CMS is defining “new enrollments” for reporting purposes as
new to the organization. A change from one Plan Beneficiary Benefit Package (PBP) to
another PBP, within the same organization, is not considered a “new enrollment” for
purposes of these reporting requirements. Also, a change from one contract to another
contract within the same organization) is not a new enrollment. New enrollments are only
considered changes from no organization or changes from one organization to an entirely
new organization. Organizations should report on all agents/brokers, not just independent
agents/brokers. For all new enrollments (initial or renewal) during the reporting
period for which an Agent/Broker is associated 4, indicate:

A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.

Contract Number.
Plan Beneficiary Benefit Package (PBP) Number.
Beneficiary Last Name.
Beneficiary First Name.
Beneficiary Middle Initial.
Beneficiary HICN or RRB Number.
Agent/Broker Last Name.
Agent/Broker First Name.
Agent/Broker Middle Initial.
Agent/Broker National Producer Number (NPN).
Organization Assigned Agent/Broker Identification Number.
Enrollment Mechanism.
1=Organization Representative Online
2=CMS Online Enrollment Center
3=Organization Call Center
4=1-800-MEDICARE
5=Paper Application
6=Auto-Assigned/Facilitated
7=Other
(Note: This should be the media type by which a member is enrolled.)
M.
Enrollment Application Date.
N.
Enrollment Effective Date.
O.
The number of Agent/Broker complaints filed by the beneficiary in the reporting period.
This should be all complaints related to agent/brokers by the beneficiary, not just confirmed
allegations. Examples would include: Agent did not show up, Agent stated premium was $0
when it was $20, Agent did not return phone call.
P.
Of the number reported in O, the number of Marketing related complaints. This should
be a subset of Element O. Marketing related complaints are complaints dealing with the
information provided by the agent. For example, the premium complaint would be marketing
4

Assistance is defined by an agent providing information/answering questions to a potential beneficiary. This
would include face to face, interactive, and telephonic. Mailing a packet of information to a member with no further
contact would not be considered “assistance.”

26

complaint, whereas an agent not returning a phone call or not showing up would not be a
marketing related complaint. It is up the Sponsor to make a determination which complaints are
reported for both Elements O and P.
13. SPECIAL NEEDS PLANS (SNPS) CARE
MANAGEMENT
Reporting
section
13. SNPs Care
Management

Organization Types
Required to Report
SNP PBPs under the
following types:
01 – Local CCP
11 – Regional CCP
15 – RFB Local CCP

Report
Freq./
Level
1/Year
PBP

Report
Period
(s)
1/1­
12/31

Data Due date (s)

Last Monday of
February in
following year

Organizations should
exclude 800 series
plans if they are SNPs.

Data elements reported under this reporting section are:
D.E
No.
13.1

Data Element
(D.E.)
Number of new
enrollees.

Inclusions

Exclusions

New enrollees are defined with respect
to the "90-day rule." The initial health
risk assessment is expected to be
completed within 90 days (before or
after) the effective date 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 completing an initial HRA are
reported as being eligible for an initial
HRA (data element 13.1=1) but not
having received an initial HRA (data

Members with a
documented initial HRA
under that plan prior to
the measurement year.
Excludes new members
who disenrolled from the
plan within 90 days
before or after the
effective date of
enrollment, if they did
not complete an initial
HRA prior to
disenrolling. Excludes
members who receive an
initial HRA and remain
continuously enrolled
under a MAO whose
contract was part of a
consolidation or merger
under the same legal
27

13.2

13.3

Number of
enrollees eligible
for an annual
health risk
reassessment
(HRA)

element 13.3=0—refer to data element
13.3 below). After that 90-day period,
members 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 before or after the
effective enrollment date.
Report all members in the same health
plan who:

1. Completed a reassessment HRA
within 365 days of their last HRA
(initial or reassessment).
2. Were enrolled for 365 days
continuously after their initial HRA
or their last reassessment HRA and
did not complete a reassessment
HRA within 365 days
3. Did not complete an initial HRA
within 90 days before or after the
effective date of enrollment and
reached the threshold of 365 days of
continuous enrollment after initial
enrollment without completing a
reassessment HRA.
Number of initial Initial HRAs performed on new
HRAs performed enrollees (as defined above in data
on new enrollees. element 13.1) within 90 days before or
after effective date of enrollment. The
HRA must be completed between
1/1and 12/31 of the measurement year.

13.4

Number of initial Initial HRAs not performed on new
HRA refusals
enrollees within 90 days (before or
after) effective date of enrollment due
to enrollee refusal.

13.5

Number of initial
HRAs where
SNP is unable to
reach new

Initial HRAs not performed on new
enrollees within 90 days before or after
the effective date of refusal due to SNP
unable to reach new enrollees

entity during the
member’s continuous
enrollment, where the
consolidated SNP is still
under the same MOC as
the enrollee’s previous
SNP.

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 complete a
reassessment HRA in
that plan within the 365
day timeframe as
required.

Excludes reporting on
number of completed
initial HRAs if there is
no documentation on
enrollee refusal.
Excludes reporting on
number of completed
initial HRAs where the
SNP has less than 3
28

enrollees

13.6

Number of
annual
reassessments
performed.

13.7

Number of
annual
reassessments
refusals

13.8

Number of
annual
reassessments
where SNP is
unable to reach
enrollee

phone calls and a follow
up letter – during the 90
day period (before or
after) the initial
assessment. Excludes
reporting on initial
HRAs if there is no
documentation that the
enrollee did not respond
to SNP solicitation.to
participate in the initial
HRA
Number of annual reassessments
performed on enrollees eligible for a
reassessment (during the measurement
year as defined in element 13.2 above).
This includes:
Reassessments performed within 365
days of last HRA (initial or
reassessment HRA) on eligible
enrollees. It also includes “first time”
assessments occurring within 365 days
of initial enrollment on individuals
continuously enrolled up to 365 days
from enrollment date without having
received an initial HRA.
Annual reassessments not performed on
an enrollee due to enrollee refusal.

Annual reassessments not performed on
an enrollee where SNP is unable to
reach enrollees.

Excludes reporting on
number of completed
reassessments if there is
no documentation on
enrollee refusal.
Excludes reporting on
number of completed
reassessments where the
SNP documents that it
has less than 3 phone
calls, and a follow up
letter. Excludes
reporting on enrollees if
there is no
documentation that the
enrollee did not respond
to SNP solicitation to
participate in the initial
HRA.
29

Notes:
This reporting section requires direct data entry into HPMS.
Complete HRAs are those that comply with guidance in Chapter 5 of the Medicare Managed
Care Manual, Quality Improvement program. For Part C reporting, there should never be more
than 365 days between Health Risk Assessment (HRAs) for special needs plans. The initial
HRA should occur within 90 days before or after the effective date of enrollment in a special
needs plan. Initial HRAs completed and received prior to the date of eligibility for benefits are
excluded from this reporting section. A SNP should not perform or report on a completed HRA
for the Part C reporting requirements if the beneficiary is not yet determined to be eligible to
enroll in the SNP. If there is no HRA occurring within 90 days (before or after) the effective
enrollment date, there should be an HRA as soon as possible but no more than 365 days from
initial enrollment. (Note that, if the initial HRA is not completed within 90 days before or after
the effective enrollment date, the SNP will be deemed non-compliant with this requirement. For
example, if a SNP enrollee’s effective date of enrollment is January 1, 2016, the SNP may
conduct the HRA 90 days before January 1, 2016 and no later than 90 days after January 1,
2016.) All reassessment HRAs should occur within 365 days of the last HRA.
SNPs will report enrollee initial HRA, and annual reassessment refusals that must be
documented in their internal records. SNPs will also report when they are unable to reach an
enrollee to perform an initial HRA or an annual reassessment. The SNP must document in its
internal records that the enrollee did not respond to at least three phone calls and a follow up
letter, all soliciting participation in the HRA. CMS can request SNP HRA refusal and/or
unable to reach documentation at any time to determine health plan compliance with Part C
reporting requirements.
Complete HRAs are those that comply with guidance in Chapter 5 of the Medicare Managed
Care Manual, titled “Quality Improvement Program.” Specifically, only completed HRAs that
comprise direct beneficiary and/or caregiver input will be considered valid for purposes of
fulfilling the Part C reporting requirements. This means, for example, that HRAs completed
only using claims and/or other administrative data, would not be acceptable. For Data Elements
13.3 and 13.6, CMS requires only completed assessments. This reporting section excludes
cancelled enrollments. 5
For Dual Eligible SNPs (D-SNPs) only, CMS will accept a Medicaid HRA that is performed
within 90 days before, or no more than 90 days after the effective date of Medicare enrollment as
compliant with Part C reporting requirements.
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 or one reassessment within the 365 day time period. The
5

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.”

30

365-day recycle period for the HRA begins after the last reassessment HRA for that
measurement year. Therefore, for example, if reassessment HRAs was completed for the same
member on 4/1/2016, 6/1/2016, 8/1/ 2016, and 11/1/2016, the plan should report only one
reassessment HRA in 2016. In this case, the 365 day recycle period would start on 11/2/2016,
and the next HRA would be due by 11/1/2017.

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 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 2014, and the HRA is completed in 2015
(within 90 days before or after the effective date of enrollment), count this beneficiary as a new
enrollee in 2015 with an HRA completed in calendar 2015.
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. Enrollees who received an initial HRA, and remain continuously enrolled under a
MAO that was part of a consolidation or merger within the same MAO or parent organization
will not need to participate in a second initial HRA.
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.

14. ENROLLMENT AND DISENROLLMENT
Reporting
section

Organization Types
Required to Report*

14. Enrollment
and
Disenrollment

All stand-alone MAOs
(MA, no Part D)

Report
Freq./
Level
2/Year
Contract

Report
Period
(s)
1/1-6/30
7/1 –
12/31

Data Due date (s)

Last Monday of
August and February

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.

31

This reporting section requires data entry into HPMS

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 is 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
Data Due to CMS

January 1 – June 30
August 31

July 1-December 31
Last Monday of August and
February

Data elements to be entered into the HPMS at the Contract level:
Four new data elements are added under disenrollment—data elements D-G. These data
elements report the number of involuntary disenrollments for failure to pay plan premium in the
specified time period, of these, the number of disenrolled individuals who submitted a timely
request for reinstatement for Good Cause, of these, the number of favorable Good Cause
determinations, and, of these, the number of individuals reinstated.

32

1. Enrollment:
A. The total number of enrollment requests (i.e., requests initiated by the beneficiary or
his/her authorized representative) received in the specified time period. Do not include
auto/facilitated or passive enrollments, rollover transactions or other enrollments
effectuated by CMS.
B. 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).
C. Of the total reported in A, the number of enrollment requests that required requests for
additional information.
D. 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).
E. Of the total reported in C, the number of incomplete enrollment requests received that are
completed within established timeframes.
F. 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.
G. Of the total reported in A, the number of paper enrollment requests received.
H. Of the total reported in A, the number of telephonic enrollment requests received (if
offered).
I. Of the total reported in A, the number of internet enrollment requests received via plan or
third-party affiliated website.
J. Of the total reported in A, the number of Online Enrollment Center (OEC) enrollment
requests received. For stand-alone prescription drug plans (PDPs) only:*
K. 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.)*
L. Of the number reported in A, the number of enrollment transactions submitted using the
SEP Election Period code "S" related to creditable coverage.*
M. 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.)*
N. 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.)*
O. 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.*
*Indicates not reported under Part C.

33

2. Disenrollment:
A. The total number of voluntary disenrollment requests received in the specified time
period.
B. 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).
C. Of the total reported in A, the number of disenrollment requests denied by the Sponsor
for any reason.
D. The total number of involuntary disenrollments for failure to pay plan premium in the
specified time period.**
E. Of the total reported in D, the number of disenrolled individuals who submitted a timely
request for reinstatement for Good Cause.**
F. Of the total reported in E, the number of favorable Good Cause determinations.**
G. Of the total reported in F, the number of individuals reinstated.**
** Indicates new data element.

15. Rewards and Incentives Programs
Reporting
section
15. Reports and
Incentives
Programs

Organization Types
Required to Report
01 – Local CCP
02 – MSA
03 – RFB PFFS
04 – PFFS
05 – MMP
11 – Regional CCP
14 – ED-PFFS
15 – RFB Local CCP

Report
Freq./
Level
1/Year
Contract

Report
Period
(s)
1/Yr.

Data Due date (s)

Last Monday of
February in
following year

Organizations should
include all 800 series
plans.
Employer/Union Direct
Contracts should also
report this reporting
section, regardless of
organization type.
This is a new reporting section. This reporting section requires data entry into HPMS.
CMS has added a new regulation at 42 CFR §422.134 that permits MA organizations to offer
one or more Rewards and Incentives Program to currently enrolled members. Plans have a
34

choice in whether or not they offer a Rewards and Incentives Program(s), but if they do, they
must comply with the regulatory requirements set forth at §422.134. CMS needs to collect
Rewards and Incentives Program data in order to track which MA organizations are offering
such programs and how those programs are structured. This will inform future policy
development and allow CMS to determine whether programs being offered adhere to CMS
standards and have proper beneficiary protections in place.
Data Elements:
15.1 Do you have a Rewards and Incentives Program(s)? (“0” = “No”; “1” = “Yes”)
If yes, please list each individual Rewards and Incentives Program you offer and provide
information on the following:
15.2 What health related services and/or activities are included in the program? Text
15.3 What reward(s) may enrollees earn for participation? Text
15.4 How do you calculate the value of the reward? Text
15.5 How do you track enrollee participation in the program? Text
15.6 How many enrollees are currently enrolled in the program? Enter _ _ _ _ _ _ _
15.7 How many rewards have been awarded so far? Enter _ _ _ _

35

16. Mid-Year Network Changes
Reporting
section
16. Mid-Year
Network
Changes

Organization Types
Required to Report
01 – Local CCP
11 – Regional CCP
15 – RFB Local CCP

Report
Freq./
Level
1/Year
Contract

Report
Period
(s)
1/Yr.

Data Due date (s)

Last Monday of
February

This is a new reporting section. This reporting section requires data entry into HPMS.
CMS is increasing its oversight and management of MAOs’ network changes in order to ensure
that changes made during the plan year do not result in inadequate access to care for enrolled
beneficiaries and that MAOs are provided timely and appropriate notification to providers and
enrollees. The data collected in this new measure will provide CMS with a better understanding
of how often Medicare Advantage Organizations (MAOs) undergo mid-year network changes
and how many enrollees are affected. CMS considers a mid-year network change to be any
change in network that is not effective January 1 of a given year (the first day of the reporting
period). In the following we are asking MAOs to report on no cause mid-year terminations of
PCPs, certain specialists (cardiologists, endocrinologists, oncologists, ophthalmologists,
pulmonologists, rheumatologists, urologists), and facilities (acute inpatient hospitals and skilled
nursing facilities) initiated by the MAO during the reporting period.
Affected enrollees are those enrollees who were assigned to a terminated PCP or who were
treated by a terminated specialist or received care in a terminated facility within 90 days prior to
the specialist/ facility contract termination date. To maintain consistency in reporting, we are
using the definition of PCP used in the CMS network adequacy criteria guidance, found on our
website at https://www.cms.gov/Medicare/Medicare­
Advantage/MedicareAdvantageApps/index.html. In addition to PCP data, we are seeking data
on the mid-year network changes for the provider and facility specialties that MAOs are required
to include on their Health Service Delivery (HSD) tables submitted with a Medicare Advantage
(MA) application.
Collecting these data will help to inform us as we determine how broadly to use the new
Network Management Module (NMM) in the Health Plan Management System (HPMS) to
verify that plans’ networks meet CMS network adequacy standards. In addition, responses from
MAOs will enhance CMS’ ability to improve our network change protocol.

Legal Basis:
In accordance with 42 CFR § 422.112 (a)(1)(i), each MA organization under Part C Medicare
that offers a coordinated care plan is required to “maintain and monitor a network of appropriate
providers that is…sufficient to provide adequate access to covered services to meet the needs of
the population served.”

36

Data Elements (at the contract level):
Element
Number
16.1

16.2

16.3

16.4

16.5-16.13

16.14-16.22

16.23-16.31

16.32-16.40

16.41
16.42
16.43-16.51

Data Elements for Provider Network Adequacy Measure
Total number of PCPs in network on first day of reporting period,
including the following PCP types - General Practice, Family Practice,
Internal Medicine, Geriatrics, Primary Care- Physician Assistants,
Primary Care-Nurse Practitioners
Total number of PCPs in network terminated during the reporting
period, including the following PCP types - General Practice, Family
Practice, Internal Medicine, Geriatrics, Primary Care- Physician
Assistants, Primary Care-Nurse Practitioners
Total number of PCPs added to network during reporting period,
including the following PCP types - General Practice, Family Practice,
Internal Medicine, Geriatrics, Primary Care- Physician Assistants,
Primary Care-Nurse Practitioners
Total number of PCPs in network on last day of reporting period,
including the following PCP types - General Practice, Family Practice,
Internal Medicine, Geriatrics, Primary Care- Physician Assistants,
Primary Care-Nurse Practitioners
Number of specialists/facilities in network on first day of reporting
period by specialist/facility type –Cardiologist (16.5), Endocrinologist
(16.6), Oncologist (16.7), Ophthalmologist (16.8), Pulmonologist
(16.9), Rheumatologist (16.10), Urologist (16.11), Acute Inpatient
Hospitals (16.12), Skilled Nursing Facilities (16.13)
Number of specialists/facilities in network terminated during the
reporting period by specialist/facility type– Cardiologist (16.14),
Endocrinologist (16.15), Oncologist (16.16), Ophthalmologist (16.17),
Pulmonologist (16.18), Rheumatologist (16.19), Urologist (16.20),
Acute Inpatient Hospitals (16.21), Skilled Nursing Facilities (16.22)
Number of specialists/facilities added during reporting period by
specialist/facility type - Cardiologist (16.23), Endocrinologist (16.24),
Oncologist (16.25), Ophthalmologist (16.26), Pulmonologist (16.27),
Rheumatologist (16.28), Urologist (16.29), Acute Inpatient Hospitals
(16.30), Skilled Nursing Facilities (16.31)
Number of specialists in network on last day of reporting period by
specialist/facility type- Cardiologist (16.32), Endocrinologist (16.33),
Oncologist (16.34), Ophthalmologist (16.35), Pulmonologist (16.36),
Rheumatologist (16.37), Urologist (16.38), Acute Inpatient Hospitals
(16.39), Skilled Nursing Facilities (16.40)
Total number of enrollees on first day of reporting period
Total number of enrollees affected by termination of PCPs during
reporting period
Total number of enrollees affected by termination of
specialists/facilities by specialist/facility type during reporting periodCardiologist (16.43), Endocrinologist (16.44), Oncologist (16.45),
37

Ophthalmologist (16.46), Pulmonologist (16.47), Rheumatologist
(16.48), Urologist (16.49), Acute Inpatient Hospitals (16.50), Skilled
Nursing Facilities (16.51
16.52

Total number of enrollees on last day of reporting period

17. Payments to Providers (new reporting section)
Reporting
section
17. Payments to
Providers

Organization Types
Required to Report
01 – Local CCP
11 – Regional CCP
15 – RFB Local CCP
04 – PFFS

Report
Freq./
Level
1/Year
Contract

Report
Period
(s)
1/Yr.

Data Due date (s)

Last Monday of
February

This is a new reporting section. This reporting section requires data entry into HPMS. We are
adding this new requirement based on internal review. In order to maintain consistency with HHS
goals of increasing the proportion of payment made based on quality and value, HHS developed four
categories of value-based payment: fee-for-service with no link to quality; fee-for-service with a link
to quality; alternative payment models built on fee-for-service architecture; and population-based
payment. CMS is seeking to collect data from MA organizations about the proportion of their
payments to providers made based on these four categories in order to help us understand the extent
and use of alternate payment models in the MA industry. This does not include MAO payments for
administrative services or payments to hospitals, facilities, and labs. As we are interested in the
direct contractual arrangements between MAOs and providers, we are also interested in the contracts
between MAOs and third party administrators who contract with providers on behalf of MAOs.

CMS considers a fee-for-service with no link to quality arrangement to include all arrangements
where payments are based on volume of services and not linked to quality of efficiency.

CMS considers a fee-for-service with a link to quality to include all arrangements where at least a
portion of payments vary based on the quality or efficiency of health care delivery , such as
physician value-based modifiers. Included in this category are for performance (P4P) payment
structures.
CMS considers alternative payment models built on fee-for-service architecture to include all
arrangements where some payment is linked to the effective management of a population or an
38

episode of care. Payments are still triggered by delivery of services, but there are opportunities
for shared savings or 2-sided risk. Included in this category are bundled payments, Accountable
Care Organizations, patient Centered Medical Homes, and other payments with upside and
downside risk.
CMS considers population-based payment arrangements to include some payment is not
directly triggered by service delivery so volume is not linked to payment. Under these
arrangements, clinicians and organizations are paid and responsible for the care of a beneficiary
for a long period (e.g., greater than a year). Collecting these data will help to inform us as we
determine how broadly MA organizations are using alternative payment arrangements.
Included in this category are partial capitation, full capitation, and risk-based models.

Data Elements (at the contract level):

39

Element
Number
17.1

17.2
17.3
17.4
17.5
17.6
17.7
17.8
17.9
17.10

Data Elements for Payments to Provider
Total Medicare Advantage payment made to contracted providers.
This includes payments to groups of providers and third party
administrators through which the MAO pays providers.
Total Medicare Advantage payment made on a fee-for-service basis
with no link to quality.
Total Medicare Advantage payment made on a fee-for-service basis
with a link to quality.
Total Medicare Advantage payment made using alternative payment
models built on fee-for-service architecture
Total Medicare Advantage payment made using population-based
payment.
Total number of Medicare Advantage contracted providers.
Please note: Third party administrators should be counted as a
single contracted provider.
Total Medicare Advantage contracted providers paid on a fee-for­
service basis with no link to quality.
Total Medicare Advantage contracted providers paid on a fee-for­
service basis with a link to quality.
Total Medicare Advantage contracted providers paid based on
alternative payment models built on a fee-for-service architecture.
Total Medicare Advantage contracted providers paid based on
population based payment.

40

Appendix 1: FAQs: Reporting Sections 5 & 6:
Grievances, Organization Determinations, & Reconsiderations

1.

2.

3.

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.
Should plans report all Dual Eligible member
grievances to CMS?

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.

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?

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.
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.

41

4.

Are plans to report only those organization
determinations defined under 42 C.F.R. 422.566?

5.

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?

6.

If we have a prior authorization request and a
claim for the same service -- is that considered a
duplicate or should we report both?

7.

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?

8.

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?

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.” For example, plans
are to include adjudicated claims in the
reportable data for Organization
Determinations.
Yes. Plans are to report fully
favorable, partially favorable, and
adverse pre-service and claims requests
(organization determinations and
reconsiderations), as described in this
guidance
Plans are to report both a prior
authorization request and a claim for
the same service; this is not considered
a duplicate.
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, noncontracted provider or member. Plans
are to report partially favorable,
adverse and fully favorable pre-service
organization determinations, as
described in this guidance.
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.

42

9.

10.

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 did not submit the claim
with the required modifier, should that be
excluded from the count?
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?

11.

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?

12.

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/ noncovered service. Neither the enrollee nor
the provider pursues it any further. Is this an
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)?

13.

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).
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.
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.
The plan is to report this denial as an
organization determination. A
request for payment (claim) is a
reportable organization determination.

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.

43

14.

15.

16.

17.

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)?

Our interpretation is that the term “contracted
provider” means “contracted with the health
plan” not “contracted 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.
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?

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.
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.”
Yes. Regardless of whether a QIO
overturns an Adverse organization
determination, plans are to report the
initial adverse or partially favorable
organization determination.
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.) Dismissed cases, or
2.) QIO determinations concerning an
inpatient hospital, skilled nursing
facility, home health and
comprehensive outpatient
rehabilitation facility services
terminations.

44

18.

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.

45