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AUDIT PROCESS AND DATA REQUEST
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Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table of Contents
Audit Purpose and General Guidelines .................................................................................................. 3
Universe Preparation & Submission ...................................................................................................... 5
Audit Elements ..................................................................................................................................... 10
I.
Timeliness - Coverage Determinations, Appeals and Grievances (TCDAG) ........................... 10
II. Appropriateness of Clinical Decision-Making & Compliance with CDA Processing
Requirements .................................................................................................................................... 12
III. Grievances and Misclassification of Requests .......................................................................... 16
Appendix .............................................................................................................................................. 18
Appendix A—Coverage Determinations, Appeals, and Grievances (CDAG) Record Layouts ...... 18
Table 1: Standard Coverage Determinations (SCD) Record Layout............................................ 18
Table 2: Standard Coverage Determination Exception Requests (SCDER) Record Layout ....... 22
Table 3: Direct Member Reimbursement Request Coverage Determinations (DMRCD) Record
Layout ........................................................................................................................................... 26
Table 4: Expedited Coverage Determinations (ECD) Record Layout ......................................... 29
Table 5: Expedited Coverage Determination Exception Requests (ECDER) Record Layout ..... 33
Table 6: Standard Redeterminations (SRD) Record Layout ........................................................ 38
Table 7: Direct Member Reimbursement Request Redeterminations (DMRRD) Record Layout41
Table 8: Expedited Redeterminations (ERD) Record Layout ...................................................... 44
Table 9: Standard IRE Auto-forwarded Coverage Determinations and Redeterminations (SIRE)
Record Layout .............................................................................................................................. 48
Table 10: Expedited IRE Auto-forwarded Coverage Determinations and Redeterminations
(EIRE) Record Layout.................................................................................................................. 51
Table 11: Standard IRE, ALJ or MAC Determinations (SIAM) Record Layout ......................... 54
Table 12: Direct Member Reimbursements decided by review entity other than sponsor
(DMRRE) Record Layout ............................................................................................................ 56
Table 13: Expedited IRE, ALJ or MAC Determinations (EIAM) Record Layout ....................... 58
Table 14: Standard Grievances Part D (SGD) Record Layout ..................................................... 60
Table 15: Expedited Grievances Part D (EGD) Record Layout ................................................... 62
Table 16: Call Logs Part D Record Layout .................................................................................. 64
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Audit Purpose and General Guidelines
1. Purpose: To evaluate performance in the three areas outlined in this protocol related to coverage
determinations, appeals, and grievances (CDAG). The Centers for Medicare and Medicaid
Services (CMS) will perform its audit activities using these instructions (unless otherwise noted).
2. Review Period: The review period for the CDAG Program Area will be decided based on your
organization’s total enrollment. CMS reserves the right to expand the review period to ensure
sufficient universe size.
•
•
•
Plans with <50,000 enrollees: The review period will be the 3-month period preceding and
including the date of the audit engagement letter.
Plans with >50,000 but <250,000 enrollees: The review period will be the 2-month period
preceding and including the date of the audit engagement letter.
Plans with >250,000 enrollees: The review period will be the 1-month period preceding and
including the date of the audit engagement letter. Note: The audit review period for the Call
Logs - Part D Universe (Table 16) is specified in the audit universe record layout and the
audit review period varies depending on organization size.
3. Responding to Documentation Requests: The sponsor is expected to present its supporting
documentation during the audit and take screen shots or otherwise upload the supporting
documentation, as requested, to the secure site using the designated naming convention and within
the timeframe specified by the CMS Audit Team.
4. Sponsor Disclosed Issues: Sponsors will be asked to provide a list of all disclosed issues of noncompliance that are relevant to the program areas being audited and may be detected during the
audit. A disclosed issue is one that has been reported to CMS prior to the receipt of the audit start
notice (which is also known as the “engagement letter”). Issues identified by CMS through ongoing monitoring or other account management/oversight activities during the plan year are not
considered disclosed.
Sponsors must provide a description of each disclosed issue as well as the status of correction and
remediation using the Pre-Audit Issue Summary template. This template is due within 5 business
days after the receipt of the audit start notice. The sponsor’s Account Manager will review the
summary to validate that “disclosed” issues were known to CMS prior to receipt of the audit start
notice.
When CMS determines that a disclosed issue was promptly identified, corrected (or is actively
undergoing correction), and the risk to beneficiaries has been mitigated, CMS will not apply the
ICAR condition classification to that condition.
5. Impact Analysis (IA): An impact analysis must be submitted as requested by CMS. The impact
analysis must identify all beneficiaries subjected to or impacted by the issue of non-compliance.
Sponsors will have up to 10 business days to complete the requested impact analysis templates.
CMS may validate the accuracy of the impact analysis submission(s). In the event an impact
analysis cannot be produced, CMS will report that the scope of non-compliance could not be fully
measured and impacted an unknown number of beneficiaries across all contracts audited.
6. Calculation of Score: CMS will determine if each condition cited is an Observation (0 points),
Corrective Action Required (CAR) (1 point) or an Immediate Corrective Action Required (ICAR)
(2 points). Invalid Data Submission (IDS) conditions will be cited when a sponsor is not able to
produce an accurate universe within 3 attempts. IDS conditions will be worth one point.
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CMS will then add the score for that audit element to the scores for the remainder of the audit
elements in a given protocol and then divide that number (i.e., total score), by the number of audit
elements tested to determine the sponsor’s overall CDAG audit score. Some elements and
program areas may not apply to certain sponsors and therefore will not be considered when
calculating program area and overall audit scores. Observations will be recorded in the draft and
final reports, but will not be scored and therefore will not be included in the program area and
audit scores.
7. Informing Sponsor of Results: CMS will provide daily updates regarding conditions discovered
that day (unless the case has been pended for further review). CMS will provide a preliminary
summary of its findings at the exit conference. The CMS Audit team will do its best to be as
transparent and timely as possible in its communication of audit findings. Sponsors will also
receive a draft audit report which they may formally comment on and then a final report will be
issued after consideration of a sponsor’s comments on the draft.
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Universe Preparation & Submission
1. Responding to Universe Requests: The sponsor is expected to provide accurate and timely
universe submissions within 15 business days of the engagement letter date. CMS may request a
revised universe if data issues are identified. The resubmission request may occur before and/or
after the entrance conference depending on when the issue was identified. Sponsors will have a
maximum of 3 attempts to provide complete and accurate universes, whether these attempts all
occur prior to the entrance conference or they include submissions prior to and after the entrance
conference. However, 3 attempts may not always be feasible depending on when the data issues
are identified and the potential for impact to the audit schedule. When multiple attempts are
made, CMS will only use the last universe submitted.
If the sponsor fails to provide accurate and timely universe submissions twice, CMS will
document this as an observation in the sponsor’s program audit report. After the third failed
attempt, or when the sponsor determines after fewer attempts that they are unable to provide an
accurate universe within the timeframe specified during the audit, the sponsor will be cited an
Invalid Data Submission (IDS) condition relative to each element that cannot be tested, grouped
by the type of case.
2. Pull Universes: The universes collected for this program area test whether the sponsor has
deficiencies related to timeliness, clinical decision making and appropriateness, andgrievances
and the misclassification of requests in the area of CDAG. Sponsors will provide universes of all
of their expedited and standard coverage determinations (CDs) (e.g., prior authorization, step
therapy authorization, etc.), all expedited and standard CD exception requests (prior authorization
exception, non-formulary exception, tiering exception, etc.), all expedited and standard
redeterminations (RDs), all direct member reimbursement requests (initial CDs, RDs, and
overturns by review entities), all untimely CDs and RDs auto-forwarded to the Independent
Review Entity (IRE), all expedited and standard IRE, Administrative Law Judge (ALJ), or
Medicare Appeals Council (MAC) determinations that overturned the sponsor’s decision, and all
expedited and standard grievances (e.g., written correspondence, calls received by customer
service representatives, etc.), as well as a call log of all calls received by the sponsor from
enrollees or their representatives relating to their Part D benefit.
Instructions for what should be included in each universe are listed above the tables listed in
Appendix A. For each respective universe, the sponsor should include all cases that match the
description for that universe for all contracts and Plan Benefit Packages (PBPs) in its organization
as identified in the audit engagement letter (e.g., all standard tiering exception CDs for all
contracts and PBPs in your organization).
The universes should be 1) all inclusive, regardless of whether the request was determined to be
favorable, partially favorable, unfavorable, auto-forwarded, dismissed, withdrawn or reopened
and 2) submitted in the appropriate record layout as described in Appendix A. These record
layouts include:
•
•
•
•
•
•
Table 1: Standard Coverage Determinations (SCD)
Table 2: Standard Coverage Determination Exception Requests (SCDER)
Table 3: Direct Member Reimbursement Request Coverage Determinations (DMRCD)
Table 4: Expedited Coverage Determinations (ECD)
Table 5: Expedited Coverage Determination Exception Requests (ECDER)
Table 6: Standard Redeterminations (SRD)
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•
•
•
•
•
•
•
•
•
•
Table 7: Direct Member Reimbursement Request Redeterminations (DMRRD)
Table 8: Expedited Redeterminations (ERD)
Table 9: Standard IRE Auto-forwarded Coverage Determinations and Redeterminations
(SIRE)
Table 10: Expedited IRE Auto-forwarded Coverage Determinations and Redeterminations
(EIRE)
Table 11: Standard IRE, ALJ, or MAC Determinations (SIAM)
Table 12: Direct Member Reimbursement Requests By Other Review Entity (DMRRE)
Table 13: Expedited IRE, ALJ, or MAC Determinations (EIAM)
Table 14: Standard Grievances Part D (SGD)
Table 15: Expedited Grievances Part D (EGD)
Table 16: Call Logs Part D (CLD)
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3. Submit Universes to CMS: Sponsors should submit each universe in the Microsoft Excel (.xlsx)
or Comma Separated Values (.csv) file format with a header row (or Text (.txt) file format
without a header row) following the record layouts shown in Appendix A, Tables 1-16. The
sponsor should submit its universes in whole and not separately for each contract and PBP.
4. Timeliness Tests: CMS will run the tests indicated below on each universe except for Table 16:
Call Logs Part D. For the effectuation tests, auditors will determine percentage of timely cases
from a sponsor’s approvals (favorable cases). For the notification timeliness tests, auditors will
determine the percentage of timely cases from a full universe of approvals and denials. If more
than one universe tests the same compliance standard, multiple timeliness tests results will be
merged for one overall score.
TABLE
#
RECORD
LAYOUT
1
SCD*
2
3
4
5
SCDER*
DMRCD*
ECD*
ECDER*
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UNIVERSE
Standard CDs
Standard CD
Exception
Requests
Part D Direct
Member
Reimbursement
Request CDs
Expedited CDs
Expedited CDs
Exception
Requests
COMPLIANCE
STANDARD TO
APPLY
No later than 72
hours. Late cases
must be autoforwarded to the IRE
within 24 hours of the
expiration of the
timeframe.
No later than 72
hours from the time
the prescriber’s
supporting statement
was received.
No later than 14 days.
If DMR request
involves an exception
the case may not be
tolled pending receipt
of a prescriber’s
supporting statement.
No later than 24
hours. Late cases
must be autoforwarded to the IRE
within 24 hours of the
expiration of the
timeframe.
No later than 24
hours from the time
the prescriber’s
supporting statement
is received
CHAP. 18
REF.
TEST
§40.2,
§40.4,
§130.1
Effectuation
§30.2,
§40.2,
§130.1
Effectuation
§30.3.2
Notification
Notification
Notification
Reimbursement
§50.4,
§50.6,
§130.1
Effectuation
§30.2,
§50.4,
§130.1
Effectuation
Notification
Notification
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Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
TABLE
#
RECORD
LAYOUT
6
SRD*
7
8
DMRRD*
ERD*
UNIVERSE
Standard RDs
Part D Direct
Member
Reimbursement
Request RDs
Expedited RDs
9
SIRE*
Standard IRE
Auto-forwarded
CDs and RDs
10
EIRE*
Expedited IRE
Auto-forwarded
CDs and RDs
11
SIAM*
Standard IRE,
ALJ or MAC
Determinations
12
DMRRE*
Part D Direct
Member
Reimbursement
Requests
decided by
review entity
other than
sponsor
Page 8 of 65
COMPLIANCE
STANDARD TO
APPLY
No later than 7 days.
Late cases must be
auto-forwarded to the
IRE within 24 hours
of the expiration of
the timeframe.
No later than 7 days.
Check mailed within
30 days.
CHAP. 18
REF.
TEST
§70.7,
§70.10,
§130.2.1
Effectuation
§70.7
§130.2.3
Notification
Notification
Reimbursement
No later than 72
hours. Late cases
must be autoforwarded to the IRE
within 24 hours of the
expiration of the
timeframe.
Within 24 hours of
the expiration of the
timeframe all late
CDs and RDs without
a fully favorable
decision must be
auto-forwarded to the
IRE.
Within 24 hours of
the expiration of the
timeframe all late
CDs and RDs without
a fully favorable
decision must be
auto-forwarded to the
IRE.
Effectuation of
benefit or authorized
reimbursement within
72 hours of notice
from appeal entity.
No later than 72
hours to authorize/
effectuate
reimbursement.
No later than 30 days
from date notified of
CD reversal to issue
reimbursement.
§70.8.1,
§70.10,
§130.2.2
Effectuation
§40.4,
§70.10
IRE Auto-Forward
§50.6,
§70.10
IRE Auto-Forward
§130.3.1
Effectuation
§130.3.3
§130.3.3
Effectuation
Notification
Reimbursement
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AUDIT PROCESS AND DATA REQUEST
TABLE
#
RECORD
LAYOUT
UNIVERSE
COMPLIANCE
STANDARD TO
APPLY
13
EIAM
Expedited IRE,
ALJ or MAC
Determinations
14
SGD
Standard
Grievances Part
D
15
EGD
Expedited
Grievances Part
D
Effectuation of
benefit within 24
hours of notice from
appeal entity.
No later than 30 days,
plus 14 days (totaling
44 days) if an
extension is used.
No later than 24
hours.
CHAP. 18
REF.
TEST
§130.3.2
Effectuation
§20.3
Notification
§20.3
Notification
*These universe may be combined with at least one other universe to determine an overall
compliance score. Merges include:
o
o
o
o
o
SCD will be combined with SCDER for effectuation and notification
ECD will be combined with ECDER for effectuation and notification
DMRRD will be combined with SRD for notification
SIRE will be combined with EIRE, SCD, SCDER, DMRCD, ECD, ECDER, ERD, SRD, and
DMRRD for an IRE auto-forward test
DMRRE will be combined with SIAM for effectuation
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Audit Elements
I. Timeliness - Coverage Determinations, Appeals and Grievances (TCDAG)
(Performed via webinar prior to the entrance conference, results communicated to sponsor
during live portion of the audit)
1. Select Sample Cases: CMS will randomly select 5 cases from record layouts 1 through 15 for a
total of up to 75 cases. CMS will not validate Table 16- Call Logs Part D during this pre-audit
webinar.
2. Verify Universe Submission: Prior to the live portion of the audit, CMS or its contractor, when
applicable, will schedule a separate webinar with the sponsor to verify that the dates and times
provided in the universe submissions are accurate. In addition, for the exception universes
(SCDER and ECDER), CMS will be evaluating that the cases provided are actually exception
requests. The sponsor should have available the information and documents necessary to
demonstrate that the dates and times provided in the record layouts were accurate. The sponsor
will need access to the following documents during both the pre-audit webinar and the live audit
webinar and may be requested to produce screenshots of any of the following:
2.1. For requests for coverage determinations or redeterminations:
• Initial request:
If request was received via fax/mail/email, copy of original request including
date/time stamp of receipt.
If request was received via phone, copy of CSR notes and/or documentation of call
including date/time stamp of call and call details.
• Copy of all supplemental information submitted by the prescriber.
If information was received via fax/mail/email, copy of documentation provided
including date/time stamp and call details.
If information was received via phone, copy of CSR notes and/or documentation of
call including date/time stamp.
• Documentation of the decision, including:
Documentation showing denial, partial denial, or approval notification to the
beneficiary and/or their representative and prescriber, if applicable.
Copy of the written decision letter and documentation of date/time letter was mailed.
If oral notification was given, copy of CSR notes and/or documentation of call
including date/time stamp.
• Any other reports, system notes, or logs that document beneficiary notification.
• Documentation of effectuation of request, including:
Approval in coverage determinations/redeterminations system(s) and evidence of
effectuation in sponsor claims system clearly showing date and time override was
entered.
• If case was untimely, include the following:
Documentation showing when the sponsor auto-forwarded the request to the IRE.
2.2. For cases overturned by IRE/ALJ/MAC:
• Copy of overturn notice from IRE/ALJ/MAC including date/time stamp of receipt by
sponsor.
• Documentation of effectuation including approval in coverage determinations/
redeterminations system(s) and evidence of effectuation in sponsor claims system clearly
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•
showing date/time the override was entered. For approved exception requests, proof that
the approval is effective for the remainder of the plan year.
Copy of effectuation notice to IRE/ALJ/MAC including sent date/time stamp.
3. Apply Compliance Standard: At a minimum, CMS will evaluate cases against the following
criteria. CMS may review factors not specifically addressed in these questions if it is determined
that there are other related CDAG requirements not being met.
3.1. Universe Accuracy Standard: CMS will test each of the first 15 universes (Tables 1 – 15)
by confirming the data through the 5 selected cases (75 total cases). The integrity of the
universe will be questioned if more than 1 of the 5 sample cases observed during the audit
does not match the data provided in the universe. If this occurs CMS will request a new
universe to test timeliness for that universe. Sponsors will be expected to produce the new
universe prior to the live portion of the audit per CMS instructions. If the sponsor cannot
produce an accurate universe after three submissions, CMS will cite all applicable IDS
conditions relative to timeliness.
Are the dates and times observed during the pre-audit webinar consistent with the
timeliness fields in the universe submission?
3.2. Calculate Universe Timeliness: CMS or its contractor, when applicable, will then calculate
the applicable timeliness tests as identified in the record layout chart above. Some universes
will have two timeliness tests performed; one for effectuation of approvals and one for
notification of all requests. Other universes may only have one timeliness test performed.
For each timeliness test in the universe, the number of late cases will be divided by the total
number of cases applicable for that test in each universe. For instance, for effectuation of
standard coverage determinations, all approvals that were effectuated untimely will be
divided by all approvals in the universe. Once the percentage of late cases is determined,
CMS will calculate the percentage of timely cases (100% - % late cases) and apply the
compliance threshold for that test.
CMS has determined 3 timeliness thresholds that apply to every test in each universe.
Sponsors that fall at or above the first threshold will generally not be cited a condition.
Sponsors that fall within the second threshold will generally be cited for a corrective action
required (CAR) for unmet timeliness requirements. Sponsors falling below the third threshold
may be cited an immediate corrective action (ICAR) for unmet timeliness requirements.
Are the sponsor’s universes timely in accordance with the CMS compliance standards
referenced in the table above?
4. Inform Sponsor of Results: CMS will inform the sponsor of the results of its analysis for each
of the 15 universes supplied during the live audit portion of the review; including if any
conditions will be cited, and if so, which condition(s).
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II. Appropriateness of Clinical Decision-Making & Compliance with CDA Processing
Requirements
1. Select Sample Cases: CMS will select a targeted sample of 40 cases (30 denials and 10
approvals) that appear clinically significant. CMS may select an additional 5 cases to review
dismissals, withdrawals and/or re-openings to assess whether the request was appropriately
classified and processed. CMS will attempt to ensure that the sample set is representative of
various types of coverage determinations (e.g., prior authorization, step therapy authorization,
tiering exception, formulary exception (including both non-formulary drugs and formulary drugs
with a UM requirement), reimbursement request, etc.). The sample set for the 40 clinical
appropriateness cases will be selected from the universe categories as follows:
•
•
•
•
•
•
10 coverage determination denials (standard cases)
5 redetermination denials (standard cases)
5 expedited cases (either coverage determination denials or redetermination denials)
10 IRE, ALJ, or MAC overturns
5 coverage determination approvals (standard and expedited)
5 redetermination approvals (standard and expedited)
In sampling, CMS will ensure that 15 of the 30 denial cases are protected class drug denials. If
the universe does not include a total of 15 different protected class drug denials, CMS will
include as many as are in the universe to get closest to 15.
2. Review Sample Case Documentation: CMS will review all sample case file documentation for
proper notification and clinical appropriateness of the decision. The sponsor will need access to
the following documents during the live audit webinar and may be requested to produce
screenshots of any of the following:
2.1. For requests for coverage determinations or redeterminations:
• Initial request:
Copy of request, if request was received via fax/mail/email.
If request was received via phone, copy of CSR notes and/or documentation of call
and call details.
• Copy of appointment of representative (AOR), or other conforming instrument, if
patient’s representative placed request and/or received response.
• Copy of all notices, letters, call logs, or other documentation showing when the sponsor
requested additional information from the prescriber. If the request was made via phone
call, copy of call log detailing what was communicated to the prescriber.
• Copy of all supplemental information submitted by the prescriber.
If information was received via fax/mail/email, copy of documentation provided
including call details.
If information was received via phone, copy of CSR notes and/or documentation of
call.
• Documentation of case review steps including any standard operating procedures or
standard decision trees used by clinical personnel.
• Name and title of final reviewer and rationale for the decision. Additional
documentation will include, but is not limited to: sponsor formulary/EOC, sponsor
clinical criteria, Federal Regulations, CMS Guidance, compendia, peer reviewed
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•
•
•
•
•
•
•
•
•
•
•
literature (where allowed), or any other documentation used when considering the
request.
Documentation of the decision, including:
Documentation showing denial, partial denial, or approval notification to the
beneficiary and/or their representative and prescriber, if applicable.
Copy of the written decision letter.
If oral notification was given, copy of CSR notes and/or documentation of call.
Any other reports, system notes, or logs that document denial or approval of the request
and beneficiary notification.
For approvals, documentation of effectuation of request, including:
Approval in coverage determinations/redeterminations system(s) and evidence of
effectuation in sponsor claims system clearly showing date and time override was
entered.
For approved exception requests, proof that the approval is effective for the
remainder of the plan year.
Documentation showing approval notification to the beneficiary and/or their
representative and prescriber, as applicable.
If rejection, explanation for why drug rejected (i.e., refill too soon).
If there are no claims for drug after date of effectuation, narrative explaining member
has not attempted to receive the drug since date of effectuation and a screen print
showing all claims for member since date of effectuation.
For reopenings:
Copy of any case notes as to why the decision was reopened,
Copy of any notice sent to the enrollee regarding the reason for the reopening,
Copy of all documentation relating to the decision of the reopening and any
subsequent notification regarding the decision.
For dismissals or withdrawals:
A copy of the initial request
Copies of any case notes as to why the case was withdrawn or dismissed
Any notification regarding the dismissal or withdrawal
If applicable, all documentation to support the sponsor’s decision to process an
expedited request under the standard timeframe, including any pertinent medical
documentation, and any associated notices provided to the enrollee and the requesting
provider/physician.
If applicable, notice to the enrollee that their request is not being expedited and the right
to file a grievance.
2.2. For cases overturned by IRE/ALJ/MAC:
• Copy of overturn notice from IRE/ALJ/MAC.
• Documentation of effectuation including approval in coverage determinations/
redeterminations system(s) and evidence of effectuation in sponsor claims system. For
approved exception requests, proof that the approval is effective for the remainder of the
plan year.
• Copy of effectuation notice to IRE/ALJ/MAC.
• Screen print of all claims for the requested drug after effectuation dates.
• If rejection, explanation for why drug rejected (i.e., refill too soon).
• If there are no claims for drug after date of effectuation, narrative explaining member
has not attempted to receive the drug since date of effectuation and a screen print
showing all claims for member since date of effectuation.
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3. Apply Compliance Standard: At a minimum, CMS will evaluate cases against the following
criteria. CMS may review factors not specifically addressed in these questions if it is determined
that there are other related CDAG requirements not being met.
3.1. Clinical Appropriateness/ Approvals:
3.1.1. Was appropriate notification (i.e., correct notice and approval language understandable
for enrollee) provided to the enrollee (or authorized representative) and
provider/physician, if applicable?
3.1.2. If representative received response, was an appointment of representative (AOR), or
other conforming instrument, on file?
3.1.3. Was approval effectuated for appropriate length of time? (i.e., duration of therapy on
CMS-approved PA criteria, end of the plan year, or prescriber-specified time)
3.2. Clinical Appropriateness/ Denials:
3.2.1. Was appropriate notification (i.e., correct notice and denial language detailed, specific
to the facts of the case, understandable for enrollee; appeal rights; etc.) provided to the
enrollee (or representative) and provider/physician, if applicable?
3.2.2. If representative received response, was an appointment of representative (AOR), or
other conforming instrument, on file?
3.2.3. Was the request reviewed by a physician or other appropriate health care professional
with sufficient medical and other expertise including knowledge of Medicare coverage
criteria?
3.2.4. Was the redetermination reviewed by a different physician with expertise in the field of
medicine that is appropriate for the services at issue?
3.2.5. Did the sponsor appropriately consider clinical information and comply with CMS
coverage and notification requirements?
3.2.6. Did the sponsor make reasonable and diligent efforts to obtain all medical records and
other pertinent documentation within the required timeframes?
3.2.7. For cases where the sponsor was untimely in its decision, did the sponsor forward the
case to the IRE properly and within the required timeframe?
3.3. IRE, ALJ, or MAC Overturns: If a reviewer determines the IRE, ALJ or MAC reversal
was in error, the sponsor will receive a score of pass for that case. For all other IRE, ALJ and
MAC cases, apply the following compliance criteria:
3.3.1. Did the IRE, ALJ or MAC receive additional information that would have changed the
sponsor’s decision to deny the case?
3.3.2. Did the sponsor attempt to obtain that information?
3.4. For Dismissals, Withdrawn Cases, and/or Re-openings:
3.4.1. Did the sponsor appropriately classify and process the coverage request?
3.4.2. If the request was a re-opening, did the sponsor follow 42 CFR 423 Subpart U
requirements?
4. Sample Case Results: CMS will test each of the 40 to 45 cases. If CMS requirements are not
met, conditions (findings) are cited. If CMS requirements are met, no conditions (findings) are
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cited. NOTE: Cases and conditions may have a one-to-one or a one-to-many relationship. For
example, one case may have a single condition or multiple conditions of non-compliance.
Page 15 of 65
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III. Grievances and Misclassification of Requests
1. Select Sample Cases: CMS will select a targeted sample of 10 total grievances: 7 from the
standard grievances record layout and 3 from the expedited grievances record layout (Appendix
A, Tables 14 and 15). If the sponsor does not have enough expedited grievances, the auditors will
sample additional cases from the standard grievance universe. CMS will also select a targeted
sample of 10 calls from the sponsor’s Part D call log universe.
2. Review Sample Case Documentation: CMS will review all sample cases file documentation to
determine that grievances were appropriately classified and that the notification properly
addressed the issue raised in the grievance. CMS will also review call logs to determine that
incoming calls were appropriately classified as either coverage determinations or grievances, as
appropriate. The sponsor will need access to the following documents or audio files during the
live webinar and may be requested to produce screenshots or transcripts of any of the following:
2.1 For Grievances:
• Initial complaint:
If complaint was received via fax/mail/email, copy of original complaint.
If request was received via phone, copy of CSR notes and/or documentation of call
including the call details.
• Copy of appointment of representative (AOR), or other conforming instrument, if
patient’s representative filed grievance or received notification.
• Documentation explaining the grievance issue(s).
• Copy of all notices, letters, call logs, or other documentation showing when the sponsor
received the grievance and/or requested additional information from the beneficiary
and/or their representative date/time stamp of the request. If request was made via phone
call, copy of call log detailing what was communicated to the enrollee.
• If the enrollee is complaining about a specific drug or about not having received a drug,
provide any information relative to the drug in question and whether a coverage request
was initiated.
• Copy of all supplemental information submitted by beneficiary and/or their
representative.
If information was received via fax/mail/email, copy of documentation provided.
If information was received via phone, copy of CSR notes and/or documentation of
call.
• Documentation showing the steps the sponsor took to resolve the issue, including
appropriate correspondence with other departments within the organization, referral to
sponsor’s fraud, waste, and abuse department, outreach to network pharmacies, and
description of the final resolution.
• Documentation showing resolution notification to the beneficiary and/or their
representative.
Copy of the written decision letter sent and documentation of date/time letter was
mailed.
If oral notification was given, copy of CSR notes and/or documentation of call.
2.2 For Call Logs:
• Initial call record:
Date and time call received
Copy of Customer Service Representative (CSR) notes and/or documentation of call
details
• Documentation explaining the call issue(s)
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•
•
•
•
•
Call log audio files (recorded calls)
Documentation of how the call was processed, routed, or handled
If the call was classified as a grievance:
Copy of grievance case file
Copy of all notification sent to the beneficiary concerning the grievance
Documentation of resolution of issue
If the call was classified as a coverage determination or redetermination:
Copy of coverage determination or redetermination case file
Dates and times request was initiated
Documentation of case file notes
Any notification sent to the beneficiary of the resolution
If the call was classified as an inquiry
Any follow-up done, if applicable.
Call notes, dates and times of the call
3. Apply Compliance Standard: At a minimum, CMS will evaluate cases against the following
criteria. CMS may review factors not specifically addressed in these questions if it is determined
that there are other related CDAG requirements not being met.
3.1. Was the case (e.g., grievance) or call correctly classified, and if not, was it quickly
transferred to the appropriate process?
3.2. For grievances, did the grievance notification appropriately address all issues raised in
the complaint?
4. Sample Case Results: CMS will test each of the 20 cases (10 grievances and 10 calls). If CMS
requirements are not met, conditions (findings) are cited. If CMS requirements are met, no
conditions (findings) are cited. NOTE: Cases and conditions may have a one-to-one or a one-tomany relationship. For example, one case may have a single condition or multiple conditions of
non-compliance.
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Appendix
Appendix A—Coverage Determinations, Appeals, and Grievances (CDAG) Record
Layouts
The universes for the Part D Coverage Determination, Appeals and Grievances (CDAG) program
area must be submitted in the Microsoft Excel (.xlsx) or Comma Separated Values (.csv) file format
with a header row (or Text (.txt) file format without a header row). Do not include the Column ID
variable which is shown in the record layout as a reference for a field’s column location in an Excel
or Comma Separated Values file. Do not include additional information outside of what is dictated in
the record layout. Submissions that do not strictly adhere to the record layout will be rejected.
Please use a comma (,) to separate multiple values within one field if there is more than one piece of
information for a specific field. Please ensure that all case information (dates and times) are included
in the specific time zone that the case was received.
If you don’t have data for any of the fields identified below, please discuss that with your Auditor in
Charge (AIC) prior to populating or submitting your universes.
NOTE: There is a maximum of 4,000 characters per record row. Therefore, should additional
characters be needed for a variable, enter this information on the next record at the appropriate start
position.
Table 1: Standard Coverage Determinations (SCD) Record Layout
• Include all requests processed as standard coverage determinations.
• Exclude all direct member reimbursement requests, exception requests and requests
processed as expedited coverage determinations.
• Submit cases based on the date the sponsor’s decision was rendered or should have been
rendered (the date the request was initiated may fall outside of the review period).
Column
ID
A
Field Name
Field Type
Beneficiary First Name
B
Beneficiary Last Name
C
Enrollment Effective
Date
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
D
Cardholder ID
E
Contract ID
F
Plan ID
Page 18 of 65
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
Field
Length
50
Description
50
Last name of the beneficiary.
10
Effective date of beneficiary’s enrollment for
the PBP that the beneficiary was enrolled in
when the coverage determination was
received. Submit in CCYY/MM/DD format
(e.g., 2017/01/01).
Cardholder identifier used to identify the
beneficiary. This is assigned by the sponsor.
20
First name of the beneficiary.
5
The contract number (e.g., H1234) of the
organization.
3
The plan number (e.g., 001) of the
organization.
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Part D Coverage Determinations, Appeals, and Grievances (CDAG)
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Column
ID
G
Field Name
Field Type
Was the beneficiary
residing in a long term
care facility?
CHAR
Always
Required
H
Date the request was
received
CHAR
Always
Required
10
I
Time the request was
received
CHAR
Always
Required
8
J
Required AOR
1
K
AOR Receipt Date
CHAR
Always
Required
CHAR
Always
Required
L
AOR Receipt Time
CHAR
Always
Required
8
M
Issue Description
2000
N
NDC_11
CHAR
Always
Required
CHAR
Always
Required
O
Drug Name, Strength &
Dosage Form
150
P
Is this a protected class
drug?
CHAR
Always
Required
CHAR
Always
Required
Page 19 of 65
Field
Length
2
10
11
1
Description
Indicate whether the beneficiary was identified
as residing in a long term care facility when
the coverage determination was received.
Valid values are:
Y = Yes
N = No
U = Unknown
Provide the date the request was received from
the enrollee, their representative, or their
prescriber. Submit in CCYY/MM/DD format
(e.g., 2017/01/01).
Provide the time of day the request was
received from the enrollee, their
representative, or their prescriber. Time is in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA if time is not available.
Yes (Y)/ No (N) indicator of whether the
request was made by a representative or
someone claiming to be a representative.
Date the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in CCYY/MM/DD format (e.g.,
2015/01/01). Answer None if no AOR was
received. Answer NA if no AOR form was
required.
Time the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in HH:MM:SS format (e.g., 23:45:59).
Answer None if no AOR was received.
Answer NA if no AOR form was required.
Provide a description of the issue and, for
denials, an explanation of why the decision
was denied.
11-Digit National Drug Code. When no NDC
is available enter the applicable Uniform
Product Code (UPC) or Health Related Item
Code (HRI). Do not include any spaces,
hyphens or other special characters. Answer
NA if these codes are not available.
Provide the drug name, strength, and dosage
form.
Protected class drug Yes (Y)/No (N) indicator.
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Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
Q
Field Name
Field Type
Field
Length
2
Description
Was request made
under the expedited
timeframe but
processed by the plan
under the standard
timeframe?
CHAR
Always
Required
R
Request Disposition
CHAR
Always
Required
20
Was the request denied
for lack of medical
necessity?
CHAR
Always
Required
2
T
If denied for lack of
medical necessity, was
the review completed
by a physician or other
appropriate health care
professional?
CHAR
Always
Required
2
U
Date of plan decision
10
V
Time of plan decision
W
Date effectuated in the
plan's system
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
X
Time effectuated in the
plan’s system
CHAR
Always
Required
8
Y
Date oral notification
provided to enrollee
CHAR
Always
Required
10
Z
Time oral notification
provided to enrollee
CHAR
Always
Required
8
Status of the request. Valid values are:
approved, denied, IRE auto-forward,
dismissed, withdrawn, re-opened approved, or
re-opened denied. Answer NA if the request
was never resolved/processed.
Yes (Y)/No (N) indicator of whether request
denied for lack of medical necessity. Answer
NA if the request was not denied (i.e.,
approved, auto-forwarded, dismissed,
withdrawn). .
Yes (Y)/No (N) indicator of review by
physician or other appropriate health care
professional if case was denied for lack of
medical necessity. Answer NA if the request
was not denied for lack of medical necessity
or the request was not denied (i.e., approved,
auto-forwarded, dismissed, withdrawn).
Date of the plan decision (e.g., denied).
Submit in CCYY/MM/DD format (e.g.,
2017/01/01).
Time of the plan decision (e.g., denied).
Submit in HH:MM:SS military time format
(e.g., 23:59:59).
Date effectuated in the plan's system. Submit
in CCYY/MM/DD format (e.g., 2017/01/01).
Answer NA for requests that were not
approved (e.g. denials/auto-forwards).
Time effectuated in the plan's system. Submit
in HH:MM:SS military time format (e.g.,
23:59:59). Answer NA for requests that were
not approved (e.g. denials/ auto-forwards).
Date oral notification (or documented good
faith attempt) provided to enrollee (or their
authorized representative). Submit in
CCYY/MM/DD format (e.g., 2017/01/01).
Answer NA if no oral notification was
provided to enrollee.
Time oral notification (or documented good
faith attempt) provided to enrollee (or their
authorized representative). Submit in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA if no oral notification
was provided to enrollee.
S
Page 20 of 65
8
10
Yes (Y)/No (N) indicator of whether the
request made under expedited timeframe was
processed under the standard timeframe based
on plan deciding that expedited case was
unnecessary. Answer NA if the request was
made under the standard timeframe.
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Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
AA
Field Name
Field Type
Date written
notification provided to
enrollee
CHAR
Always
Required
AB
Time written
notification provided to
enrollee
CHAR
Always
Required
8
AC
Date forwarded to IRE
CHAR
Always
Required
10
AD
Time forwarded to IRE
CHAR
Always
Required
8
AE
Date enrollee notified
request has been
forwarded to IRE
CHAR
Always
Required
10
Page 21 of 65
Field
Length
10
Description
Date written notification provided to enrollee.
The term “provided” means when the letter
left the sponsor’s establishment by US Mail,
fax, or electronic communication. Do not enter
the date a letter is generated or printed within
the sponsor’s organization. Submit in
CCYY/MM/DD format (e.g., 2017/01/01).
Answer NA if no written notification was
provided to enrollee.
Time written notification provided to enrollee.
The term “provided” means when the letter
left the sponsor’s establishment by US Mail,
fax, or electronic communication. Do not enter
the date a letter is generated or printed within
the sponsor’s organization. Submit in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA if no written
notification was provided to enrollee.
For untimely decisions, provide the date the
request was forwarded to the IRE. Submit in
CCYY/MM/DD format (e.g., 2017/01/01).
Answer NA for timely decision or if request
was not forwarded to the IRE.
For untimely decisions, provide the time the
request was forwarded to the IRE. Submit in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA for timely decision or
if request was not forwarded to the IRE.
For untimely decisions, provide the date the
enrollee was notified in writing that the
request was forwarded to the IRE. Submit in
CCYY/MM/DD format (e.g., 2017/01/01).
Answer NA for timely decision or if enrollee
was not notified.
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Part D Coverage Determinations, Appeals, and Grievances (CDAG)
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Table 2: Standard Coverage Determination Exception Requests (SCDER) Record Layout
• Include all requests processed as standard coverage determination exception requests.
• Exclude all requests processed as standard coverage determination requests, including
direct member reimbursement requests resolved under the exceptions process.
• Submit cases based on the date the sponsor’s decision was rendered or should have been
rendered (the date the request was initiated may fall outside of the review period).
Column
ID
A
Field Name
Field Type
Beneficiary First
Name
Beneficiary Last
Name
Enrollment Effective
Date
CHAR Always
Required
CHAR Always
Required
CHAR Always
Required
D
Cardholder ID
CHAR Always
Required
20
E
Contract ID
5
F
Plan ID
G
Was the beneficiary
residing in a long
term care facility?
CHAR Always
Required
CHAR Always
Required
CHAR Always
Required
H
Date the request was
received
CHAR Always
Required
10
I
Time the request was
received
CHAR Always
Required
8
J
Required AOR
CHAR Always
Required
1
B
C
Page 22 of 65
Field
Length
50
Description
50
Last name of the beneficiary.
10
Effective date of beneficiary’s
enrollment for the PBP that the
beneficiary was enrolled in when the
coverage determination was received.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01).
Cardholder identifier used to identify
the beneficiary. This is assigned by the
sponsor.
The contract number (e.g., H1234) of
the organization.
The plan number (e.g., 001) of the
organization.
Indicate whether the beneficiary was
identified as residing in a long term care
facility when the coverage
determination was received. Valid
values are:
Y = Yes
N = No
U = Unknown
Provide the date the request was
received from the enrollee, their
representative, or their prescriber.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01).
Provide the time of day the request was
received from the enrollee, their
representative, or their prescriber. Time
is in HH:MM:SS military time format
(e.g., 23:59:59).
Yes (Y)/ No (N) indicator of whether
the request was made by a
representative or someone claiming to
be a representative.
3
2
First name of the beneficiary.
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
K
Field Name
AOR Receipt Date
CHAR Always
Required
L
AOR Receipt Time
CHAR Always
Required
8
M
Issue Description
CHAR Always
Required
2000
N
NDC_11
CHAR
Always
Required
11
O
Drug Name, Strength
& Dosage Form
150
P
Is this a protected class
drug?
Q
Was request made
under the expedited
timeframe but
processed by the plan
under the standard
timeframe?
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
R
Exception Type
CHAR
Always
Required
25
S
Formulary UM
Exception Type
CHAR
Always
Required
2
T
List expiration date of
the approval
CHAR
Always
Required
10
Page 23 of 65
Field Type
Field
Length
10
Description
Date the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in CCYY/MM/DD format (e.g.,
2015/01/01). Answer None if no AOR was
received. Answer NA if no AOR form
was required.
Time the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in HH:MM:SS format (e.g.,
23:45:59). Answer None if no AOR was
received. Answer NA if no AOR form
was required.
Provide a description of the issue and, for
denials, an explanation of why the
decision was denied.
11-Digit National Drug Code. When no
NDC is available enter the applicable
Uniform Product Code (UPC) or Health
Related Item Code (HRI). Do not include
any spaces, hyphens or other special
characters. Answer NA if these codes are
not available.
Provide the drug name, strength, and
dosage form.
1
Protected class drug Yes (Y)/No (N)
indicator.
2
Yes (Y)/No (N) indicator of whether the
request made under expedited timeframe
was processed under the standard
timeframe based on plan deciding that
expedited case was unnecessary. Answer
NA if the request was made under the
standard timeframe.
Type of exception request. Valid values
are: tiering exception, non-formulary
exception, formulary UM exception and
hospice.
If the case was a formulary UM exception;
please indicate what criteria the enrollee
was attempting to waive. Valid fields are:
PA, ST, or QL. Enter NA if the request
was not a formulary UM exception.
Expiration date of the exception approval.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if the exception
was not approved.
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Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
U
Field Name
Field Type
Date prescriber
supporting statement
received
CHAR
Always
Required
V
Time prescriber
supporting statement
received
CHAR
Always
Required
8
W
Request Disposition
CHAR
Always
Required
20
X
Was the request denied
for lack of medical
necessity?
CHAR
Always
Required
2
Y
If denied for lack of
medical necessity, was
the review completed
by a physician or other
appropriate health care
professional?
CHAR
Always
Required
2
Z
Date of plan decision
10
AA
Time of plan decision
AB
Date effectuated in the
plan's system
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
AC
Time effectuated in the
plan’s system
CHAR
Always
Required
8
AD
Date oral notification
provided to enrollee
CHAR
Always
Required
10
Page 24 of 65
Field
Length
10
8
10
Description
Date the prescriber's supporting statement
was received. Submit in CCYY/MM/DD
format (e.g., 2017/01/01). Answer NA if
no prescriber supporting statement was
received.
Time the prescriber's supporting statement
was received. Submit in HH:MM:SS
military time format (e.g., 23:59:59).
Answer NA if no prescriber supporting
statement was received.
Status of the request. Valid values are:
approved, denied, IRE auto-forward,
dismissed, withdrawn, re-opened
approved, or re-opened denied. Answer
NA if the request was never
resolved/processed.
Yes (Y)/No (N) indicator of whether
request denied for lack of medical
necessity. Answer NA if the request was
not denied (i.e., approved, auto-forwarded,
dismissed, withdrawn)..
Yes (Y)/No (N) indicator of review by
physician or other appropriate health care
professional if case was denied for lack of
medical necessity. Answer NA if the
request was not denied for lack of medical
necessity or not denied (i.e., approved,
auto-forwarded, dismissed, withdrawn)..
Date of the plan decision (e.g., denied).
Submit in CCYY/MM/DD format (e.g.,
2017/01/01).
Time of the plan decision (e.g., denied).
Submit in HH:MM:SS military time
format (e.g., 23:59:59).
Date effectuated in the plan's system.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA for requests that
were not approved (e.g., denials/ autoforwards).
Time effectuated in the plan's system.
Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA for
requests that were not approved (e.g.,
denials/ auto-forwards).
Date oral notification (or documented
good faith attempt) provided to enrollee
(or their authorized representative).
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if no oral
notification was provided to enrollee.
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Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
AE
Field Name
Field Type
Time oral notification
provided to enrollee
CHAR
Always
Required
AF
Date written
notification provided
to enrollee
CHAR
Always
Required
10
AG
Time written
notification provided
to enrollee
CHAR
Always
Required
8
AH
Date forwarded to IRE
CHAR
Always
Required
10
AI
Time forwarded to IRE
CHAR
Always
Required
8
AJ
Date enrollee notified
request has been
forwarded to IRE
CHAR
Always
Required
10
Page 25 of 65
Field
Length
8
Description
Time oral notification (or documented
good faith attempt) provided to enrollee
(or their authorized representative).
Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA if no
oral notification was provided to enrollee.
Date written notification provided to
enrollee. The term “provided” means
when the letter left the sponsor’s
establishment by US Mail, fax, or
electronic communication. Do not enter
the date a letter is generated or printed
within the sponsor’s organization. Submit
in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if no written
notification was provided to enrollee.
Time written notification provided to
enrollee. The term “provided” means
when the letter left the sponsor’s
establishment by US Mail, fax, or
electronic communication. Do not enter
the date a letter is generated or printed
within the sponsor’s organization. Submit
in HH:MM:SS military time format (e.g.,
23:59:59). Answer NA if no written
notification was provided to enrollee.
For untimely decisions, provide the date
the request was forwarded to the IRE.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA for timely
decision or if request was not forwarded to
the IRE.
For untimely decisions, provide the time
the request was forwarded to the IRE.
Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA for
timely decision or if request was not
forwarded to the IRE.
For untimely decisions, date the enrollee
was notified in writing that the request was
forwarded to the IRE. Submit in
CCYY/MM/DD format (e.g., 2017/01/01).
Answer NA for timely decision or if
enrollee was not notified.
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 3: Direct Member Reimbursement Request Coverage Determinations (DMRCD) Record
Layout
• Include all requests processed as coverage determination direct member reimbursement
requests.
• Exclude all requests processed as standard coverage determination requests.
• Submit cases based on the date the sponsor’s decision was rendered or should have been
rendered (the date the request was initiated may fall outside of the review period).
Column
ID
A
Field Name
Field Type
Field Length
Description
Beneficiary First Name
50
First name of the beneficiary.
B
Beneficiary Last Name
50
Last name of the beneficiary.
C
Enrollment Effective
Date
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
10
D
Cardholder ID
20
E
Contract ID
F
Plan ID
G
Date the request was
received
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
Effective date of beneficiary’s enrollment
for the PBP that the beneficiary was
enrolled in when the coverage
determination was received. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01).
Cardholder identifier used to identify the
beneficiary. This is assigned by the
sponsor.
The contract number (e.g., H1234) of the
organization.
H
Required AOR
1
I
AOR Receipt Date
CHAR
Always
Required
CHAR
Always
Required
J
Authorization or Claim
Number
CHAR
Always
Required
40
Page 26 of 65
5
3
The plan number (e.g., 001) of the
organization.
10
Provide the date the request was received
from the enrollee, their representative, or
their prescriber. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01).
Yes (Y)/ No (N) indicator of whether the
request was made by a representative or
someone claiming to be a representative.
Date the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in CCYY/MM/DD format (e.g.,
2015/01/01). Answer None if no AOR
was received. Answer NA if no AOR
form was required.
The associated claim or payment request
number assigned by the sponsor for this
request. If a claim or payment request
number is not available, please provide
your internal tracking or case number.
Answer NA if there is no claim, payment
request or other tracking numbers
available.
10
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
K
Field Name
Field Type
Field Length
Description
Issue Description
2000
L
Was this request
processed as an
exception?
NDC_11
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
Provide a description of the issue and, for
denials, an explanation of why the
decision was denied.
Exception request Yes (Y)/No (N)
indicator.
CHAR
Always
Required
CHAR
Always
Required
150
CHAR
Always
Required
CHAR
Always
Required
10
M
1
11
N
Drug Name, Strength &
Dosage Form
O
Request Disposition
P
Date of plan decision
Q
Date written
notification provided to
enrollee
R
Date reimbursement
provided
CHAR
Always
Required
10
S
Date forwarded to IRE
CHAR
Always
Required
10
Page 27 of 65
20
10
11-Digit National Drug Code. When no
NDC is available enter the applicable
Uniform Product Code (UPC) or Health
Related Item Code (HRI). Do not include
any spaces, hyphens or other special
characters. Answer NA if these codes are
not available.
Provide the drug name, strength, and
dosage form.
Status of the request. Valid values are:
approved, denied, IRE auto-forward,
dismissed, withdrawn, re-opened
approved, or re-opened denied. Answer
NA if the request was never
resolved/processed.
Date of the plan decision (e.g., denied).
Submit in CCYY/MM/DD format (e.g.,
2017/01/01).
Date written notification provided to
enrollee. The term “provided” means
when the letter left the sponsor’s
establishment by US Mail, fax, or
electronic communication. Do not enter
the date a letter is generated or printed
within the sponsor’s organization. Submit
in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if no written
notification was provided to enrollee.
Date check or reimbursement provided to
the enrollee (i.e., mailed to the enrollee).
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Enter NRD if the request
was approved but no reimbursement was
due to the enrollee. Answer NA if the
request was not approved.
For untimely decisions, provide the date
the request was forwarded to the IRE.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA for timely
decision or if request was not forwarded
to the IRE.
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
T
Field Name
Field Type
Field Length
Description
Date enrollee notified
request has been
forwarded to IRE
CHAR
Always
Required
10
For untimely decisions, provide the date
the enrollee was notified in writing that
the request was forwarded to the IRE in
writing. Submit in CCYY/MM/DD
format (e.g., 2017/01/01). Answer NA for
timely decision or if enrollee was not
notified.
Page 28 of 65
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 4: Expedited Coverage Determinations (ECD) Record Layout
• Include all requests processed as expedited coverage determination requests.
• Exclude all requests processed as exception requests.
• Submit cases based on the date the sponsor’s decision was rendered or should have been
rendered (the date the request was initiated may fall outside of the review period).
Column
ID
A
Field Name
Field Type
Beneficiary First
Name
Beneficiary Last
Name
Enrollment Effective
Date
CHAR Always
Required
CHAR Always
Required
CHAR Always
Required
D
Cardholder ID
CHAR Always
Required
20
E
Contract ID
5
F
Plan ID
G
Was the beneficiary
residing in a long
term care facility?
CHAR Always
Required
CHAR Always
Required
CHAR Always
Required
H
Date the request was
received
CHAR Always
Required
10
I
Time the request was
received
CHAR Always
Required
8
J
Required AOR
CHAR Always
Required
1
B
C
Page 29 of 65
Field
Length
50
Description
50
Last name of the beneficiary.
10
Effective date of beneficiary’s
enrollment for the PBP that the
beneficiary was enrolled in when the
coverage determination was received
Submit in CCYY/MM/DD format
(e.g., 2017/01/01).
Cardholder identifier used to identify
the beneficiary. This is assigned by
the plan.
The contract number (e.g., H1234) of
the organization.
The plan number (e.g., 001) of the
organization.
Indicate whether the beneficiary was
identified as residing in a long term
care facility when the coverage
determination was received. Valid
values are:
Y = Yes
N = No
U = Unknown
Provide the date the request was
received from the enrollee, their
representative, or their prescriber.
Submit in CCYY/MM/DD format
(e.g., 2017/01/01).
Provide the time of day the request
was received from the enrollee, their
representative, or their prescriber.
Time is in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA if
time is not available.
Yes (Y)/ No (N) indicator of whether
the request was made by a
representative or someone claiming to
be a representative.
3
2
First name of the beneficiary.
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
K
Field Name
Field Type
Field Length
Description
AOR Receipt Date
CHAR
Always
Required
10
L
AOR Receipt Time
CHAR
Always
Required
8
M
Issue Description
2000
N
NDC_11
CHAR
Always
Required
CHAR
Always
Required
O
Drug Name, Strength
& Dosage Form
150
P
Is this a protected class
drug?
Q
Was request initially
made under the
standard timeframe but
processed by the plan
under the expedited
timeframe?
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
Date the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in CCYY/MM/DD format (e.g.,
2015/01/01). Answer None if no AOR
was received. Answer NA if no AOR
form was required.
Time the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in HH:MM:SS format (e.g.,
23:45:59). Answer None if no AOR was
received. Answer NA if no AOR form
was required.
Provide a description of the issue and,
for denials, an explanation of why the
decision was denied.
11-Digit National Drug Code. When no
NDC is available enter the applicable
Uniform Product Code (UPC) or Health
Related Item Code (HRI). Do not
include any spaces, hyphens or other
special characters. Answer NA if these
codes are not available.
Provide the drug name, strength, and
dosage form.
R
Date request was
upgraded to expedited
CHAR
Always
Required
10
Page 30 of 65
11
1
Protected class drug Yes (Y)/No (N)
indicator.
2
Yes (Y)/No (N) indicator of whether the
initial request made under the standard
timeframe was processed under the
expedited timeframe based on updated
request to expedite from enrollee, their
authorized representative, or their
prescriber, or based on medical exigency
as determined by the sponsor. Answer
NA if the initial request was made under
the expedited timeframe.
Provide the date the request was
received to upgrade the initial standard
request to expedited from the enrollee,
their authorized representative, or their
prescriber, or the sponsor determined the
request should be expedited. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if the initial
request was made under the expedited
timeframe.
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
S
Field Name
Field Type
Field Length
Description
Time request was
upgraded to expedited
CHAR
Always
Required
8
T
Request Disposition
CHAR
Always
Required
20
U
Was the request denied
for lack of medical
necessity?
CHAR
Always
Required
2
V
If denied for lack of
medical necessity, was
the review completed
by a physician or other
appropriate health care
professional?
CHAR
Always
Required
2
W
Date of plan decision
10
X
Time of plan decision
Y
Date effectuated in the
plan's system
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
Z
Time effectuated in the
plan’s system
CHAR
Always
Required
8
AA
Date oral notification
provided to enrollee
CHAR
Always
Required
10
Provide the time of day the request was
received to upgrade the initial standard
request to expedited from the enrollee,
their authorized representative, or their
prescriber, or the sponsor determined the
request should be expedited. Time is in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA if the initial
request was made under the expedited
timeframe.
Status of the request. Valid values are:
approved, denied, IRE auto-forward,
dismissed, withdrawn, re-opened
approved, or re-opened denied. Answer
NA if the request was never
resolved/processed.
Yes (Y)/No (N) indicator of whether
request denied for lack of medical
necessity. Answer NA if the request was
not denied (i.e., approved, autoforwarded, dismissed, withdrawn).
Yes (Y)/No (N) indicator of review by
physician or other appropriate health
care professional if case was denied for
lack of medical necessity. Answer NA if
the request was not denied for lack of
medical necessity or not denied (i.e.,
approved, auto-forwarded, dismissed,
withdrawn).
Date of the plan decision (e.g., denied).
Submit in CCYY/MM/DD format (e.g.,
2017/01/01).
Time of the plan decision (e.g., denied).
Submit in HH:MM:SS military time
format (e.g., 23:59:59).
Date effectuated in the plan's system.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA for requests
that were not approved (e.g., denials/
auto-forwards).
Time effectuated in the plan's system.
Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA for
requests that were not approved (e.g.,
denials/ auto-forwards).
Date oral notification (or documented
good faith attempt) provided to enrollee
(or their authorized representative).
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if no oral
notification was provided to enrollee.
Page 31 of 65
8
10
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
AB
Field Name
Field Type
Field Length
Description
Time oral notification
provided to enrollee
CHAR
Always
Required
8
AC
Date written
notification provided
to enrollee
CHAR
Always
Required
10
AD
Time written
notification provided
to enrollee
CHAR
Always
Required
8
AE
Date forwarded to IRE
CHAR
Always
Required
10
AF
Time forwarded to IRE
CHAR
Always
Required
8
AG
Date enrollee notified
request has been
forwarded to IRE
CHAR
Always
Required
10
Time oral notification provided to
enrollee. Submit in HH:MM:SS military
time format (e.g., 23:59:59). Answer NA
if no oral notification was provided to
enrollee.
Date written notification provided to
enrollee. The term “provided” means
when the letter left the sponsor’s
establishment by US Mail, fax, or
electronic communication. Do not enter
the date a letter is generated or printed
within the sponsor’s organization.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if no written
notification was provided to enrollee.
Time written notification provided to
enrollee. The term “provided” means
when the letter left the sponsor’s
establishment by US Mail, fax, or
electronic communication. Do not enter
the date a letter is generated or printed
within the sponsor’s organization.
Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA if
no written notification was provided to
enrollee.
For untimely decisions, provide the date
the request was forwarded to the IRE.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA for timely
decision or if request was not forwarded
to the IRE.
For untimely decisions, provide the time
the request was forwarded to the IRE.
Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA for
timely decision or if request was not
forwarded to the IRE.
For untimely decisions, provide the date
the enrollee was notified in writing that
the request was forwarded to the IRE.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA for timely
decision or if enrollee was not notified.
Page 32 of 65
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 5: Expedited Coverage Determination Exception Requests (ECDER) Record Layout
• Include all request processed as expedited coverage determination exception requests.
• Exclude all requests processed as expedited coverage determination requests.
• Submit cases based on the date the sponsor’s decision was rendered or should have been
rendered (the date the request was initiated may fall outside of the review period).
Column
ID
A
Field Name
Field Type
Beneficiary First
Name
Beneficiary Last
Name
Enrollment Effective
Date
CHAR Always
Required
CHAR Always
Required
CHAR Always
Required
D
Cardholder ID
CHAR Always
Required
20
E
Contract ID
5
F
Plan ID
G
Was the beneficiary
residing in a long
term care facility?
CHAR Always
Required
CHAR Always
Required
CHAR Always
Required
H
Date the request was
received
CHAR Always
Required
10
I
Time the request was
received
CHAR Always
Required
8
J
Required AOR
CHAR Always
Required
1
B
C
Page 33 of 65
Field
Length
50
Description
50
Last name of the beneficiary.
10
Effective date of beneficiary’s
enrollment for the PBP that the
beneficiary was enrolled in when the
coverage determination was received.
Submit in CCYY/MM/DD format
(e.g., 2017/01/01).
Cardholder identifier used to identify
the beneficiary. This is assigned by
the plan.
The contract number (e.g., H1234) of
the organization.
The plan number (e.g., 001) of the
organization.
Indicate whether the beneficiary was
identified as residing in a long term
care facility when the coverage
determination was received. Valid
values are:
Y = Yes
N = No
U = Unknown
Provide the date the request was
received from the enrollee, their
representative, or their prescriber.
Submit in CCYY/MM/DD format
(e.g., 2017/01/01).
Provide the time of day the request
was received from the enrollee, their
representative, or their prescriber.
Time is in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA if
time is not available.
Yes (Y)/ No (N) indicator of whether
the request was made by a
representative or someone claiming to
be a representative.
3
2
First name of the beneficiary.
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
K
Field Name
Field Type
Field Length
Description
AOR Receipt Date
CHAR
Always
Required
10
L
AOR Receipt Time
CHAR
Always
Required
8
M
Issue Description
2000
N
NDC_11
CHAR
Always
Required
CHAR
Always
Required
O
Drug Name, Strength
& Dosage Form
150
P
Is this a protected
class drug?
Q
Was request initially
made under the
standard timeframe
but processed by the
plan under the
expedited timeframe?
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
Date the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in CCYY/MM/DD format (e.g.,
2015/01/01). Answer None if no AOR
was received. Answer NA if no AOR
form was required.
Time the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in HH:MM:SS format (e.g.,
23:45:59). Answer None if no AOR was
received. Answer NA if no AOR form
was required.
Provide a description of the issue and,
for denials, an explanation of why the
decision was denied.
11-Digit National Drug Code. When no
NDC is available enter the applicable
Uniform Product Code (UPC) or Health
Related Item Code (HRI). Do not
include any spaces, hyphens or other
special characters. Answer NA if these
codes are not available.
Provide the drug name, strength, and
dosage form.
R
Date request was
upgraded to expedited
CHAR
Always
Required
10
Page 34 of 65
11
1
Protected class drug Yes (Y)/No (N)
indicator.
2
Yes (Y)/No (N) indicator of whether the
initial request made under the standard
timeframe was processed under the
expedited timeframe based on updated
request to expedite from enrollee, their
authorized representative, or their
prescriber, or based on medical exigency
as determined by the sponsor. Answer
NA if the initial request was made under
the expedited timeframe.
Provide the date the request was
received to upgrade the initial standard
request to expedited from the enrollee,
their authorized representative, or their
prescriber, or the sponsor determined the
request should be expedited. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if the initial
request was made under the expedited
timeframe.
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
S
Field Name
Field Type
Field Length
Description
Time request was
upgraded to expedited
CHAR
Always
Required
8
T
Exception Type
CHAR
Always
Required
25
U
Formulary UM
Exception Type
CHAR
Always
Required
2
V
List expiration date of
the approval
CHAR
Always
Required
10
W
Date prescriber
supporting statement
received
CHAR
Always
Required
10
X
Time prescriber
supporting statement
received
CHAR
Always
Required
8
Y
Request Disposition
CHAR
Always
Required
20
Z
Was the request
denied for lack of
medical necessity?
CHAR
Always
Required
2
Provide the time of day the request was
received to upgrade the initial standard
request to expedited from the enrollee,
their authorized representative, or their
prescriber, or the sponsor determined the
request should be expedited. Time is in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA if the initial
request was made under the expedited
timeframe.
Type of exception request. Valid values
are: tiering exception, non-formulary
exception, formulary UM exception and
hospice.
If the case was a formulary UM
exception; please indicate what criteria
the enrollee was attempting to waive.
Valid fields are: PA, ST, or QL. Enter
NA if the request was not a formulary
UM exception.
Expiration date of the exception
approval. Submit in CCYY/MM/DD
format (e.g., 2017/01/01). Answer NA if
the exception was not approved.
Date the prescriber's supporting
statement was received. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if no
prescriber supporting statement was
received.
Time the prescriber's supporting
statement was received. Submit in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA if no prescriber
supporting statement was received.
Status of the request. Valid values are:
approved, denied, IRE auto-forward,
dismissed, withdrawn. re-opened
approved, or re-opened denied. Answer
NA if the request was never
resolved/processed.
Yes (Y)/No (N) indicator of whether
request denied for lack of medical
necessity. Answer NA if the request was
not denied (i.e., approved, autoforwarded, dismissed, withdrawn)..
Page 35 of 65
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
AA
Field Name
Field Type
Field Length
Description
If denied for lack of
medical necessity,
was the review
completed by a
physician or other
appropriate health
care professional?
CHAR
Always
Required
2
AB
Date of plan decision
10
AC
Time of plan decision
AD
Date effectuated in
the plan's system
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
AE
Time effectuated in
the plan’s system
CHAR
Always
Required
8
AF
Date oral notification
provided to enrollee
CHAR
Always
Required
10
AG
Time oral notification
provided to enrollee
CHAR
Always
Required
8
AH
Date written
notification provided
to enrollee
CHAR
Always
Required
10
Yes (Y)/No (N) indicator of review by
physician or other appropriate health
care professional if case was denied for
lack of medical necessity. Answer NA if
the request was not denied for lack of
medical necessity or not denied (i.e.,
approved, auto-forwarded, dismissed,
withdrawn).
Date of the plan decision (e.g., denied).
Submit in CCYY/MM/DD format (e.g.,
2017/01/01).
Time of the plan decision (e.g., denied).
Submit in HH:MM:SS military time
format (e.g., 23:59:59).
Date effectuated in the plan's system.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if request was
not approved (e.g. denials/ autoforwards).
Time effectuated in the plan's system.
Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA if
request was not approved (e.g., denials/
auto-forwards).
Date oral notification (or documented
good faith attempt) provided to enrollee
(or their authorized representative).
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if no oral
notification was provided to enrollee.
Time oral notification provided to
enrollee. Submit in HH:MM:SS military
time format (e.g., 23:59:59). Answer NA
if no oral notification was provided to
enrollee.
Date written notification provided to
enrollee. The term “provided” means
when the letter left the sponsor’s
establishment by US Mail, fax, or
electronic communication. Do not enter
the date a letter is generated or printed
within the sponsor’s organization.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if no written
notification was provided to enrollee.
Page 36 of 65
8
10
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
AI
Field Name
Time written
notification provided
to enrollee
AJ
Field Length
Description
CHAR
Always
Required
8
Date forwarded to
IRE
CHAR
Always
Required
10
AK
Time forwarded to
IRE
CHAR
Always
Required
8
AL
Date enrollee notified
request has been
forwarded to IRE
CHAR
Always
Required
10
Time written notification provided to
enrollee. The term “provided” means
when the letter left the sponsor’s
establishment by US Mail, fax, or
electronic communication. Do not enter
the date a letter is generated or printed
within the sponsor’s organization.
Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA if
no written notification was provided to
enrollee.
For untimely decisions, provide the date
the request was forwarded to the IRE.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA for timely
decision or if request was not forwarded
to the IRE.
For untimely decisions, provide the time
the request was forwarded to the IRE.
Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA for
timely decision or if request was not
forwarded to the IRE.
For untimely decisions, provide the date
the enrollee was notified in writing that
the request was forwarded to the IRE.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA for timely
decision or if enrollee was not notified.
Page 37 of 65
Field Type
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 6: Standard Redeterminations (SRD) Record Layout
• Include all requests processed as standard pre-service redetermination requests.
• Exclude requests processed as direct member reimbursement redetermination requests or
expedited pre-service redetermination requests.
• Submit cases based on the date the sponsor’s decision was rendered or should have been
rendered (the date the request was initiated may fall outside of the review period).
Column
ID
A
Field Name
Field Type
Field Length
Description
Beneficiary First Name
50
First name of the beneficiary.
B
Beneficiary Last Name
50
Last name of the beneficiary.
C
Enrollment Effective
Date
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
10
D
Cardholder ID
20
E
Contract ID
F
Plan ID
G
Date the request was
received
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
Effective date of beneficiary’s
enrollment for the PBP that the
beneficiary was enrolled in when the
redetermination was received. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01).
Cardholder identifier used to identify the
beneficiary. This is assigned by the plan.
H
Required AOR
CHAR
Always
Required
1
I
AOR Receipt Date
CHAR
Always
Required
10
J
Issue Description
CHAR
Always
Required
2000
Page 38 of 65
5
The contract number (e.g., H1234) of
the organization.
3
The plan number (e.g., 001) of the
organization.
10
Provide the date the redetermination
request was received from the enrollee,
their representative, or their prescriber.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01).
Yes (Y)/ No (N) indicator of whether
the request was made by a representative
or someone claiming to be a
representative.
Date the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in CCYY/MM/DD format (e.g.,
2015/01/01). Answer None if no AOR
was received. Answer NA if no AOR
form was required.
Provide a description of the issue and,
for denials, an explanation of why the
decision was denied.
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
K
Field Name
Field Type
Field Length
Description
NDC_11
CHAR
Always
Required
11
L
Drug Name, Strength
& Dosage Form
150
M
Is this a protected class
drug?
N
Was request made
under the expedited
timeframe but
processed by the plan
under the standard
timeframe?
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
11-Digit National Drug Code. When no
NDC is available enter the applicable
Uniform Product Code (UPC) or Health
Related Item Code (HRI). Do not
include any spaces, hyphens or other
special characters. Answer NA if these
codes are not available.
Provide the drug name, strength, and
dosage form.
O
Was this request
processed as an
exception?
Exception Type
CHAR
Always
Required
CHAR
Always
Required
1
Q
List expiration date of
the approval
CHAR
Always
Required
10
R
Request Disposition
CHAR
Always
Required
20
S
Was the request denied
for lack of medical
necessity?
CHAR
Always
Required
2
T
If denied for lack of
medical necessity, was
the review completed
by a physician?
CHAR
Always
Required
2
P
Page 39 of 65
1
Protected class drug Yes (Y)/No (N)
indicator.
2
Yes (Y)/No (N) indicator of whether the
request made under expedited timeframe
was processed under the standard
timeframe based on plan deciding that
expedited case was unnecessary.
Answer NA if the request was made
under the standard timeframe.
Exception request Yes (Y)/No (N)
indicator.
25
Type of exception request. Valid values
are: tiering exception, non-formulary
exception, formulary UM exception and
hospice. Answer NA if request was not
processed as an exception.
Expiration date of the exception
approval. Submit in CCYY/MM/DD
format (e.g., 2017/01/01). Answer NA if
request was not processed as an
exception or if the exception was not
approved.
Status of the request. Valid values are:
approved, denied, IRE auto-forward,
dismissed, withdrawn, re-opened
approved, or re-opened denied. Answer
NA if the request was never
resolved/processed.
Yes (Y)/No (N) indicator of whether
request denied for lack of medical
necessity. Answer NA if the request was
not denied (i.e., approved, autoforwarded, dismissed, withdrawn).
Yes (Y)/No (N) indicator of review by
physician if the coverage determination
was denied for lack of medical
necessity. Answer NA if the request was
not denied for lack of medical necessity
or not denied (e.g., approved).
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
U
Field Name
Field Type
Field Length
Description
Date of plan decision
10
V
Date effectuated in the
plan's system
CHAR
Always
Required
CHAR
Always
Required
W
Date written
notification provided to
enrollee
CHAR
Always
Required
10
X
Date forwarded to IRE
CHAR
Always
Required
10
Y
Time forwarded to IRE
CHAR
Always
Required
8
Z
Date enrollee notified
request has been
forwarded to IRE
CHAR
Always
Required
10
Date of the plan decision (e.g., denied).
Submit in CCYY/MM/DD format (e.g.,
2017/01/01).
Date effectuated in the plan's system.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA for requests
that were not approved (e.g.
denials/auto-forwards).
Date written notification provided to
enrollee. The term “provided” means
when the letter left the sponsor’s
establishment by US Mail, fax, or
electronic communication. Do not enter
the date a letter is generated or printed
within the sponsor’s organization.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if no written
notification was provided to enrollee.
For untimely decisions, provide the date
the request was forwarded to the IRE.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA for timely
decision or if request was not forwarded
to the IRE.
For untimely decisions, provide the time
the request was forwarded to the IRE.
Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA for
timely decision or if request was not
forwarded to the IRE.
For untimely decisions, provide the date
the enrollee was notified in writing that
the request was forwarded to the IRE.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA for timely
decision or if enrollee was not notified.
Page 40 of 65
10
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 7: Direct Member Reimbursement Request Redeterminations (DMRRD) Record Layout
• Include all requests processed as redeterminations for direct member reimbursement
requests.
• Exclude all requests processed as pre-service redetermination requests.
• Submit cases based on the date the sponsor’s decision was rendered or should have been
rendered (the date the request was initiated may fall outside of the review period).
Column
ID
A
Field Name
Field Type
Field Length
Description
Beneficiary First Name
50
First name of the beneficiary.
B
Beneficiary Last Name
50
Last name of the beneficiary.
C
Enrollment Effective
Date
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
10
D
Cardholder ID
20
E
Contract ID
F
Plan ID
G
Date the request was
received
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
Effective date of beneficiary’s enrollment
for the PBP that the beneficiary was
enrolled in when the redetermination was
received. Submit in CCYY/MM/DD
format (e.g., 2017/01/01).
Cardholder identifier used to identify the
beneficiary. This is assigned by the plan.
H
Required AOR
1
I
AOR Receipt Date
CHAR
Always
Required
CHAR
Always
Required
J
Authorization or Claim
Number
CHAR
Always
Required
40
Page 41 of 65
5
The contract number (e.g., H1234) of the
organization.
3
The plan number (e.g., 001) of the
organization.
10
Provide the date the redetermination
request was received from the enrollee,
their representative, or their prescriber.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01).
Yes (Y)/ No (N) indicator of whether the
request was made by a representative or
someone claiming to be a representative.
Date the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in CCYY/MM/DD format (e.g.,
2015/01/01). Answer None if no AOR
was received. Answer NA if no AOR
form was required.
The associated claim or payment request
number assigned by the sponsor for this
request. If a claim or payment request
number is not available, please provide
your internal tracking or case number.
Answer NA if there is no claim, payment
request or other tracking numbers
available.
10
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
K
Field Name
Field Type
Field Length
Description
Issue Description
2000
L
Was this request
processed as an
exception?
Exception Type
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
Provide a description of the issue and, for
denials, an explanation of why the
decision was denied.
Exception request Yes (Y)/No (N)
indicator.
M
1
25
N
List expiration date of
the approval
CHAR
Always
Required
10
O
NDC_11
CHAR
Always
Required
11
P
Drug Name, Strength &
Dosage Form
150
Q
Request Disposition
CHAR
Always
Required
CHAR
Always
Required
R
Was the request denied
for lack of medical
necessity?
CHAR
Always
Required
2
S
If denied for lack of
medical necessity, was
the review completed
by a physician?
CHAR
Always
Required
2
T
Date of plan decision
CHAR
Always
Required
10
Page 42 of 65
20
Type of exception request. Valid values
are: tiering exception, non-formulary
exception, formulary UM exception and
hospice. Answer NA if request was not
processed as an exception.
Expiration date of the exception approval.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if request was
not processed as an exception or if the
exception was not approved.
11-Digit National Drug Code. When no
NDC is available enter the applicable
Uniform Product Code (UPC) or Health
Related Item Code (HRI). Do not include
any spaces, hyphens or other special
characters. Answer NA if these codes are
not available.
Provide the drug name, strength, and
dosage form.
Status of the request. Valid values are:
approved, denied, IRE auto-forward,
dismissed, withdrawn, re-opened
approved, or re-opened denied. Answer
NA if the request was never
resolved/processed.
Yes (Y)/No (N) indicator of whether
request denied for lack of medical
necessity. Answer NA if the request was
not denied (i.e., approved, autoforwarded, dismissed, withdrawn).
Yes (Y)/No (N) indicator of review by
physician if the coverage determination
was denied for lack of medical necessity.
Answer NA if the request was not denied
for lack of medical necessity or not
denied (e.g., approved).
Date of the plan decision (e.g., denied).
Submit in CCYY/MM/DD format (e.g.,
2017/01/01).
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
U
Field Name
Field Type
Field Length
Description
Date written
notification provided to
enrollee
CHAR
Always
Required
10
V
Date reimbursement
provided
CHAR
Always
Required
10
W
Date forwarded to IRE
CHAR
Always
Required
10
X
Date enrollee notified
request has been
forwarded to IRE
CHAR
Always
Required
10
Date written notification provided to
enrollee. The term “provided” means
when the letter left the sponsor’s
establishment by US Mail, fax, or
electronic communication. Do not enter
the date a letter is generated or printed
within the sponsor’s organization. Submit
in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if no written
notification was provided to enrollee.
Date check or reimbursement provided to
enrollee (i.e., date check mailed to the
enrollee). Submit in CCYY/MM/DD
format (e.g., 2017/01/01). Enter NRD if
the request was approved but no
reimbursement was due to the enrollee.
Answer NA if the request was not
approved.
For untimely decisions, provide the date
the request was forwarded to the IRE.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA for timely
decision or if request was not forwarded
to the IRE.
For untimely decisions, provide the date
the enrollee was notified in writing that
the request was forwarded to the IRE.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA for timely
decision or if enrollee was not notified.
Page 43 of 65
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 8: Expedited Redeterminations (ERD) Record Layout
• Include all requests processed as expedited redetermination requests.
• Submit cases based on the date the sponsor’s decision was rendered or should have been
rendered (the date the request was initiated may fall outside of the review period).
Column
ID
A
Field Name
Field Type
Field Length
Description
Beneficiary First Name
50
First name of the beneficiary.
B
Beneficiary Last Name
50
Last name of the beneficiary.
C
Enrollment Effective
Date
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
10
D
Cardholder ID
20
E
Contract ID
F
Plan ID
G
Date the request was
received
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
Effective date of beneficiary’s
enrollment for the PBP that the
beneficiary was enrolled in when the
redetermination was received. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01).
Cardholder identifier used to identify the
beneficiary. This is assigned by the plan.
H
Time the request was
received
CHAR
Always
Required
8
I
Required AOR
1
J
AOR Receipt Date
CHAR
Always
Required
CHAR
Always
Required
Page 44 of 65
5
The contract number (e.g., H1234) of
the organization.
3
The plan number (e.g., 001) of the
organization.
10
Provide the date the redetermination
request was received from the enrollee,
their representative, or their prescriber.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01).
Provide the time of day the
redetermination request was received
from the enrollee, their authorized
representative, or their prescriber. Time
is in HH:MM:SS military time format
(e.g., 23:59:59). .
Yes (Y)/ No (N) indicator of whether the
request was made by a representative or
someone claiming to be a representative.
Date the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in CCYY/MM/DD format (e.g.,
2015/01/01). Answer None if no AOR
was received. Answer NA if no AOR
form was required.
10
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
K
Field Name
Field Type
Field Length
Description
AOR Receipt Time
CHAR
Always
Required
8
L
Issue Description
2000
M
NDC_11
CHAR
Always
Required
CHAR
Always
Required
N
Drug Name, Strength
& Dosage Form
150
O
Is this a protected class
drug?
P
Was request initially
made under the
standard timeframe but
processed by the plan
under the expedited
timeframe?
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
Time the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in HH:MM:SS format (e.g.,
23:45:59). Answer None if no AOR was
received. Answer NA if no AOR form
was required.
Provide a description of the issue and,
for denials, an explanation of why the
decision was denied.
11-Digit National Drug Code. When no
NDC is available enter the applicable
Uniform Product Code (UPC) or Health
Related Item Code (HRI). Do not
include any spaces, hyphens or other
special characters. Answer NA if these
codes are not available.
Provide the drug name, strength, and
dosage form.
Q
Date request was
upgraded to expedited
CHAR
Always
Required
10
R
Time request was
upgraded to expedited
CHAR
Always
Required
8
Page 45 of 65
11
1
Protected class drug Yes (Y)/No (N)
indicator.
2
Yes (Y)/No (N) indicator of whether the
initial request made under the standard
timeframe was processed under the
expedited timeframe based on updated
request to expedite from enrollee, their
authorized representative, or their
prescriber, or based on medical exigency
as determined by the sponsor. Answer
NA if the initial request was made under
the expedited timeframe.
Provide the date the request was
received to upgrade the initial standard
request to expedited from the enrollee,
their authorized representative, or their
prescriber, or the sponsor determined the
request should be expedited. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if the initial
request was made under the expedited
timeframe.
Provide the time of day the request was
received to upgrade the initial standard
request to expedited from the enrollee,
their authorized representative, or their
prescriber, or the sponsor determined the
request should be expedited. Time is in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA if the initial
request was made under the expedited
timeframe.
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
S
Field Name
Field Type
Field Length
Description
Was this request
processed as an
exception?
Exception Type
CHAR
Always
Required
CHAR
Always
Required
1
Exception request Yes (Y)/No (N)
indicator.
25
U
List expiration date of
the approval
CHAR
Always
Required
10
V
Request Disposition
CHAR
Always
Required
20
W
Was the request denied
for lack of medical
necessity?
CHAR
Always
Required
2
X
If denied for lack of
medical necessity, was
the review completed
by a physician?
CHAR
Always
Required
2
Y
Date of plan decision
10
Z
Time of plan decision
AA
Date effectuated in the
plan's system
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
AB
Time effectuated in the
plan’s system
CHAR
Always
Required
8
AC
Date oral notification
provided to enrollee
CHAR
Always
Required
10
Type of exception request. Valid values
are: tiering exception, non-formulary
exception, formulary UM exception and
hospice. Answer NA if request was not
processed as an exception request.
Expiration date of the exception
approval. Submit in CCYY/MM/DD
format (e.g., 2017/01/01). Answer NA if
request was not processed as an
exception or if the exception was not
approved.
Status of the request. Valid values are:
approved, denied, IRE auto-forward,
dismissed, withdrawn, re-opened
approved or re-opened denied. Answer
NA if the request was never
resolved/processed.
Yes (Y)/No (N) indicator of whether
request denied for lack of medical
necessity. Answer NA if the request was
not denied (i.e., approved, autoforwarded, dismissed or withdrawn).
Yes (Y)/No (N) indicator of review by
physician if the coverage determination
was denied for lack of medical
necessity. Answer NA if the request was
not denied for lack of medical necessity
or not denied (e.g., approved).
Date of the plan decision (e.g., denied).
Submit in CCYY/MM/DD format (e.g.,
2017/01/01).
Time of the plan decision (e.g., denied).
Submit in HH:MM:SS military time
format (e.g., 23:59:59).
Date effectuated in the plan's system.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA for requests
that were not approved (e.g.
denials/auto-forwards).
Time effectuated in the plan's system.
Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA if
the request was not approved (e.g.,
denied/ auto-forward).
Date oral notification (or documented
good faith attempt) provided to enrollee
(or their authorized representative).
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if no oral
notification was provided to enrollee.
T
Page 46 of 65
8
10
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
AD
Field Name
Field Type
Field Length
Description
Time oral notification
provided to enrollee
CHAR
Always
Required
8
AE
Date written
notification provided
to enrollee
CHAR
Always
Required
10
AF
Time written
notification provided
to enrollee
CHAR
Always
Required
8
AG
Date forwarded to IRE
CHAR
Always
Required
10
AH
Time forwarded to IRE
CHAR
Always
Required
8
AI
Date enrollee notified
request has been
forwarded to IRE
CHAR
Always
Required
10
Time oral notification provided to
enrollee. Submit in HH:MM:SS military
time format (e.g., 23:59:59). Answer NA
if no oral notification was provided to
enrollee.
Date written notification provided to
enrollee. The term “provided” means
when the letter left the sponsor’s
establishment by US Mail, fax, or
electronic communication. Do not enter
the date a letter is generated or printed
within the sponsor’s organization.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if no written
notification was provided to enrollee.
Time written notification provided to
enrollee. The term “provided” means
when the letter left the sponsor’s
establishment by US Mail, fax, or
electronic communication. Do not enter
the date a letter is generated or printed
within the sponsor’s organization.
Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA if
no written notification was provided to
enrollee.
For untimely decisions, provide the date
the request was forwarded to the IRE.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA for timely
decision or if request was not forwarded
to the IRE.
For untimely decisions, provide the time
the request was forwarded to the IRE.
Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA for
timely decision or if request was not
forwarded to the IRE.
For untimely decisions, provide the date
the enrollee was notified in writing that
the request was forwarded to the IRE.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA for timely
decision or if enrollee was not notified.
Page 47 of 65
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 9: Standard IRE Auto-forwarded Coverage Determinations and Redeterminations
(SIRE) Record Layout
• Include all requests processed as standard coverage determination or redetermination
requests that were auto-forwarded to the IRE, including coverage determination and
redetermination reimbursement requests.
• Submit cases based on the date the sponsor auto-forwarded the case to the IRE (the date
the request was initiated may fall outside of the review period).
Column
ID
A
Field Name
Field Type
Field Length
Description
Beneficiary First Name
50
First name of the beneficiary.
B
Beneficiary Last Name
50
Last name of the beneficiary.
C
Enrollment Effective
Date
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
10
D
Cardholder ID
20
E
Contract ID
F
Plan ID
G
Type of request
H
Date the request was
received
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
Effective date of beneficiary’s
enrollment for the PBP that the
beneficiary was enrolled in when the
coverage determination or
redetermination was received. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01).
Cardholder identifier used to identify the
beneficiary. This is assigned by the plan.
I
Time the request was
received
CHAR
Always
Required
8
J
Required AOR
CHAR
Always
Required
1
Page 48 of 65
5
The contract number (e.g., H1234) of
the organization.
3
The plan number (e.g., 001) of the
organization.
22
Type of request. Valid values are: Preservice CD. Reimbursement CD or
Redetermination.
Provide the date the request (either
coverage determination or
redetermination) was received from the
enrollee, their representative, or their
prescriber. Submit in CCYY/MM/DD
format (e.g., 2017/01/01).
Provide the time of day the request was
received from the enrollee, their
representative, or their prescriber. Time
is in HH:MM:SS military time format
(e.g., 23:59:59). Enter NA if the request
was a reimbursement or a
redetermination.
Yes (Y)/ No (N) indicator of whether the
request was made by a representative or
someone claiming to be a representative.
10
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
K
Field Name
Field Type
Field Length
Description
AOR Receipt Date
CHAR
Always
Required
10
L
AOR Receipt Time
CHAR
Always
Required
8
M
Issue Description
2000
N
NDC_11
CHAR
Always
Required
CHAR
Always
Required
Date the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in CCYY/MM/DD format (e.g.,
2015/01/01). Answer None if no AOR
was received. Answer NA if no AOR
form was required.
Time the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in HH:MM:SS format (e.g.,
23:45:59). Answer None if no AOR was
received. Answer NA if no AOR form
was required or if the request was a
reimbursement or a redetermination.
Description of the issue.
O
Drug Name, Strength
& Dosage Form
150
P
Is this a protected class
drug?
Q
Was this request
processed as an
exception?
Date prescriber
supporting statement
received
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
S
Time prescriber
supporting statement
received
CHAR
Always
Required
8
T
Date forwarded to IRE
CHAR
Always
Required
10
R
Page 49 of 65
11
11-Digit National Drug Code. When no
NDC is available enter the applicable
Uniform Product Code (UPC) or Health
Related Item Code (HRI). Do not
include any spaces, hyphens or other
special characters. Answer NA if these
codes are not available.
Provide the drug name, strength, and
dosage form.
1
Protected class drug Yes (Y)/No (N)
indicator.
1
Exception request Yes (Y)/No (N)
indicator.
10
Date the prescriber's supporting
statement was received. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if no
prescriber supporting statement was
received or if the request was not an
exception request
Time the prescriber's supporting
statement was received. Submit in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA if no prescriber
supporting statement was received or if
the request was not an exception request
Provide the date the request was
forwarded to the IRE. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01).
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
U
Field Name
Field Type
Field Length
Description
Time forwarded to IRE
CHAR
Always
Required
8
V
Date enrollee notified
request has been
forwarded to IRE
CHAR
Always
Required
10
Provide the time the request was
forwarded to the IRE. Submit in
HH:MM:SS military time format (e.g.,
23:59:59).
Provide the date the enrollee was
notified in writing that the request was
forwarded to the IRE. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if enrollee was
not notified.
Page 50 of 65
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 10: Expedited IRE Auto-forwarded Coverage Determinations and Redeterminations
(EIRE) Record Layout
• Include all requests processed as expedited coverage determination or redetermination
requests that were auto-forwarded to the IRE.
• Submit cases based on the date the sponsor auto-forwarded the case to the IRE (the date the
request was initiated may fall outside of the review period).
Column
ID
A
Field Name
Field Type
Field Length
Description
Beneficiary First Name
50
First name of the beneficiary.
B
Beneficiary Last Name
50
Last name of the beneficiary.
C
Enrollment Effective
Date
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
10
D
Cardholder ID
20
E
Contract ID
F
Plan ID
G
Type of request
H
Date the request was
received
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
Effective date of beneficiary’s
enrollment for the PBP that the
beneficiary was enrolled in when the
coverage determination or
redetermination was received. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01).
Cardholder identifier used to identify the
beneficiary. This is assigned by the plan.
I
Time the request was
received
CHAR
Always
Required
8
J
Required AOR
CHAR
Always
Required
1
Page 51 of 65
5
The contract number (e.g., H1234) of
the organization.
3
The plan number (e.g., 001) of the
organization.
22
Type of request. Valid values are: Preservice CD or Redetermination.
10
Provide the date the request (either
coverage determination or
redetermination as applicable) was
received from the enrollee, their
representative, or their prescriber.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01).
Provide the time of day the request was
received from the enrollee, their
representative, or their prescriber. Time
is in HH:MM:SS military time format
(e.g., 23:59:59).
Yes (Y)/ No (N) indicator of whether the
request was made by a representative or
someone claiming to be a representative.
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
K
Field Name
Field Type
Field Length
Description
AOR Receipt Date
CHAR
Always
Required
10
L
AOR Receipt Time
CHAR
Always
Required
8
M
Issue Description
2000
N
NDC_11
CHAR
Always
Required
CHAR
Always
Required
Date the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in CCYY/MM/DD format (e.g.,
2015/01/01). Answer None if no AOR
was received. Answer NA if no AOR
form was required.
Time the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in HH:MM:SS format (e.g.,
23:45:59). Answer None if no AOR was
received. Answer NA if no AOR form
was required.
Description of the issue.
O
Drug Name, Strength
& Dosage Form
150
P
Is this a protected class
drug?
Q
Was this request
processed as an
exception?
Date prescriber
supporting statement
received
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
S
Time prescriber
supporting statement
received
CHAR
Always
Required
8
T
Date forwarded to IRE
CHAR
Always
Required
10
R
Page 52 of 65
11
11-Digit National Drug Code. When no
NDC is available enter the applicable
Uniform Product Code (UPC) or Health
Related Item Code (HRI). Do not
include any spaces, hyphens or other
special characters. Answer NA if these
codes are not available.
Provide the drug name, strength, and
dosage form.
1
Protected class drug Yes (Y)/No (N)
indicator.
1
Exception request Yes (Y)/No (N)
indicator.
10
Date the prescriber's supporting
statement was received. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if no
prescriber supporting statement was
received or if the request was not an
exception request
Time the prescriber's supporting
statement was received. Submit in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA if no prescriber
supporting statement was received or if
the request was not an exception request.
Provide the date the request was
forwarded to the IRE. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01).
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
U
Field Name
Field Type
Field Length
Description
Time forwarded to IRE
CHAR
Always
Required
8
V
Date enrollee notified
request has been
forwarded to IRE
CHAR
Always
Required
10
Provide the time the request was
forwarded to the IRE. Submit in
HH:MM:SS military time format (e.g.,
23:59:59).
Provide the date the enrollee was
notified in writing that the request was
forwarded to the IRE. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if enrollee was
not notified.
Page 53 of 65
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 11: Standard IRE, ALJ or MAC Determinations (SIAM) Record Layout
• Include all requests processed as standard pre-service coverage determination or
redetermination requests that were overturned by the IRE, ALJ, or MAC. This includes
requests that were auto-forwarded to the IRE and overturned by the IRE, ALJ, or MAC
(i.e., a favorable decision was rendered).
• Exclude all requests processed as reimbursement requests or expedited requests.
• Submit cases based on the date of receipt of the IRE, ALJ, or MAC overturn decision (the
date the request was initiated may fall outside of the review period).
Column
ID
A
Field Name
Field Type
Field Length
Description
Beneficiary First Name
50
First name of the beneficiary.
B
Beneficiary Last Name
50
Last name of the beneficiary.
C
Enrollment Effective
Date
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
10
D
Cardholder ID
20
Effective date of beneficiary’s
enrollment for the PBP that the
beneficiary was enrolled in when the
coverage determination or
redetermination was received. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01).
Cardholder identifier used to identify the
beneficiary. This is assigned by the plan.
E
Contract ID
F
Plan ID
G
Issue Description
H
Was this request
processed as an
exception?
Drug Name, Strength
& Dosage Form
8
J
Date of receipt of
IRE/ALJ/MAC
decision
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
K
Time of receipt for
IRE/ALJ/MAC
decision
CHAR
Always
Required
I
Page 54 of 65
5
The contract number (e.g., H1234) of
the organization.
3
The plan number (e.g., 001) of the
organization.
2000
Provide a description of the issue.
1
Exception request Yes (Y)/No (N)
indicator.
150
Provide the drug name, strength, and
dosage form.
10
Date the sponsor received the
IRE/ALJ/MAC overturn decision.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01).
Time the sponsor received the
IRE/ALJ/MAC overturn decision.
Submit in HH:MM:SS military time
format (e.g., 23:59:59).
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
L
Field Name
Field Type
Field Length
Description
Date effectuated in the
plan's system
CHAR
Always
Required
10
M
Time effectuated in the
plan's system
CHAR
Always
Required
8
N
List expiration date of
the exception approval
CHAR
Always
Required
10
Date overturn decision effectuated in the
plan's system. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if not
effectuated in the plan’s system.
Time overturn decision effectuated in
the plan's system. Submit in HH:MM:SS
military time format (e.g., 23:59:59).
Answer NA if not effectuated in the
plan’s system.
Expiration date of the exception
approval. Submit in CCYY/MM/DD
format (e.g., 2017/01/01). Answer NA if
request was not processed as an
exception or if the exception was not
approved.
Page 55 of 65
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 12: Direct Member Reimbursements decided by review entity other than sponsor
(DMRRE) Record Layout
• Include all requests processed as coverage determination or redetermination reimbursement
requests that were overturned by the IRE, ALJ, or MAC. This includes requests that were
auto-forwarded to the IRE and overturned by the IRE, ALJ, or MAC (i.e., a favorable
decision was rendered).
• Exclude all requests processed as pre-service coverage determination or redetermination
requests.
• Submit cases based on the date of receipt of the IRE, ALJ, or MAC overturn decision (the
date the request was initiated may fall outside of the review period).
Column
ID
A
Field Name
Field Type
Field Length
Description
Beneficiary First
Name
50
First name of the beneficiary.
B
Beneficiary Last
Name
50
Last name of the beneficiary.
C
Enrollment Effective
Date
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
10
D
Cardholder ID
20
E
Contract ID
F
Plan ID
G
Authorization or
Claim Number
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
Effective date of beneficiary’s enrollment
for the PBP that the beneficiary was
enrolled in when the reimbursement
(coverage determination or
redetermination) was received. Submit in
CCYY/MM/DD format (e.g., 2017/01/01).
Cardholder identifier used to identify the
beneficiary. This is assigned by the plan.
H
Issue Description
2000
I
Was this request
processed as an
exception?
Drug Name, Strength
& Dosage Form
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
J
Page 56 of 65
5
The contract number (e.g., H1234) of the
organization.
3
The plan number (e.g., 001) of the
organization.
40
The associated claim or payment request
number assigned by the sponsor for this
request. If a claim or payment request
number is not available, please provide
your internal tracking or case number.
Answer NA if there is no claim, payment
request or other tracking numbers available.
Provide a description of the issue.
1
Exception request Yes (Y)/No (N)
indicator.
150
Provide the drug name, strength, and
dosage form.
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
K
Field Name
Field Type
Field Length
Description
Date of receipt of
IRE/ALJ/MAC
decision
CHAR
Always
Required
10
L
Date sponsor
authorized
reimbursement of
overturn decision in
their system
Date reimbursement
provided
CHAR
Always
Required
10
CHAR
Always
Required
10
List expiration date of
the exception approval
CHAR
Always
Required
10
Date the sponsor received the
IRE/ALJ/MAC overturn decision. Submit
in CCYY/MM/DD format (e.g.,
2017/01/01). .
Date that appeal entity overturn was
authorized in the plan's system. Submit in
CCYY/MM/DD format (e.g., 2017/01/01).
Answer NA if reimbursement was not
authorized.
Date check or reimbursement provided to
enrollee (i.e., date check mailed to the
enrollee). Submit in CCYY/MM/DD format
(e.g., 2017/01/01). Enter NRD if no
reimbursement was due to the enrollee.
Expiration date of the exception approval.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if request was not
processed as an exception or if the
exception was not approved.
M
N
Page 57 of 65
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 13: Expedited IRE, ALJ or MAC Determinations (EIAM) Record Layout
• Include all requests processed as expedited coverage determination or redetermination
requests that were overturned by the IRE, ALJ, or MAC. This includes requests that were
auto-forwarded to the IRE and overturned by the IRE, ALJ, or MAC (i.e., a favorable
decision was rendered).
• Exclude all requests processed as standard coverage determination or redetermination
requests or reimbursement requests.
• Submit cases based on the date of receipt of the IRE, ALJ, or MAC overturn decision (the
date the request was initiated may fall outside of the review period).
Column
ID
A
Field Name
Field Type
Field Length
Description
Beneficiary First Name
50
First name of the beneficiary.
B
Beneficiary Last Name
50
Last name of the beneficiary.
C
Enrollment Effective
Date
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
10
D
Cardholder ID
20
Effective date of beneficiary’s
enrollment for the PBP that the
beneficiary was enrolled in when the
coverage determination or
redetermination was received. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01).
Cardholder identifier used to identify the
beneficiary. This is assigned by the plan.
E
Contract ID
F
Plan ID
G
Issue Description
H
Was this request
processed as an
exception?
Drug Name, Strength
& Dosage Form
8
J
Date of receipt of
IRE/ALJ/MAC
decision
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
K
Time of receipt for
IRE/ALJ/MAC
decision
CHAR
Always
Required
I
Page 58 of 65
5
The contract number (e.g., H1234) of
the organization.
3
The plan number (e.g., 001) of the
organization.
2000
Provide a description of the issue.
1
Exception request Yes (Y)/No (N)
indicator.
150
Provide the drug name, strength, and
dosage form.
10
Date the sponsor received the
IRE/ALJ/MAC overturn decision.
Submit in CCYY/MM/DD format (e.g.,
2017/01/01).
Time the sponsor received the
IRE/ALJ/MAC overturn decision.
Submit in HH:MM:SS military time
format (e.g., 23:59:59).
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
L
Field Name
Field Type
Field Length
Description
Date effectuated in the
plan's system
CHAR
Always
Required
10
M
Time effectuated in the
plan's system
CHAR
Always
Required
8
N
List expiration date of
the exception approval
CHAR
Always
Required
10
Date overturn decision effectuated in the
plan's system. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if overturn
decision not effectuated in the plan’s
system.
Time overturn decision effectuated in
the plan's system. Submit in HH:MM:SS
military time format (e.g., 23:59:59).
Answer NA if overturn decision not
effectuated in the plan’s system.
Expiration date of the exception
approval. Submit in CCYY/MM/DD
format (e.g., 2017/01/01). Answer NA if
request was not processed as an
exception or if the exception was not
approved.
Page 59 of 65
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 14: Standard Grievances Part D (SGD) Record Layout
• Include all requests processed as standard oral and written grievances.
• Exclude CTM complaints, however if a sponsor received both a grievance and a CTM
complaint concerning the same issue, the sponsor should include the grievance.
• Submit cases based on date of resolution notification of the standard oral and written
grievances (the date the grievance was received may fall outside of the review period).
Column
ID
A
Field Name
Field Type
Beneficiary First Name
B
Beneficiary Last Name
C
Enrollment Effective
Date
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
D
Cardholder ID
E
Contract ID
F
Plan ID
G
Field
Length
50
Description
50
Last name of the beneficiary.
10
Effective date of beneficiary’s
enrollment for the PBP that the
beneficiary was enrolled in when the
grievance was received. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01).
Cardholder identifier used to identify the
beneficiary. This is assigned by the plan.
20
Date
Grievance/Complaint
was received
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
H
How was the
grievance/complaint
received?
CHAR
Always
Required
7
I
Category of the
grievance/complaint
CHAR
Always
Required
50
J
Grievance/ Complaint
Description
1800
K
Was this a quality of
care grievance?
CHAR
Always
Required
CHAR
Always
Required
Page 60 of 65
First name of the beneficiary.
5
The contract number (e.g., H1234) of the
organization.
3
The plan number (e.g., 001) of the
organization.
10
Date the grievance/complaint was
received from the enrollee or their
authorized representative. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01).
Describe how the grievance/complaint
was first received from the enrollee or
authorized representative. Valid fields
include: Oral or Written.
Describe the category of the
grievance/complaint. At a minimum,
categories must include each of the
following: Enrollment/Disenrollment;
Plan Benefits; Pharmacy Access;
Marketing; Customer Service; Coverage
Determinations/Redetermination
Process; Quality of Care; CMS Issues;
or; Other.
Provide a description of the
grievance/complaint issue.
1
Yes (Y)/No (N) indicator of whether the
grievance was a quality of care
grievance.
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
L
Field Name
Field Type
Was a timeframe
extension taken?
M
If an extension was
taken, did the plan
notify the member of
the reason(s) for the
delay?
If the extension was
taken because the plan
needed more
information, did the
notice include how the
delay was in the best
interest of the enrollee?
Date oral notification
provided to enrollee
CHAR
Always
Required
CHAR
Always
Required
N
O
Field
Length
1
Description
2
Yes (Y)/No (N) indicator of whether the
sponsor notified the enrollee of the
delay. Answer NA if no timeframe
extension was taken.
CHAR
Always
Required
2
Yes (Y)/No (N) indicator of whether the
sponsor notified the enrollee of how the
extension of the timeframe was in the
interest of the enrollee. Answer NA if no
timeframe extension was taken.
CHAR
Always
Required
10
Date oral notification of resolution
provided to enrollee. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if no oral
notification was provided to enrollee.
Date written notification of resolution
provided to enrollee. The term
“provided” means when the letter left the
sponsor’s establishment by US Mail, fax,
or electronic communication. Do not
enter the date a letter is generated or
printed within the sponsor’s
organization. Submit in CCYY/MM/DD
format (e.g., 2017/01/01). Answer NA if
no written notification was provided to
enrollee.
Provide a full description of the
grievance resolution.
P
Date written
notification provided to
enrollee
CHAR
Always
Required
10
Q
Resolution Description
CHAR
Always
Required
1800
Page 61 of 65
Yes (Y)/No (N) indicator of whether
grievance timeframe was extended.
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 15: Expedited Grievances Part D (EGD) Record Layout
• Include all requests processed as expedited oral and written grievances.
• Submit cases based on date of resolution notification of the standard oral and written
grievances (the date the grievance was received may fall outside of the review period).
Column
ID
A
Field Name
Field Type
Beneficiary First Name
B
Beneficiary Last Name
C
Enrollment Effective
Date
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
D
Cardholder ID
E
Contract ID
F
Plan ID
G
Field
Length
50
Description
50
Last name of the beneficiary.
10
Effective date of beneficiary’s
enrollment for the PBP that the
beneficiary was enrolled in when the
grievance was received. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01).
Cardholder identifier used to identify the
beneficiary. This is assigned by the plan.
20
Date
Grievance/Complaint
was received
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
H
Time
Grievance/Complaint
was received
CHAR
Always
Required
8
I
How was the
grievance/complaint
received?
CHAR
Always
Required
7
J
Category of the
grievance/complaint
CHAR
Always
Required
50
K
Grievance/Complaint
Description
CHAR
Always
Required
1800
Page 62 of 65
First name of the beneficiary.
5
The contract number (e.g., H1234) of the
organization.
3
The plan number (e.g., 001) of the
organization.
10
Date the grievance/complaint was
received from the enrollee or their
authorized representative. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01).
Time of day the grievance/complaint
was received from the enrollee or their
authorized representative. Time is in
HH:MM:SS military time format (e.g.,
23:59:59).
Describe how the grievance/complaint
was received from the enrollee or
authorized representative. Valid fields
include: Oral or Written.
Describe the category of the
grievance/complaint. If this grievance
was over the plan’s refusal to expedite a
request, indicate Refusal to Expedite in
this field. If the sponsor expedited a
grievance for any other issue, please
indicate “other”.
Provide a description of the
grievance/complaint issue.
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
L
Field Name
Field Type
Field Length
Description
Date oral notification
provided to enrollee
CHAR
Always
Required
10
M
Time oral notification
provided to enrollee
CHAR
Always
Required
8
N
Date written
notification provided to
enrollee
CHAR
Always
Required
10
O
Time written
notification provided to
enrollee
CHAR
Always
Required
8
P
Resolution Description
CHAR
Always
Required
1800
Date oral notification of resolution
provided to enrollee. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01). Answer NA if no oral
notification was provided to enrollee.
Time oral notification of resolution
provided to enrollee. Submit in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA if no oral
notification was provided to enrollee.
Date written notification of resolution
provided to enrollee. The term
“provided” means when the letter left the
sponsor’s establishment by US Mail, fax,
or electronic communication. Do not
enter the date a letter is generated or
printed within the sponsor’s
organization. Submit in CCYY/MM/DD
format (e.g., 2017/01/01). Answer NA if
no written notification was provided to
enrollee.
Time written notification of resolution
provided to enrollee. The term
“provided” means when the letter left the
sponsor’s establishment by US Mail, fax,
or electronic communication. Do not
enter the date a letter is generated or
printed within the sponsor’s
organization. Submit in HH:MM:SS
military time format (e.g., 23:59:59).
Answer NA if no written notification
was provided to enrollee.
Provide a full description of the
grievance resolution.
Page 63 of 65
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 16: Call Logs Part D Record Layout
NOTE: Sponsors are not required to submit the information below in the format provided by the
record layout as long as the information provided is sufficient for CMS review.
•
•
•
•
Include all incoming calls received by your organization (or another entity) from Part D
enrollees and/or their representatives that relate to your Medicare Part D line of business
(i.e., calls made to your customer service line(s)).
Exclude any calls not relating to your Part D business (i.e., Medicare advantage,
commercial).
Exclude provider/ prescriber calls, or any calls not from an enrollee/ representative.
Submit all calls based on the date the call was received by your organization, PBM or
other entity using the following criteria:
Plans with <50,000 enrollees: Plans should submit calls for the first 4-weeks of the
audit review period as defined above in the Audit Purpose and General Guidelines.
Plans with >50,000 but <250,000 enrollees: Plans should submit calls for the first 3weeks of the audit review period as defined above in the Audit Purpose and General
Guidelines.
Plans with >250,000 enrollees: Plans should submit calls for the first 2-weeks of the
audit review period as defined above in the Audit Purpose and General Guidelines.
Column ID
Field Name
Field Type
Field
Length
50
Description
A
Beneficiary First
Name
CHAR Always
Required
B
Beneficiary Last
Name
CHAR Always
Required
50
Last name of the beneficiary.
C
Enrollment
Effective Date
CHAR Optional
10
D
Cardholder ID
CHAR Always
Required
20
E
Contract ID
CHAR Optional
5
Effective date of beneficiary’s
enrollment for the PBP that the
beneficiary was enrolled in when the
call was received. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01).
Cardholder identifier used to identify
the beneficiary. This is assigned by
the plan.
The contract number (e.g., H1234,
S1234) of the organization.
F
Plan ID
CHAR Optional
3
The plan number (e.g., 001, 002) of
the organization.
G
Date the call was
received
CHAR Always
Required
10
Date the call was received from the
beneficiary or their authorized
representative. Submit in
CCYY/MM/DD format (e.g.,
2017/01/01).
Page 64 of 65
First name of the beneficiary.
v. 10-2016
Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column ID
Field Name
Field Type
H
Time the call was
received
CHAR Always
Required
I
Category of the call
J
K
Page 65 of 65
Field
Length
8
Description
CHAR Optional
50
Description of the
call
CHAR Always
Required
1800
Description of the
outcome of the call
CHAR Always
Required
1800
Provide a general category of the call
issue(s) (e.g. benefit dispute,
enrollment, formulary question).
Provide a brief description of what the
call was about, or any call notes from
the call.
Full description of the call outcome
and any resolution. This should
include whether a subsequent action
was started (CD, RD or grievance).
Time of day the call was received
from the beneficiary or their
authorized representative. Time is in
HH:MM:SS military time format
(e.g., 23:59:59).
v. 10-2016
| File Type | application/pdf |
| File Title | Part D Coverage Determinations, Appeals and Grievances (CDAG) Program Area |
| Subject | 2017 Protocols, CDAG Program Audits |
| Author | CMS |
| File Modified | 2016-12-06 |
| File Created | 2016-10-04 |