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 2017

Effective Date: January 1, 2017

Version Date: August 12, 2016

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

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to
respond to a collection of information unless it displays a valid OMB control number. The valid OMB
control number for this information collection is 0938-1054 (expires: TBD). The time required to
complete this information collection is estimated to average 48 hours per response, including the time to
review instructions, search existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time estimate(s) or
suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports
Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Table of Contents
BACKGROUND AND INTRODUCTION…………………………………………… 1
GENERAL INFORMATION…………………………………………………………. 1
REPORTING REQUIREMENT REPORTING SECTIONS LIST…………………… 4
REPORTING SECTIONS………………………………………………………………..7
1. BENEFIT UTILIZATION (SUSPENDED)...................................................................7
2. PROCEDURE FREQUENCY (SUSPENDED).............................................................7
3. SERIOUS REPORTABLE ADVERSE EVENTS (SUSPENDED) ..............................7
4. PROVIDER NETWORK ADEQUACY (SUSPENDED) .............................................7
5. GRIEVANCES ...............................................................................................................7
6. ORGANIZATION DETERMINATIONS/RECONSIDERATIONS ..........................12
7. EMPLOYER GROUP PLAN SPONSORS .................................................................19
8. PROVIDER FEE-FOR-SERVICE ((PFFS) PLAN ENROLLMENT
VERIFICATION CALLS; MONITORING PURPOSES ONLY ...............................21
9. PFFS PROVIDER PAYMENT DISPUTE RESOLUTION PROCESS;
MONITORING PURPOSES ONLY ...........................................................................22
10. AGENT COMPENSATION STRUCTURE – SUSPENDED ...................................23
11. AGENT TRAINING AND TESTING – SUSPENDED ............................................23
12. SPONSOR OVERSIGHT OF AGENTS –................................................................23
13. SPECIAL NEEDS PLANS (SNPS) CARE MANAGEMENT..................................23
14. ENROLLMENT AND DISENROLLMENT .............................................................28
15. REWARDS AND INCENTIVES PROGRAMS .......................................................31
16. MID-YEAR NETWORK CHANGES .......................................................................33
17. PAYMENTS TO PROVIDERS ................................. Error! Bookmark not defined.
APPENDIX 1: FAQS: REPORTING SECTIONS 5 & 6: ..............................................40

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 independently provide 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.

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;
Reporting section #12 Sponsor Oversight of Agents
Major Changes from CY 2016 Technical Specifications
Organization Determinations and Reconsiderations (#6) has five new data elements:
 Case Level (Organization Determination or Reconsideration)
 Was the case processed under the expedited timeframe? (Y/N)
 Case Type (Service or Payment)
 Status of treating provider (Contract or Non-Contract)
 Additional Information (optional)
Payments to Providers has four new data elements.
Sponsor Oversight of Agents is suspended.
Special Needs Plans Care Management, Mid-Year Network Changes, and Payments to Providers
underwent additional text clarification

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.

2

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 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 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] .

3

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
1. Benefit
Utilization
2. Procedure
Frequency
3. Serious
Reportable
Adverse Events
4. Provider
Network
Adequacy
5. Grievances
(Revised)

6. Organization
Determinations/
Reconsiderations
(Revised)

Organization
Types Required
to Report

Report
Freq./
Level
Suspended

Report
Period (s)

Data Due date
(s)

1/1-3/31
4/1-6/30
7/1-9/30
10/1-12/31
(2/6/2017
reporting will
include each
quarter)

First Monday of
February in
following year

1/1-3/31
4/1-6/30
7/1-9/30
10/1-12/31
(2/27/2017
reporting will
include each
quarter)

Last Monday of
February in
following year

Suspended
Suspended

Suspended

Coordinated
1/Year
Care Plans
Contract
(CCPs), Provider
Fee-For-Service
Plans (PFFS),
1876 Cost,
MedicareMedicaid Plans
(MMPs),
Medicare
Savings
Accounts
(MSAs)
(includes all 800
series plans),
Employer/Union
Direct Contract
CCP, PFFS,
1876 Cost,
MMP, MSA
(includes all 800
series plans),
Employer/Union
Direct Contract

1/Year
Contract

4

Reporting
Section
7. Employer
Group Plan
Sponsors

8. PFFS Plan
Enrollment
Verification
Calls

9. PFFS Provider
Payment Dispute
Resolution
Process

10. Agent
Compensation
Structure
11. Agent
Training and
Testing
12. Sponsor
Oversight of
Agents
13. Special
Needs Plans
(SNPs) Care
Management

Organization
Types Required
to Report
CCP, PFFS,
1876 Cost,
MSA (includes
800 series plans
and any
individual plans
sold to employer
groups),
Employer/Union
Direct Contract

Report
Freq./
Level
1/year
PBP

PFFS

1/year
PBP

Report
Period (s)
1/1 - 12/31

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

1/1-12/31

(800-series plans
should NOT
report)

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

Data Due date
(s)

1/year
PBP

1/1-12/31

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

Suspended

Suspended

Suspended

Local CCP,
Regional CCP,
RFB Local CCP
with SNPs.
Includes 800
series plans.

1/Year
PBP

1/1-12/31

Last Monday
of February in
following year

5

Reporting
Section

14.
Enrollment/Dise
nrollment

15. Rewards and
Incentives
Programs

16. Mid-Year
Network
Changes

17. Payments to
Providers

Organization
Types Required
to Report
Only 1876 Cost
Plans with no
Part D.*

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

Local CCP
Regional CCP
RFB Local CCP
PFFS
MMP**

Report
Freq./
Level
2/Year
Contract

1/Year
Contract

Report
Period (s)

1/1-6/30
7/1-12/31

1/1-12/31

Data Due date
(s)

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

1/Year
Contract

1/Year
Contract

1/1-12/31

1/1-12/31

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

Validation
unnecessary—
using for
monitoring only
* MA-only. MA-PDs and PDPs report under Part D. MSA and chronic care excluded.
** MMPs should report for all APMs, not just Medicare MMPs.

6

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

Organization Types
Required to Report

5. Grievances

01 – Local CCP
02 – MSA
03 – Religious
Fraternal Benefit(RFB
PFFS)
04 – PFFS
05 – MMP
06 – 1876 Cost
11 – Regional CCP
14 – Employee Union
Direct (ED)-PFFS
15 – RFB Local CCP

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
10/112/31
(2/6/2017
reporting
will
include
each
quarter)

Organizations should
include all 800 series
plans.
Employer/Union Direct
Contracts should also
report this reporting
section, regardless of
organization type.

7

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

Total number
of Grievances
(5.1)
(5.3)
(5.5)
(5.7)
(5.9)
(5.11)
(5.13)
(5.15)

Number of grievances in which
timely notification* was given
(5.2)
(5.4)
(5.6)
(5.8)
(5.10)
(5.12)
(5.14)
(5.16)

Total Grievances
Number of Expedited Grievances
Enrollment/Disenrollment
Benefit Package Grievances
Access Grievances
Marketing Grievances
Customer Service Grievances
Organization determination and
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)
Dismissed Grievances*
NA
* 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: Medicare Managed Care Appeals & Grievances. For an explanation of
grievance procedures for MMPs, refer to the Demonstration-specific three-way contracts.
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
8

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 grievance procedures outlined in
42 CFR Part 422, Subpart M (i.e., Part C grievances). Please note that MMP grievances
are also included for reporting under these technical specifications.



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.



*Dismissals: CMS expects that dismissed grievances represent a very small percentage of
total Part C grievances a plan receives. However, this element has been added to provide
plans with a means to report grievances that are received but not processed by the plan
because they do not meet the requirements for a valid grievance. Generally, a dismissal
would occur when the procedure requirements for a valid grievance are not met and the
plan is unable to cure the defect. For example, a grievance is received from a purported
representative of the enrollee, but a properly executed appointment of representative form
has not been filed and there is no other documentation to show that the individual is
9

legally authorized to act on the enrollee’s behalf and the plan is unable to obtain the
required documentation in a reasonable amount of time and therefore, dismisses the
grievance. See guidance set forth in section 10.4.1 of Chapter 13.

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


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 1/1/2016 at 04:00pm. An extension is requested at 1/31/2016 04:05pm.
Plan completes investigation and provides notification on 2/5/2016 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.

10



If the enrollee files a grievance with a previous plan, but enrolls in a new plan before the
grievance is resolved, the previous plan is still responsible for investigating, resolving
and reporting the 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.

11

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

Report
Freq./
Level
1/Year
Contract

Report
Period (s)

Data Due date (s)

1/1-3/31
Last Monday of
4/1-6/30
February in
7/1-9/30
following year
10/1-12/31
(2/27/2017
reporting
will
include
each
quarter)

Organizations should
include all 800 series
plans.
Employer/Union
Direct Contracts
should also report this
reporting section,
regardless of
organization type.

12

Data elements for this reporting section are contained in Table 1. There are five new data
elements:






Case Level (Organization Determination or Reconsideration)
Was the case processed under the expedited timeframe? (Y/N)
Case Type (Service or Payment)
Status of treating provider (Contract or Non-Contract)
Additional Information (optional)

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 6.11, 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
13

Element
Number
6.25
6.26
6.27
6.28
6.29
6.30
6.31
6.32
6.33
6.34
6.35

Data Elements for Organization Determinations/Reconsiderations
Case level (Organization Determination or Reconsideration)
Date of original disposition
Original disposition (Fully Favorable; Partially Favorable or Adverse)
Was the case processed under the expedited timeframe? (Y/N)
Case type (Service or Claim)
Status of treating provider (Contract, Non-contract)
Date case was reopened
Reason(s) for reopening (Clerical Error, Other Error, New and Material
Evidence, Fraud or Similar Fault, or Other)
Additional Information (Optional)
Date of reopening disposition (revised decision)*
Reopening disposition (Fully Favorable; Partially Favorable, Adverse or
Pending)

* The date of disposition is the date the required written notice of revised decision was sent per
405.982.
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: Medicare Managed Care
Appeals & Grievances. For an explanation of organization determination and reconsideration
procedures for MMPs, refer to the Demonstration-specific three-way contracts.
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.

14

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.
If the plan receives an Organization Determination or Reconsideration Request and issues a
timely decision, however, the request is withdrawn, the plan would report the timely decision as
well as the withdrawn request.
If the plan receives an Organization Determination or Reconsideration Request and the request is
withdrawn prior to a decision being issued, the plan would report the withdrawal only.

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, service
authorizations which include prior-authorization (authorization that is issued prior to the
services being rendered), concurrent authorization (authorization that is issued at the time
the service is being rendered) and post-authorization (authorization that is issued after the
services has already been provided) , 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 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.



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
15

individual requests a 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 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 in addition to guidance provided in the September 10, 2013 HPMS
memo regarding Part C Reconsideration Dismissal Procedures 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.

16

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.



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 a Medicare request for coverage (payment or provision) of an item or service
as either partially favorable or adverse, regardless of whether Medicaid payment or
provision 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 1/1/2016 at 04:00pm. An extension is
requested at 1/31/2016 04:05pm. Plan completes reconsideration and provides
notification on 2/5/2016 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.



Reopenings requested or completed by the IRE, Administrative Law Judge (ALJ), and
Appeals Council.



Concurrent reviews during hospitalization.



Concurrent review of Skilled Nursing Facility (SNF), Home Health Agency (HHA) or
Comprehensive Outpatient Rehabilitation Facility (CORF) care.

17



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.
Reopenings (Organization Determinations and Redeterminations)
1. A reopening is a remedial action taken to change a final determination or decision even

2.
3.
4.

5.

though the determination or decision may have been correct at the time it was made
based on the evidence of record.
Refer to 42 CFR §422.616 and Chapter 13, section 130 of the Medicare Managed Care
Manual for additional information and CMS requirements related to reopenings.
All reopened coverage determinations and redeterminations should be included.
For cases that are in a reopening status across multiple reporting periods, contracts should
report those cases in each applicable reporting period. For example, if a plan reopened an
organization determination on 3/15/2017 and sent the notice of the revised decision on
4/22/2017, 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).
If the IRE fully or partially overturns the plan’s determination, the case is not and must
not be reported as a reopening.

18

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

19

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, 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 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.

20

8. PRIVATE 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)
1/112/31

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.

21

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)
1/112/31

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).

22

10. AGENT COMPENSATION STRUCTURE – SUSPENDED
11. AGENT TRAINING AND TESTING – SUSPENDED
12. SPONSOR OVERSIGHT OF AGENTS – SUSPENDED
13. SPECIAL NEEDS PLANS (SNP) 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)
1/112/31

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 due for
an Initial Health
Risk Assessment
(HRA)

Inclusions

Exclusions

To be included as new enrollees due for
an Initial HRA, enrollees must have an
effective enrollment date that falls
within this measurement year,* they
must complete an initial HRA within 90
days of enrollment, or be continuously
enrolled in the plan for at least 90 days
without receiving an initial HRA.. The
initial HRA is expected to be completed
within 90 days (before or after) the
effective date of enrollment. A member
who disenrolls from one SNP and
enrolls in another one is reported as
eligible for an initial HRA any time
during the period of 90 days before or
after the effective enrollment date in the
new SNP.

Enrollees who are
continuously enrolled in
a plan with a
documented initial or
reassessment HRA in the
previous measurement
year.
New enrollees who
disenroll from the plan
prior to the effective
enrollment date or within
the first 90 days after the
effective enrollment date
if they did not complete
an initial HRA prior to
disenrolling.
Enrollees who receive an
23

D.E
No.

Data Element
(D.E.)

Inclusions

Exclusions
initial or reassessment
HRA and remain
continuously enrolled
under a MAO whose
contract was part of a
consolidation or merger
under the same legal
entity during the
member’s continuous
enrollment, where the
consolidated SNP is still
under the same Model of
Care (MOC) as the
enrollee’s previous SNP.

13.2

Number of
enrollees eligible
for an annual
reassessment
HRA

Report all enrollees in the same health
plan:
Who were enrolled more than 365 days
continuously after their last HRA and
never received an initial HRA within 90
days of enrollment.
Enrollees who were continuously enrolled
and completed an HRA in the previous
measurement year and were due a
reassessment HRA in the current
measurement year, whether or not they
received that reassessment HRA. **

13.3

13.4

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 the effective date of enrollment.
If the initial HRA is performed in the
90 days prior to the effective enrollment
date, it is reported as an initial HRA in
the reporting year in which the effective
enrollment date falls.
Number of initial Initial HRAs not performed on new
HRA refusals
enrollees within 90 days (before or
after) of the effective date of enrollment
due to enrollee refusal and for which
the SNP has documentation of enrollee
refusal.

Initial HRAs not
performed for which
there is no
documentation of
enrollee refusal.

24

D.E
No.
13.5

13.6

Data Element
(D.E.)
Number of initial
HRAs not
performed
because SNP is
unable to reach
new enrollees

Inclusions

Exclusions

Initial HRAs not performed on new
enrollees within 90 days (before or
after) of the effective date of enrollment
due to the SNP being unable to reach
new enrollees and for which the SNP
has documentation showing that the
enrollee did not respond to the SNP’s
attempts to reach him/her.
Documentation must show that a SNP
representative made at least 3 “nonautomated” phone calls and sent a
follow-up letter in its attempts to reach
the enrollee.

Initial HRAs not
performed where the
SNP does not have
documentation showing
that the enrollee did not
respond to the SNP’s
attempts to reach
him/her.

Number of
annual
reassessments
performed on
enrollees eligible
for a
reassessment

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.

13.7

Number of
annual
reassessment
refusals

13.8

Number of
annual
reassessments
where SNP is

When an initial assessment is performed
in the 90 days prior to the effective
enrollment date, the first annual
reassessment must completed no more
than 365 days after the initial HRA.
Annual reassessments not performed
due to enrollee refusal and for which the
SNP has documentation of enrollee
refusal.

Annual reassessments
not performed for which
there is no
documentation of
enrollee refusal.
Annual reassessments not performed
Annual reassessments
due to the SNP’s inability to reach
not performed for which
enrollees and for which the SNP has
the SNP does not have
documentation showing that the enrollee documentation showing
25

D.E
No.

Data Element
(D.E.)
unable to reach
enrollee

Inclusions

Exclusions

did not respond to the plan’s attempts to
reach him/her. Documentation must
show that a SNP representative made at
least 3 non-automated phone calls and
sent a follow-up letter in its attempts to
reach the enrollee.

that the enrollee did not
respond to the SNP’s
attempts to reach
him/her. Required
documentation of SNP’s
attempts to contact the
enrollee show that the
SNP made at least 3
phone calls and sent a
follow-up letter in its
attempts to reach the
enrollee.
* The “measurement year” is the same as the calendar year for this version of these technical
specifications.
** If a new enrollee does not receive an initial HRA within 90 days of enrollment, that enrollee’s
annual HRA is due to be completed within 365 days of enrollment. A new enrollee who receives
an HRA within 90 days of enrollment is due to complete a reassessment HRA no more than 365
days after the initial HRA was completed.
Notes:
This reporting section requires direct data entry into HPMS.
For Part C reporting, there are never to be more than 365 days between Health Risk Assessments
(HRAs) for enrollees in special needs plans. SNPs are required to conduct an initial HRA within
90 days before or after a beneficiary’s effective enrollment date. Initial HRAs conducted prior to
the effective enrollment date are counted as initial HRAs in the year in which the effective
enrollment date falls. For example, an initial HRA performed on November 23, 2015 for an
enrollee with an effective date of enrollment of January 1, 2016, would be counted as an initial
HRA in 2016. A SNP should not perform, or report on, a HRA 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) of the effective enrollment date, the
SNP is to complete a HRA as soon as possible. In this case, the HRA would be considered a
reassessment.
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.
All annual reassessment HRAs are due to occur within 365 days of the last HRA. Thus, when an
initial HRA is performed in the 90 days prior to an effective enrollment date that falls in the
beginning of a calendar year, in order to comply with the requirement to perform the annual
reassessment within 365 days of the last assessment, the first annual reassessment will be due
within the same measurement year as the initial HRA. Note that is such cases, a new enrollee
26

who has remained enrolled in the SNP for 365 days after the date of the initial HRA, will be
counted in both data elements 13.1 and 13.2 because he/she is a new enrollee (13.1) and an
enrollee eligible for an annual reassessment (13.2). (Example: The effective enrollment date is
1-1-2016 and the initial HRA was completed in November 2015. The annual reassessment will
be due in November 2016. The initial HRA and the annual reassessment HRA will both be
reported for 2016 and the enrollee will be counted as both a new enrollee and as an enrollee
eligible for annual reassessment.)
The plan must have documentation of any HRAs not performed based on enrollee refusal or the
SNP’s inability to reach the enrollee. The SNP must document in its internal records that the
enrollee did not respond to at least 3 “non-automated” phone calls and a follow up letter, all
soliciting participation in the HRA. Automated calls (“robo” or “blast” calls) as a means of
soliciting enrollees’ participation in completing an HRA are inappropriate and do not count
toward the three phone call attempts. Further, phone call attempts must be made by a SNP
representative so that when an enrollee is reached, it is possible to perform the HRA at that time,
by phone. 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.
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.2
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 period in order to meet the reporting requirement. The count for the 365
day cycle period for the HRA begins with the day after the date the previous HRA was
completed for the enrollee.
If eligibility records received after completion of the HRA indicate the member was never
enrolled in the plan, 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.
Questions have arisen regarding how to report data elements in this reporting section when enrollees
disenroll and then re-enroll, either in the same SNP or a different one (different organization or
sponsor) within the measurement year. When a member disenrolls from one SNP and enrolls into
another SNP (a different sponsor or organization), the member should be counted as a “new enrollee”
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.”

27

for the receiving plan. 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 HRA may 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 SNP care management.

14. ENROLLMENT AND DISENROLLMENT
Reporting
section
14. Enrollment
and
Disenrollment

Organization Types
Required to Report*
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.
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
28

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. 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 29, 2016

July 1-December 31
February 27, 2017

Data elements to be entered into the HPMS at the Contract level:
For measurement year 2017, four new data elements were 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.
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 for which the sponsor was
required to request additional information from the applicant (or his/her representative).
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).

29

I. Of the total reported in A, the number of internet enrollment requests received via plan or
affiliated third-party website (if sponsor offers this mechanism).
J. Of the total reported in A, the number of Online Enrollment Center (OEC) enrollment
requests received.
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).
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” for individuals affected by a contract nonrenewal, plan
termination or service area reduction.
*Indicates not reported under Part C.
2. Disenrollment:
A. The total number of voluntary disenrollment requests received in the specified time
period. Do not include disenrollments resulting from an individual’s enrollment in
another plan.
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.

30

15. REWARDS AND INCENTIVES PROGRAMS
Reporting
section
15. Rewards 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)
1/112/31

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.
The data collection method is partially a data entry and an upload. A plan user needs to select
"Yes" or "No" for data element 15.1 on the edit page. If the plan user selected "No", no upload
is necessary. If the plan user select "Yes", then the user will be required to upload additional
information in accordance with the file record layout.
In 2015, CMS added a new regulation at 42 CFR §422.134 that permits MA organizations to
offer one or more Rewards and Incentives Program (s) to currently enrolled enrollees. Plans
have a 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

31

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 _ _ _ _

32

16. MID-YEAR NETWORK CHANGES
Reporting
section

Organization Types
Required to Report

16. Mid-Year
Network
Changes

01 – Local CCP
02 – MSA*
04 – PFFS*
06 – 1876 Cost
11 – Regional CCP**
15 – RFB Local CCP

Report
Freq./
Level
1/Year
Contract

Report
Period
(s)
1/112/31

Data Due date (s)

Last Monday of
February in
following year

*Only network-based MSA and PFFS plans are required to report.
**Regional Preferred Provider Organizations (RPPOs) should only report on the network areas
of their plans (not the non-network areas).
This reporting section requires a file upload into HPMS.
CMS is increasing its oversight and management of Medicare Advantage organizations’
(MAOs’) network changes in order to ensure that changes made during the contract year do not
result in inadequate access to care for enrollees. The data collected in this measure will provide
CMS with a better understanding of how often MAOs undergo mid-year network changes and
how many enrollees are affected. In addition, the data will enhance CMS’s ability to improve its
Medicare Advantage (MA) network change protocol.
CMS considers a mid-year network change to be any change in network (i.e., provider
termination) 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 mid-year terminations of primary care
physicians (PCPs), certain specialists (cardiologists, endocrinologists, oncologists,
ophthalmologists, pulmonologists, rheumatologists, urologists), and facilities (acute inpatient
hospitals and skilled nursing facilities) during the reporting period. MAOs are to report on both
for-cause and no-cause terminations, as well as both MAO-initiated and provider-initiated
terminations.3
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 current CMS network adequacy criteria guidance, found
on the Medicare Advantage Applications website. In addition to PCP data, we are seeking data
on the mid-year network changes for some of the provider and facility specialty types that MAOs
3

Note: MAOs are to report on terminations of contracts between the MAO and the providers, where there is a
disruption in the ability of enrollees to see the provider(s). For example, if a PCP terminates its contract with a
certain medical group and then joins a different medical group that is also contracted with the MAO, but the
enrollees assigned to that PCP are still able to see him/her continuously with no disruption, then this type of
termination would not be counted. Only terminations of the MAO/provider contract are to be counted.

33

are required to include in their networks and to submit on their Health Service Delivery (HSD)
tables with a Medicare Advantage (MA) application or in the Network Management Module
(NMM) in HPMS.
Legal Basis:
CMS regulations at 42 CFR §422.112(a)(1)(i) and §422.114(a)(3)(ii) require that all MAOs
offering coordinated care plans (e.g., HMO, PPO) or other network-based plans (e.g., networkbased PFFS, network-based MSA, section 1876 cost plan) maintain a network of appropriate
providers that is sufficient to provide adequate access to covered services to meet the needs of
the population served.
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

Data Elements for Mid-Year Network Changes 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 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 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 to network during reporting
period by specialist/facility type - Cardiologist (16.23),
Endocrinologist (16.24), Oncologist (16.25), Ophthalmologist (16.26),

34

Element
Number

16.32-16.40

16.41
16.42
16.43-16.51

16.52

Data Elements for Mid-Year Network Changes Measure
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),
Ophthalmologist (16.46), Pulmonologist (16.47), Rheumatologist
(16.48), Urologist (16.49), Acute Inpatient Hospitals (16.50), Skilled
Nursing Facilities (16.51)
Total number of enrollees on last day of reporting period

35

17. PAYMENTS TO PROVIDERS
Reporting
section
17. Payments to
Providers

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

Report
Freq./
Level
1/Year
Contract

Report
Period
(s)
1/112/31

Data Due date (s)

Last Monday of
February in
following year

* MMPs should report for all APMs, not just Medicare MMPs.
This reporting section requires a file upload.
In order to maintain consistency with HHS goals of increasing the proportion of Medicare
payments made based on quality and value, HHS developed the four categories of value based
payment: fee-for-service with no link to quality (category 1); fee-for-service with a link to
quality (category 2); alternative payment models built on fee-for-service architecture (category
3); and population-based payment (category 4). CMS will collect data from MA organizations
about the proportion of their payments made to contracted providers based on these four
categories in order to understand the extent and use of alternate payment models in the MA
industry. Descriptions of the four categories are as follows:



Category one includes 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.



Category two includes 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 including hospital value-based purchasing and physician value-based modifiers.



Category three includes 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 episode of care. Payments are still triggered by delivery of services,
but there are opportunities for shared savings or 2-sided risk.



Category four includes population-based payment arrangements to include some payment
is not directly triggered by service delivery so volume is not linked to payment. Under
36

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).
For detailed information regarding these categories, please refer to the Alternative Payment
Model (APM) Framework at https://hcp-lan.org/workproducts/apm-whitepaper.pdf
Based on internal review, we propose to add four data elements (shown in table below) in order
to more accurately categorize existing MA payment arrangements. Categories 2, 3 and 4 of value
based payment are inherently linked to quality as defined in the HHS developed Alternative
Payment Model (APM) Definitional Framework. However, CMS recognizes that some providers
are paid based on pure risk based or pure capitation models with no link to quality (e.g. 3N and
4N in the APM definitional framework), which are not specified under the current reporting data
elements. The addition of the four proposed elements would allow more accurate reporting
about the full spectrum and prevalence of alternative payment models in Medicare Advantage.
Collecting these data will help to inform us as we determine how broadly MA organizations are
using alternative payment arrangements.
Data Elements (at the contract level):
Element
Number
17.1
17.2
17.3
17.4a
17.4b
17.5a
17.5b
17.6
17.7
17.8
17.9a

Data Elements for Payments to Provider
Total Medicare Advantage payment made to contracted providers.
Total Medicare Advantage payment made on a fee-for-service basis
with no link to quality (category 1).
Total Medicare Advantage payment made on a fee-for-service basis
with a link to quality (category 2).
Total Medicare Advantage payment made using alternative payment
models built on fee-for-service architecture (category 3)
Total Risk-based payments not linked to quality (e.g. 3N in APM
definitional framework)
Total Medicare Advantage payment made using population-based
payment (category 4).
Total capitation payment not linked to quality (e.g. 4N in the APM
definitional framework)
Total number of Medicare Advantage contracted providers.
Total Medicare Advantage contracted providers paid on a fee-forservice basis with no link to quality (category 1).
Total Medicare Advantage contracted providers paid on a fee-forservice basis with a link to quality (category 2).
Total Medicare Advantage contracted providers paid based on
alternative payment models built on a fee-for-service architecture
(category 3).

37

Element
Number
17.9b

17.10a
17.10b

Data Elements for Payments to Provider
Total Medicare Advantage contracted providers paid based risk-based
payments not linked to quality (e.g. 3N in the APM definitional
framework)
Total Medicare Advantage contracted providers paid based on
population based payment (category 4).
Total Medicare Advantage contracted providers paid based on
capitation with no link to quality (e.g. category 4N in the APM
definitional framework).

38

39

APPENDIX 1: FAQS: REPORTING SECTIONS 5 & 6:
Grievances, Organization Determinations, & Reconsiderations
PLAN INQUIRIES

CMS RESPONSES

1.

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.

2.

Should plans report all Dual Eligible member
grievances to CMS?

3.

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 grievance
procedures outlined under 42 CFR Part
422, Subpart M. For example,
grievances filed under the state
Medicaid process but not filed with the
plan and addressed under the plan’s
Subpart M grievance process, should
not be reported.”
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.

40

4.

5.

6.

7.

8.

Are plans to report only those organization
CMS requires plans to report requests
determinations defined under 42 C.F.R. 422.566? 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.
We are seeking information on how we should
Yes. Plans are to report fully
report pre-service requests and claims requests
favorable, partially favorable, and
for this category. Do you want fully favorable,
adverse pre-service and claims requests
partially favorable, and adverse for both pre(organization determinations and
service requests and claims requests?
reconsiderations), as described in this
guidance
If we have a prior authorization request and a
Plans are to report both a prior
claim for the same service -- is that considered a authorization request and a claim for
duplicate or should we report both?
the same service; this is not considered
a duplicate.
Is a request for a predetermination to be counted Organization determinations include a
as an organization determination? Does it matter request for a pre-service
who requests the predetermination – contracted
(“predetermination”) decision
provider, non-contracted provider or member? If submitted to the plan, regardless of
so, should they also be counted as partially and
who makes the pre-service request –
fully unfavorable?
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.
Should plans report determinations made by
Yes. Plans are to report decisions
delegated entities or only decisions that are made made by delegated entities – such as an
directly by the plan – e.g., should plans report
external, contracted entity responsible
decisions made by contracted radiology or dental for organization determinations (e.g.,
groups?
claims processing and pre-service
decisions) or reconsiderations.

41

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 didn’t 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.

42

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)?

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
Yes. For purposes of Part C Reporting
provider” means “contracted with the health
Section 6 reporting requirements,
plan” not “contracted with Medicare”.
“contracted provider” means
“contracted with the health plan” not
“contracted” (or participating) with
Medicare.”
When we make an adverse determination that is
Yes. Regardless of whether a QIO
sent to the QIO for review and later our adverse
overturns an Adverse organization
determination is overturned, should we count and determination, plans are to report the
report the initial Adverse determination that goes initial adverse or partially favorable
to the QIO? We understand that QIO
organization determination.
determinations are excluded from our reporting.
Should cases forwarded to the Part C IRE be
When a plan upholds its adverse or
counted once in the reporting section, i.e., as the partially favorable organization
Partially Favorable or adverse decision prior to
determination at the reconsideration
sending to the IRE?
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.

43

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.

44