Cms-10191 Odag Audit Process And Data Request

Medicare Parts C and D Program Audit Protocols and Data Requests (CMS-10191)

Attachment_IV_ODAG_AuditProcess_DataRequest

Medicare Parts C and D Program Audit Protocols and Data Requests

OMB: 0938-1000

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-1000 can be found here:

2020-01-07 - Revision of a currently approved collection

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Part C Organization
Determinations, Appeals and
Grievances (ODAG) Program
Area
AUDIT PROCESS AND DATA REQUEST

Expires: TBD
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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST

Table of Contents
Audit Purpose and General Guidelines ......................................................................................................... 3
Universe Preparation & Submission ............................................................................................................. 5
Audit Elements.............................................................................................................................................. 8
I. Timeliness - Organization Determinations, Appeals and Grievances (TODAG).................................. 8
II. Appropriateness of Clinical Decision-Making & Compliance with ODA Processing Requirements 11
III. Grievances and Misclassification of Requests .................................................................................. 14
IV. Dismissals ......................................................................................................................................... 16
Appendix ..................................................................................................................................................... 17
Appendix A—Organization Determinations, Appeals and Grievances (ODAG) Record Layouts ........ 17
Table 1: Standard Pre-service Organization Determinations (SOD) Record Layout ......................... 17
Table 2: Expedited Pre-service Organization Determinations (EOD) Record Layout ....................... 21
Table 3: Requests for Payment Organization Determinations (Claims) Record Layout .................... 25
Table 4: Direct Member Reimbursement (DMR) Requests Record Layout ....................................... 28
Table 5: Standard Pre-service Reconsiderations (SREC) Record Layout .......................................... 31
Table 6: Expedited Pre-service Reconsiderations (EREC) Record Layout ........................................ 34
Table 7: Requests for Payment Reconsiderations (PREC) Record Layout ........................................ 38
Table 8: Pre-service IRE Cases Requiring Effectuation (IREEFF) Record Layout ........................... 40
Table 9: IRE Payment Cases Requiring Effectuation (IREClaimsEFF) Record Layout .................... 42
Table 10: All Part C ALJ and MAC Cases Requiring Effectuation (ALJMACEFF) Record Layout 44
Table 11: Part C Oral & Written Standard Grievances (GRV_S) Record Layout .............................. 46
Table 12: Part C Oral & Written Expedited Grievances (GRV_E) Record Layout............................ 48
Table 13: Dismissals Record Layout .................................................................................................. 50
Table 14: Call Logs Part C (CLC) Record Layout ............................................................................. 52

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST

Audit Purpose and General Guidelines
1. Purpose: To evaluate performance in the four areas outlined in this protocol related to Part C
Organization Determinations, Appeals and Grievances (ODAG). 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 ODAG 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 C universe (Table 14) 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 on-going
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.

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AUDIT PROCESS AND DATA REQUEST
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.
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 ODAG 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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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST

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, dismissals and
grievances and the misclassification of requests in the area of ODAG. The sponsor will provide
universes of all of its organization determinations (both payment and pre-service, both expedited and
standard), all sponsor reconsiderations (both payment and pre-service, both expedited and standard),
all requests for direct member reimbursement, all IRE, ALJ and MAC cases that required
effectuation, all expedited and standard grievances, as well as a call log of all calls received by the
sponsor from enrollees or their representatives relating to their Part C 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 ODs 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 or dismissed and 2) submitted in the
appropriate record layout as described in Appendix A. Please note that for audit purposes, partially
favorable decisions are treated as denials. These record layouts include:
•
•
•
•
•
•
•
•
•
•
•
•

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Table 1: Standard Pre-Service Organization Determinations (SOD)
Table 2: Expedited Pre-Service Organization Determinations (EOD)
Table 3: Requests for Part C Payment Organization Determinations (Claims)
Table 4: Direct Member Reimbursement (DMR) Requests
Table 5: Standard Pre-Service Reconsiderations (SREC)
Table 6: Expedited Pre-Service Reconsiderations (EREC)
Table 7: Requests for Payment Reconsiderations (PREC)
Table 8: Pre-Service IRE Cases Requiring Effectuation (IREEFF)
Table 9: IRE Payment Cases Requiring Effectuation (IREClaimsEFF)
Table 10: All ALJ and MAC Cases Requiring Effectuation (ALJMACEFF)
Table 11: Part C Oral and Written Standard Grievances (GRV_S)
Table 12: Part C Oral and Written Expedited Grievances (GRV_E)

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
•
•

Table 13: Dismissals (DIS)
Table 14: Call Logs Part C (CLC)

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 1-14. 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 14: Call
Logs Part C. 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.
TABLE
#

RECORD
LAYOUT

SOD

EOD

Claims

DMR

SREC

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UNIVERSE

COMPLIANCE STANDARD TO
APPLY

CHAP. 13 REF.

DecisionMaking

Standard Preservice ODs

No later than 14 days, plus 14
days (totaling 28 days) if an
extension is used.

§ 40.1

Expedited Preservice ODs

No later than 72 hours, plus 14
days (totaling 17 days) if an
extension is used.

§ 50.1
§ 50.2
§ 50.4

Requests for Part
C payment ODsClaims
(designate if the
request was a
clean claim or an
unclean claim)
Requests for
Payment ODsDirect Member
Reimbursement
Requests
Standard Preservice
Reconsiderations

TEST

Notification
DecisionMaking
Notification
Effectuation

95% in 30 days for clean
claims and 60 days for unclean
claims.

§ 40.1
Notification

Effectuation
No later than 60 days.

§ 40.1
Notification

No later than 30 days, plus 14
days (totaling 44 days) if an
extension is used. Late and
unfavorable cases must be
forwarded to the IRE within
this timeframe.

Effectuation
§ 70.7.1
§ 70.7.4

IRE AutoForward
Notification

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
TABLE
#

RECORD
LAYOUT

EREC

PREC

IREEFF
8

UNIVERSE

Expedited Preservice
Reconsiderations

Requests for
Payment
Reconsiderations

Pre-service IRE
Cases Requiring
Effectuation

IREClaimsEFF

IRE Payment
Cases Requiring
Effectuation

ALJMACEFF

All ALJ and
MAC Cases
Requiring
Effectuation

GRV_S

GRV_E

DIS

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Part C Oral &
Written Standard
Grievances
Part C Oral &
Written
Expedited
Grievances

Dismissals

COMPLIANCE STANDARD TO
APPLY

No later than 72 hours, plus 14
days (totaling 17 days) if an
extension is used. Late cases
must be forwarded to the IRE
within this timeframe.
No later than 60 days.
Requests that are processed
outside the required timeframe
must be forwarded to the IRE
within this timeframe.
No later than 14 days
(standard) or 72 hours
(expedited) after receipt of the
notice of IRE reversal.
Payment must be made no
later than 30 days after receipt
of the notice of IRE reversal.
The sponsor must pay for,
authorize, or provide the
service under dispute no later
than 60 calendar days from the
date it receives notice
reversing the initial
organization determination.
No later than 30 days plus 14
days if an extension is used
(totaling 44 days).

CHAP. 13 REF.

TEST

Effectuation
§ 80.1
§ 80.2

IRE AutoForward
Notification
Effectuation

§ 70.7.3
§ 70.7.4

IRE AutoForward
Notification

§ 140.2.
§ 140.2.2

Effectuation

§ 140.2.3

Effectuation

§ 140.3

Effectuation

§ 20.3

Notification

No later than 24 hours.

§ 20.3

Notification

See SOD, EOD, Claims,
DMR, SREC, EREC and
PREC timeframes.

§ 10.4.1
§ 60.1
§ 70.7.5
HPMS Memo “Change
in Part C
Reconsideration
Dismissal Procedures”
(9/10/2013).

Notification

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Audit Elements
I. Timeliness - Organization Determinations, Appeals and Grievances (TODAG)
(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 13 for a total
of 65 cases. CMS will not validate the Call Logs Part C universe (Table 14) 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. 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 the live webinar and CMS
may request the sponsor to produce screenshots of any of the following:
2.1. For requests for organization determinations or reconsiderations:
• Original pre-service or payment (i.e., claim) or reconsideration request.
• Letters, emails or documentation confirming the sponsor’s receipt of the request:
o If request was received via fax/mail/email, copy of original request including
date/time stamp of receipt.
o If request was received via phone, copy of Customer Service Representative (CSR)
notes and/or documentation of call including date/time stamp of call and call details.
• Description of the service/benefit requested from the provider/physician or the enrollee.
• Notices, letters, call logs or other documentation showing the sponsor requested additional
information (if applicable) from the requesting provider/physician, including date, time, and
type of communication. If the request was made via phone call, copy of the call log detailing
what was communicated to the physician/provider.
• All supplemental information submitted by the requesting provider/physician or enrollee,
including documentation showing when information was received by the sponsor.
o If information was received via fax/mail/email, copy of original request including
date/time stamp of receipt.
o If information was received via phone, copy of CSR notes and/or documentation of
call including date/time stamp of call and call details.
• Documentation of case review steps including name and title of final reviewer; rationale for
denial; any reference to CMS guidance, Federal Regulations, clinical criteria, peer reviewed
literature (where allowed), and sponsor documents (e.g., Evidence of Coverage (EOC)); or
any other documentation used when considering the request.
• Documentation of effectuation including approval in organization
determinations/reconsiderations systems and evidence of effectuation in sponsor’s claims
adjudication system, clearly showing date and time override was entered.
• Documentation showing approval notification to the enrollee and/or their representative and
physician/provider, as applicable.
o Copy of the written decision letter and documentation of date/time letter was printed
and mailed.
o If oral notification was given, copy of CSR notes and/or documentation of call
including date/time of call.

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
•
•

•
•

Records indicating that payments were made/issued such as Electronic Fund Transfer (EFT)
records.
Documentation showing denial notification to the enrollee and/or their representative and
provider/physician, if applicable:
o Copy of written decision letter and documentation of date/time letter was printed and
mailed;
o If oral notification was given, copy of CSR notes and/or documentation of call
including date/time of call.
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 a reconsidered case was untimely, include the following:
o Documentation showing when the sponsor auto-forwarded the request to the IRE.

2.2. For cases overturned by the 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 organization
determinations/reconsiderations system(s) and evidence of effectuation in sponsor claims
system clearly showing date/time the override was entered.
• Copy of reconsideration effectuation notice to IRE including sent date/time stamp.
 Screen print of all claims for the requested service after approval date
• If denied, explanation why the service was denied (i.e., exceeds authorized number of
visits).
• If there are no claims for service after date of effectuation, narrative explaining
member has not attempted to receive the service since the date of effectuation and a
screen print showing all claims for members since date of effectuation.
3. Apply Compliance Standards: 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 ODAG requirements not being met.
3.1. Universe Accuracy Standard: CMS will test each of the 13 universes by confirming the data
through the 5 selected cases (65 total cases). The integrity of the universe will be questioned if
the timeliness data on more than 1 of the 5 selected 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.
3.1.1.

Are the dates and times observed during the webinar in the sponsor’s systems
consistent with 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 organization

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
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.
3.2.1.

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
13 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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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
II. Appropriateness of Clinical Decision-Making & Compliance with ODA Processing
Requirements
1. Select Sample Cases: CMS will select a targeted sample of 40 cases total that appear clinically
significant from the pre-service and payment requests and IRE/ALJ/MAC reversal record layouts
(Appendix A, Tables 1 through 10). CMS will attempt to ensure, to the extent possible, that the
sample set is representative of various medical services (e.g., ER services, outpatient hospital,
inpatient hospital, urgent care, etc.). CMS will select the sample set from the universe categories as
follows:
•
•
•
•
•

10 organization determination denials (5 pre-service and 5 payment);
10 reconsideration denials (5 pre-service and 5 payment);
10 IRE, ALJ, or MAC overturns (5 pre-service and 5 payment);
5 organization determination approvals (standard and expedited); and
5 reconsideration approvals (standard and expedited).

Note: For audit purposes, partially favorable decisions are treated as denials.
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 webinar and CMS may request the sponsor to produce
screenshots of any of the following:
2.1. For requests for organization determinations or reconsiderations:
• Original pre-service or payment (i.e., claim or reimbursement request) or reconsideration
request.
• Letters, emails or documentation confirming the sponsor’s receipt of the request:
o If request was received via fax/mail/email, copy of original request.
o If request was received via phone, copy of CSR notes and/or documentation of call.
• Description of the service/benefit requested from the provider/physician or the enrollee.
• Notices, letters, call logs or other documentation showing the sponsor requested additional
information (if applicable) from the requesting provider/physician, including type of
communication. If the request was made via phone call, copy of the call log detailing what
was communicated to the physician/provider.
• All supplemental information submitted by the requesting provider/physician or enrollee.
o If information was received via fax/mail/email, copy of original request.
o If information was received via phone, copy of CSR notes and/or documentation of
call.
• Documentation of case review steps including name and title of final reviewer; rationale for
denial; any reference to CMS guidance, Federal Regulations, clinical criteria, peer reviewed
literature (where allowed), and sponsor documents (e.g., EOC); or any other documentation
used when considering the request.
• Documentation of effectuation including approval in organization
determinations/reconsiderations systems and evidence of effectuation in sponsor’s claims
adjudication system.
• Documentation showing approval notification to the enrollee and/or their representative and
physician/provider, as applicable.
o Copy of the written decision letter;
o If oral notification was given, copy of CSR notes and/or documentation of call.
• Records indicating that payments were made/issued such as EFT records.

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
•

•

•
•

Documentation showing denial notification to the enrollee and/or their representative and
provider/physician, if applicable:
o Copy of written decision letter;
o If oral notification was given, copy of CSR notes and/or documentation of call.
Documentation showing reconsideration denial notification to the enrollee and/or their
representative and provider/physician, if applicable:
o Copy of written decision letter;
o If oral notification was given, copy of CSR notes and/or documentation of call.
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 reconsidered case was untimely, include the following:
o Documentation showing the sponsor auto-forwarded the request to the IRE.

2.2. IRE, ALJ or MAC Overturns:
• Copy of overturn notice from IRE/ALJ/MAC.
• Documentation of effectuation including approval in organization
determinations/reconsiderations system(s) and evidence of effectuation in sponsor claims
system.
• Copy of effectuation notice to IRE.
• Screen print of all claims for the requested service after approval date
• If denied, explanation why the service was denied (i.e., exceeds authorized
number of visits).
• If there are no claims for service after date of effectuation, narrative
explaining member has not attempted to receive the service since the date
of effectuation and a screen print showing all claims for members since
date of effectuation.
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 ODAG requirements not being met.
3.1. Clinical Appropriateness/Approvals:
3.1.1.

3.1.2.
3.1.3.
3.1.4.
3.1.5.

Was appropriate notification (i.e., correct notice and approval language understandable
for enrollee) provided to the enrollee (or representative) and provider/physician, if
applicable?
If representative received response, was an appointment of representative (AOR), or
other conforming instrument, on file?
Did the sponsor appropriately consider clinical information and comply with CMS
coverage and notification requirements?
Did the sponsor make reasonable and diligent efforts to obtain all medical records and
other pertinent documentation within the required timeframes?
Did the sponsor effectuate the request in its system?

3.2. Clinical Appropriateness/Denials:
3.2.1.

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Was appropriate notification (i.e., correct notice and denial language understandable for
enrollee; appeal rights for non-contract providers) provided to the enrollee (or
representative) and provider/physician, if applicable?
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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
If representative received response, was an appointment of representative (AOR), or
other conforming instrument, on file?
3.2.3. Was the organization determination 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 reconsideration 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 upheld its adverse decision or was untimely in its decision,
did the sponsor forward the case to the IRE properly and within the required timeframe?
3.2.8. Documentation showing the enrollee was notified their case had been forwarded to the
IRE for review including copy of notification letter.
3.2.9. If care or services were provided by a contract provider or a provider referred by a
contract provider, was the member held harmless, unless notice was provided that
services would not be covered?
3.2.10. Did the enrollee get a clinically equivalent or alternate service, if applicable?
3.2.2.

3.3. IRE, ALJ or MAC Overturns: If a reviewer determines the IRE, ALJ or MAC reversal was in
error, the case will pass. For all other IRE, ALJ and MAC cases, apply the following compliance
criteria:
3.3.1.
3.3.2.

Did the IRE, ALJ or MAC receive additional information that would have changed the
sponsor’s decision to deny the case?
Did the sponsor attempt to obtain that information?

4. Sample Case Results: CMS will test each of the 40 cases. 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-to-many relationship. For example, one
case may have a single condition or multiple conditions of non-compliance.

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
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 11
and 12). If the sponsor does not have enough expedited grievances, the auditors sample additional
cases from the standard grievance universe. CMS will also select a targeted sample of 10 calls from
the sponsor’s Part C Call Log universe (Table 14).
2. Review Sample Case Documentation: CMS will review all sample case 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 organization determinations or grievances. The sponsor will
need access to the following documents or audio files during the live webinar and CMS may request
the sponsor to produce screenshots or transcripts of any of the following:
2.1. For Grievances:
• Initial Complaint:
o If complaint was received via fax/mail/email, copy of original complaint including
date/time stamp of receipt;
o If complaint was received via phone, copy of CSR notes and/or documentation of call
including date/time of call and call details.
• Any documentation explaining the issue.
• Where applicable, copy of all notices, letters, call logs, or other documentation showing when the
sponsor acknowledged receipt of the grievance to the enrollee, and/or requested additional
information from the enrollee and/or their representative, including the date and time of the
acknowledgement. If the request was made via phone call, copy of the CSR notes and/or
documentation of call, as well as what was communicated to the enrollee.
• Documentation of all supplemental information submitted by enrollee and/or their representative:
o If information was received via fax/mail/email, copy of documentation provided
including date/time stamp of receipt;
o If information was received via phone, copy of CSR notes and/or documentation of call
including date/time of call and call details.
• Documentation showing the steps the sponsor took to resolve the issue and a description of the
final resolution. Documentation showing the steps the sponsor took to resolve the issue may
include, but is not limited to, appropriate correspondence with other departments within the
organization; referral to the sponsor’s fraud, waste, and abuse department; and outreach to
providers.
• Documentation showing the sponsor’s investigation, follow-up steps, and description of the final
grievance outcome. Include all notices, letters, and beneficiary communications.
• Documentation showing resolution notification to the enrollee and/or their representative:
o Copy of the written decision letter sent and documentation of date/time letter was printed
and mailed.
o If oral notification was given, copy of CSR notes and/or documentation of call including
date/time stamp.
• For quality of care grievances: provide documentation that supports that an investigation and
appropriate follow up (including issuance of written notice) took place.

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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)
• 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 an organization determination or reconsideration:
• Copy of organization determination or reconsideration 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 ODAG requirements not being met.
3.1. Was the grievance or call correctly classified, and, if not, was it 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 to 15 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-to-many relationship. For example, one
case may have a single condition or multiple conditions of non-compliance.

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IV. Dismissals
1. Select Sample Cases: CMS will select a targeted sample of 15 dismissals as follows:
•
•
•

5 pre-service dismissals;
5 payment dismissals; and
5 grievances.

2. Review Sample Case Documentation: For each case, the sponsor must be able to access all relevant
documentation during the webinar and provide screen shots of any applicable documentation,
including, but not limited to:
• The pre-service or payment (i.e., claim) organization determination request.
• The pre-service or payment reconsideration request.
• Letters, emails or documentation confirming the sponsor’s receipt of the request.
• Notices, letters, or other documentation showing the sponsor requested additional information
and/or attempted to obtain the missing documentation (i.e., the Waiver of Liability (WOL) or
Appointment of Representative (AOR), or other conforming instrument) from the requesting
provider/physician or purported representative, including date, time and type of communication.
• All supplemental information submitted by the requesting provider/physician or representative,
including documentation showing when the information was received by the sponsor.
• Written notice of dismissal.
• If applicable, providing timely notification of dismissals to enrollees or another party, and
informing enrollees and other parties about the right to request IRE review of the
dismissal since sponsors will no longer automatically forward such reconsideration cases
to the IRE for review.
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 ODAG requirements not being met.
3.1. Did the sponsor make a reasonable effort to obtain the AOR (or other conforming
instrument) or WOL and document those efforts in the case file?
3.2. Did the sponsor send a written notice of the dismissal to the parties at their last known
addresses within the applicable adjudication timeframe pursuant to the requirements of 42
CFR Part 422, Subpart M?
3.3. Did the dismissal notice state the reason for the dismissal?
3.4. Did the dismissal notice explain the right to request IRE review of the dismissal within 60
calendar days after receipt of the written notice of the sponsor’s dismissal?
3.5. If applicable, did the sponsor assemble and forward the case file to the IRE within 24 hours
of receiving the IRE’s case file request?
4. Sample Case Results: CMS will test each of the 15 cases. 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-to-many relationship. For example, one
case may have a single condition or multiple conditions of non-compliance.

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Appendix
Appendix A—Organization Determinations, Appeals and Grievances (ODAG)
Record Layouts
The universes for the Part C Organization Determination, Appeals and Grievances (ODAG) program area
must be submitted as a Microsoft Excel (.xlsx) or Comma Separated Values (.csv) file with a header row
reflecting the field names (or Text (.txt) file without a header row). 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 cases in your universes are populated based on the
time zone where the request was received.
If you do not 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 and spaces count toward this 4,000
character limit. Therefore, should additional characters be needed for a variable, enter this information on
the next record at the appropriate start position.
Table 1: Standard Pre-service Organization Determinations (SOD) Record Layout
• Include all requests processed as standard pre-service organization determinations, including all
supplemental services, such as dental and vision, and include all approvals and denials.
• Exclude payment requests, dismissals, reopenings, withdrawn requests and all requests processed
as expedited organization 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).
• If a standard pre-service organization determination includes more than one service include all of
the request’s line items in a single row and enter the multiple line items as a single organization
determination request.
Column
ID

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Cardholder ID

Cardholder identifier used to identify the
beneficiary. This is assigned by the sponsor.

Contract ID

The contract number (e.g., H1234) of the
organization.

Plan ID

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

The plan number (e.g., 001) of the organization.

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Column
ID

Field Name

Field Type

Field
Length

Description

Authorization or
Claim Number

CHAR
Always
Required

Who made the
request?

CHAR
Always
Required

The associated authorization number assigned by
the sponsor for this request. If an authorization
number is not available, please provide your
internal tracking or case number. Answer NA if
there is no authorization or other tracking number
available.
Indicate whether the pre-service request was
made by a contract provider (CP), non-contract
provider (NCP), beneficiary (B) or beneficiary’s
representative (BR).
Note: the term “provider” encompasses
physicians and facilities.
Indicate whether the provider performing the
service is a contract provider (CP) or non-contract
provider (NCP).

Provider Type

CHAR
Always
Required

Date the request was
received

CHAR
Always
Required

Provide the date the request was received by your
organization. Submit in CCYY/MM/DD format
(e.g., 2015/01/01).

Diagnosis

CHAR
Always
Required

100

Issue description and
type of service

CHAR
Always
Required

2,000

Level of service

CHAR
Always
Required

Provide the enrollee diagnosis/diagnoses ICD-10
codes related to this request. If the ICD codes are
unavailable, provide a description of the
diagnosis, or for drugs provide the 11-digit
National Drug Code (NDC) as well as the ICD-10
code related to the request.
Provide a description of the service, medical
supply or drug requested and why it was
requested (if known). For denials, also provide an
explanation of why the pre-service request was
denied.
Provide the level of service requested (e.g.,
inpatient/outpatient/ER/urgent care/point of sale
transaction).

Was request made
under the expedited
timeframe but
processed by the plan
under the standard
timeframe?
Request for expedited
timeframe

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the request
was made under an expedited timeframe but was
processed under the standard timeframe.

CHAR
Always
Requested

Was a timeframe
extension taken?

CHAR
Always
Required

If a request was made after the organization
determination to expedite the request, indicate
who made the subsequent request to expedite the
request: non-contract provider (NCP), beneficiary
(B), beneficiary’s representative (BR). Answer
NA if no expedited timeframe was requested.
Yes (Y)/No (N) indicator of whether the sponsor
extended the timeframe to make the organization
determination.

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AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

If an extension was
taken, did the sponsor
notify the member of
the reason(s) for the
delay and of their right
to file an expedited
grievance?
Request Disposition

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the sponsor
notified the beneficiary of the delay. Answer NA
if no extension was taken.

CHAR
Always
Required

Status of the request. Valid values are: approved,
or denied. Sponsors should note any requests that
are untimely and not yet resolved (still
outstanding) as denied.

All untimely and pending cases should be treated
as denials for the purposes of populating the rest
of this record layout’s fields.
Date of the sponsor decision. Submit in
CCYY/MM/DD format (e.g., 2015/01/01).
Sponsors should answer NA for untimely cases
that are still open.
Yes (Y)/No (N) indicator of whether the request
was denied for lack of medical necessity. Answer
NA if the request was approved. Answer No if the
request was denied because it was untimely.
Yes (Y)/No (N) indicator of review by a
physician or other appropriate health care
professional if request was denied for lack of
medical necessity. Answer NA if the request was
approved or not denied due to lack of medical
necessity.

Date of sponsor
decision

CHAR
Always
Required

Was the request
denied for lack of
medical necessity?

CHAR
Always
Required

If denied for lack of
medical necessity, was
the review completed
by a physician or other
appropriate health care
professional?

CHAR
Always
Required

Date oral notification
provided to enrollee

CHAR
Always
Required

Date oral notification provided to enrollee.
Submit in CCYY/MM/DD format (e.g.,
2015/01/01). Answer NA if no oral notification.

Date written
notification provided
to enrollee

CHAR
Always
Required

Date service
authorization
entered/effectuated in
the sponsor's system
AOR receipt date

CHAR
Always
Required

Page 19 of 53

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 NA if no AOR form
was required.

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Insert the name of the First Tier, Downstream,
and Related Entity that processed the standard
pre-service organization determination (e.g.,
Independent Physician Association, Physicians
Medical Group or Third Party Administrator).
Answer NA if not applicable.

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Table 2: Expedited Pre-service Organization Determinations (EOD) Record Layout
• Include all requests processed as expedited pre-service organization determinations, including all
supplemental services, such as dental and vision, and include all approvals and denials.
• Exclude payment requests, dismissals, reopenings, withdrawn requests and all requests processed
as standard organization 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).
• If an expedited pre-service organization determination includes more than one service include all
of the request’s line items in a single row and enter the multiple line items as a single
organization determination request.
Column
ID

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Cardholder ID

Cardholder identifier used to identify the
beneficiary. This is assigned by the sponsor.

Contract ID

The contract number (e.g., H1234) of the
organization.

Plan ID

The plan number (e.g., 001) of the organization.

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Who made the
request?

CHAR
Always
Required

The associated authorization number assigned by
the sponsor for this request. If an authorization
number is not available, please provide your
internal tracking or case number. Answer NA if
there is no authorization or other tracking number
available.
Indicate whether the pre-service request was made
by a contract provider (CP), non-contract provider
(NCP), beneficiary (B) or beneficiary’s
representative (BR).

Provider Type

CHAR
Always
Required

Date the request was
received

CHAR
Always
Required

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AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Time the request was
received

CHAR
Always
Required

Provide the time the request was received by your
organization. Submit in HH:MM:SS military time
format (e.g., 23:59:59).

Diagnosis

CHAR
Always
Required

100

Issue description and
type of service

CHAR
Always
Required

2,000

Level of service

CHAR
Always
Required

Subsequent expedited
request

CHAR
Always
Requested

Was a timeframe
extension taken?

If an extension was
taken, did the sponsor
notify the member of
the reason(s) for the
delay and of their right
to file an expedited
grievance?
Request Disposition

CHAR
Always
Required
CHAR
Always
Required

CHAR
Always
Required

Date of sponsor
decision

Page 22 of 53

CHAR
Always
Required

Note: If the request was received as a standard
organization determination request, but later
expedited, enter the time of the request to expedite
the organization determination.
Provide the enrollee diagnosis/diagnoses ICD-10
codes related to this request. If the ICD codes are
unavailable, provide a description of the diagnosis,
or for drugs provide the 11-digit National Drug
Code (NDC) as well as the ICD-10 code related to
the request.
Provide a description of the service, medical
supply or drug requested and why it was requested
(if known). For denials, also provide an
explanation of why the expedited pre-service
request was denied.
Provide the level of service requested (e.g.,
inpatient/outpatient/ER/urgent care/point of sale
transaction).
If a request was made after the organization
determination to expedite the request, indicate who
made the subsequent request to expedite the
request: contract provider (CP), non-contract
provider (NCP), beneficiary (B), beneficiary’s
representative (BR) or sponsor (S). Answer NA if
no subsequent expedited timeframe was requested.
Yes (Y)/No (N) indicator of whether the Sponsor
extended the timeframe to make the organization
determination.
Yes (Y)/No (N) indicator of whether the sponsor
notified the beneficiary of the delay. Answer NA if
no extension was taken.

Status of the request. Valid values are: approved,
or denied. Sponsors should note any requests that
are untimely and not yet resolved (still
outstanding) as denied.
All untimely and pending cases should be treated
as denials for the purposes of populating the rest of
this record layout’s fields.
Date of the sponsor decision. Submit in
CCYY/MM/DD format (e.g., 2015/01/01).
Sponsors should answer NA for untimely cases
that are still open.

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST

Column
ID

Field Name

Field Type

Field
Length

Description

Time of sponsor
decision

CHAR
Always
Required

Time of the sponsor decision (e.g., approved,
denied). Submit in HH:MM:SS military time
format (e.g., 23:59:59). Sponsors should answer
NA for untimely cases that are still open.

Was the request
denied for lack of
medical necessity?

CHAR
Always
Required

If denied for lack of
medical necessity, was
the review completed
by a physician or other
appropriate health care
professional?
Date oral notification
provided to enrollee

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the request
was denied for lack of medical necessity. Answer
NA if the request was approved. Answer No if the
request was denied because it was untimely.
Yes (Y)/No (N) indicator of review by physician or
other appropriate health care professional if the
expedited pre-service request was denied for lack
of medical necessity. Answer NA if request was
approved or not denied due to lack of medical
necessity.
Date oral notification provided to enrollee. Submit
in CCYY/MM/DD format (e.g., 2015/01/01).
Answer NA if no oral notification.

Time oral notification
provided to enrollee

CHAR
Always
Required

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.

Date written
notification provided
to enrollee

CHAR
Always
Required

Time written
notification provided
to enrollee

CHAR
Always
Required

Date service
authorization
entered/effectuated in
the sponsor's system
Time service
authorization
entered/effectuated in
the sponsor's system
AOR receipt date

CHAR
Always
Required

Time written notification provided to enrollee.
Submit in HH:MM:SS military time format (e.g.,
23:59:59). Answer NA if no written notification
was provided.
Date service authorization was entered in the
sponsor's system. Submit in CCYY/MM/DD
format (e.g., 2015/01/01). Answer NA for denials.

CHAR
Always
Required

Time service authorization entered in the sponsor's
system. Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA for denials.

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 NA if no AOR form
was required.

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Column
ID

Field Name

Field Type

Field
Length

Description

AOR receipt time

CHAR
Always
Required

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Time the Appointment of Representative (AOR)
form or other appropriate documentation received
by sponsor. Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA if no AOR
form was required.
Insert the name of the First Tier, Downstream, and
Related Entity that processed the expedited
organization determination (e.g., Independent
Physician Association, Physicians Medical Group
or Third Party Administrator). Answer NA if not
applicable.

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 3: Requests for Payment Organization Determinations (Claims) Record Layout
• Include all requests processed as both contract and non-contract provider denied claims and only
non-contract provider paid claims.
• Exclude all requests processed as direct member reimbursements, dismissals, duplicate claims
and payment adjustments to claims, reopenings, claims denied for invalid billing codes, denied
claims for beneficiaries who are not enrolled on the date of service and claims denied due to
recoupment of payment.
• Submit payment organization determinations (claims) based on the date the claim was paid, or
should have been paid, or the notification date of the denial, or the date the denial notification
should have been sent (the date the request was initiated may fall outside of the review period).
• If a claim has more than one line item, include all of the claim’s line items in a single row and
enter the multiple line items as a single claim.
Column
ID

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Cardholder ID

Cardholder identifier used to identify the
beneficiary. This is assigned by the sponsor.

Contract ID

The contract number (e.g., H1234) of the
organization.

Plan ID

The plan number (e.g., 001) of the organization.

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Provider Type

CHAR
Always
Required

Is this a clean claim?

CHAR
Always
Required

Date the request was
received

CHAR
Always
Required

Page 25 of 53

Note: the term “provider” encompasses physicians
and facilities.
Yes/No indicator flag to indicate whether the claim
is clean (Y) or unclean (N). Answer NA for
untimely requests that are still open or if clean
status has not yet been determined.
Provide the date the payment request was received
by your organization. Submit in CCYY/MM/DD
format (e.g., 2015/01/01).

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Diagnosis

CHAR
Always
Required

100

Issue description and
type of service

CHAR
Always
Required

2,000

Provide the enrollee diagnosis/diagnoses ICD-10
codes related to this request. If the ICD codes are
unavailable, provide a description of the diagnosis,
or for drugs provide the 11-digit National Drug
Code (NDC) as well as the ICD-10 code related to
the request.
Provide a description of the service, medical
supply or drug requested and why it was requested
(if known). For denials, also provide an
explanation of why the claim was denied.

Level of service

CHAR
Always
Required

Provide the level of service requested (e.g.,
inpatient/outpatient/ER/urgent care/point of sale
transaction).

Request Disposition

CHAR
Always
Required

Status of the request. Valid values are: approved,
or denied. Sponsors should note any requests that
are untimely and not yet resolved (still
outstanding) as denied.

Date the claim was
paid

CHAR
Always
Required

Was interest paid on
the claim?

Was the request
denied for lack of
medical necessity?

CHAR
Always
Required
CHAR
Always
Required

If denied for lack of
medical necessity, was
the review completed
by a physician or other
appropriate health care
professional?
Date written
notification provided
to enrollee

CHAR
Always
Required

Page 26 of 53

All untimely and pending cases should be treated
as denials for the purposes of populating the rest
of this record layout’s fields.
Date the claim was paid. Submit in
CCYY/MM/DD format (e.g., 2015/01/01).
Answer DENIED for claims that were denied.
Answer NA for untimely cases that are still open.
Yes (Y)/No (N) indicator of whether interest was
paid on the claim.
Yes (Y)/No (N) indicator of whether the request
was denied for lack of medical necessity. Answer
NA if the request was approved. Answer No if the
request was denied because it was untimely.
Yes (Y)/No (N) indicator of review by a physician
or other appropriate health care professional if
request was denied for lack of medical necessity.
Answer NA if the request was approved or not
denied due to lack of medical necessity.
Date written notification provided to enrollee. The
term “provided” means when the EOB, IDN or
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., 2015/01/01). Answer Pending if
written notification has not yet been provided, but
is anticipated to be provided in a forthcoming
EOB or IDN notice. Answer NA if no written
notification provided to the enrollee.

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Date written
notification provided
to provider

CHAR
Always
Required

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Date written notification provided to the provider.
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., 2015/01/01). Answer NA if no written
notification was provided.
Insert the name of the First Tier, Downstream, and
Related Entity that processed the claim (e.g.,
Independent Physician Association, Physicians
Medical Group or Third Party Administrator).
Answer NA if not applicable.

Page 27 of 53

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 4: Direct Member Reimbursement (DMR) Requests Record Layout
• Include all requests processed as direct member reimbursements, including approvals, denials,
partial approvals, reconsiderations and non-contract provider claim reconsiderations submitted by
beneficiaries.
• Exclude all requests processed as contract and non-contract provider claims, reopenings and
dismissals.
• Submit direct member reimbursement requests based on the date the reimbursement was issued,
or should have been issued, or the notification date of the denial, or the date the denial
notification should have been sent (the date the request was initiated may fall outside of the
review period).
• If a reimbursement request has more than one line item, include all of the request’s line items in a
single row and enter the multiple line items as a single reimbursement request.
Column
ID

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Cardholder ID

Cardholder identifier used to identify the beneficiary.
This is assigned by the sponsor.

Contract ID

The contract number (e.g., H1234) of the
organization.

Plan ID

The plan number (e.g., 001) of the organization.

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Person who made the
request

Provider Type

Date the request was
received

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Diagnosis

CHAR
Always
Required

100

Page 28 of 53

Indicate whether the provider who performed the
service is a contract provider (CP) or non-contract
provider (NCP).
Provide the date the reimbursement request was
received by your organization. Submit in
CCYY/MM/DD format (e.g., 2015/01/01).
Provide the enrollee diagnosis/diagnoses ICD-10
codes related to this request. If the ICD codes are
unavailable, provide a description of the diagnosis, or
for drugs provide the 11-digit National Drug Code
(NDC) as well as the ICD-10 code related to the
request.

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Issue description and
type of service

CHAR
Always
Required

2,000

Level of service

CHAR
Always
Required

Provide a description of the service, medical supply
or drug requested and why it was requested (if
known). For denials, also provide an explanation of
why the direct member reimbursement request was
denied.
Provide the level of service requested (e.g.,
inpatient/outpatient/ER/urgent care/point of sale
transaction).

Request Disposition

CHAR
Always
Required

Date reimbursement
paid

CHAR
Always
Required

Was interest paid on
the reimbursement
request?

CHAR
Always
Required

Date written
notification provided
to enrollee

CHAR
Always
Required

Date forwarded to IRE
if denied or untimely

CHAR
Always
Required

If request denied or
untimely, date enrollee
notified request has
been forwarded to IRE

CHAR
Always
Required

AOR receipt date

CHAR
Always
Required

Page 29 of 53

Status of the request. Valid values are: approved,
denied, denied with IRE auto forward or IRE autoforward due to untimely decision. Sponsors should
note any requests that are untimely and not yet
resolved (still outstanding) as denied.
All untimely and pending cases should be treated as
denials for the purposes of populating the rest of this
record layout’s fields.
Date the sponsor issued payment to the member or
provider. Submit in CCYY/MM/DD format (e.g.,
2015/01/01). Answer DENIED for reimbursement
requests that were denied. Sponsors should answer
NA for untimely cases that are still open.
Yes (Y)/No (N) indicator of whether interest was paid
on the reimbursement request.

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.,
2015/01/01). Answer Pending if written notification
has not yet been provided, but is anticipated to be
provided in a forthcoming EOB notice. Answer
Untimely if reimbursement request was not timely
paid or denied.
Date the sponsor forwarded request to the IRE if
request denied or untimely. Submit in
CCYY/MM/DD format (e.g., 2015/01/01). Answer
NA if approved, request was an organization
determination or not forwarded to IRE.
Date enrollee notified that request was forwarded to
the IRE due to denial or untimely decision. Submit in
CCYY/MM/DD format (e.g., 2015/01/01). Answer
NA if approved, request was an organization
determination or not forwarded to IRE.
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 NA if no AOR form was
required.

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Insert the name of the First Tier, Downstream, and
Related Entity that processed the direct member
reimbursement request (e.g., Independent Physician
Association, Physicians Medical Group or Third Party
Administrator). Answer NA if not applicable.

Page 30 of 53

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 5: Standard Pre-service Reconsiderations (SREC) Record Layout
• Include all requests processed as standard pre-service reconsiderations.
• Exclude all requests processed as expedited reconsiderations, dismissals, reopenings and
withdrawn reconsideration 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

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Cardholder ID

Cardholder identifier used to identify the beneficiary.
This is assigned by the sponsor.

Contract ID

The contract number (e.g., H1234) of the
organization.

Plan ID

The plan number (e.g., 001) of the organization.

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Who made the
request?

CHAR
Always
Required

The associated authorization number assigned by the
sponsor for this request. If an authorization number is
not available, please provide your internal tracking or
case number. Answer NA if there is no authorization
or other tracking number available.
Indicate whether the reconsideration request was
made by a contract provider (CP), non-contract
provider (NCP), beneficiary (B) or beneficiary’s
representative (BR).
Note: the term “provider” encompasses physicians
and facilities.
Indicate whether the provider performing the service
is a contract provider (CP) or non-contract provider
(NCP).

Provider Type

CHAR
Always
Required

Date the request was
received

CHAR
Always
Required

Provide the date the request was received by your
organization. Submit in CCYY/MM/DD format (e.g.,
2015/01/01).

Diagnosis

CHAR
Always
Required

100

Issue description and
type of service

CHAR
Always
Required

2,000

Provide the enrollee diagnosis/diagnoses ICD-10
codes related to this request. If the ICD codes are
unavailable, provide a description of the diagnosis, or
for drugs provide the 11-digit National Drug Code
(NDC) as well as the ICD-10 code related to the
request.
Provide a description of the service, medical supply
or drug requested and why it was requested (if
known). For denials, also provide an explanation of
why the pre-service reconsideration was denied.

Page 31 of 53

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Level of service

CHAR
Always
Required

Provide the level of service requested (e.g.,
inpatient/outpatient/ER/urgent care/point of sale
transaction).

Was request made
under the expedited
timeframe but
processed by the plan
under the standard
timeframe?
Request for expedited
timeframe

CHAR
Always
Required

CHAR
Always
Requested

Was a timeframe
extension taken?

If an extension was
taken, did the sponsor
notify the member of
the reason(s) for the
delay and of their right
to file an expedited
grievance?
Request Disposition

CHAR
Always
Required
CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the request made
under an expedited timeframe was processed under
the standard timeframe (e.g., based on the sponsor
deciding that the expedited pre-service request was
unnecessary). Answer NA if the request was received
as a standard request.
If an expedited timeframe was requested, indicate
who requested the expedited reconsideration
timeframe: non-contract provider (NCP), beneficiary
(B) or beneficiary’s representative (BR). Answer NA
if no expedited timeframe was requested. Answer BR
if a contract provider submitted an expedited
reconsideration request as the enrollee’s
representative.
Yes (Y)/No (N) indicator of whether the Sponsor
extended the timeframe to make the determination.

Yes (Y)/No (N) indicator of whether the sponsor
notified the beneficiary of the delay. Answer NA if no
extension was taken.

CHAR
Always
Required

Date of sponsor
decision

CHAR
Always
Required

Was the request
denied for lack of
medical necessity?

CHAR
Always
Required

If denied for lack of
medical necessity, was
the review completed
by a physician or other
appropriate health care
professional?

CHAR
Always
Required

Page 32 of 53

All untimely and pending cases should be treated as
denials for the purposes of populating the rest of this
record layout’s fields.
Date of the sponsor decision. Submit in
CCYY/MM/DD format (e.g., 2015/01/01).
Sponsors should answer NA for untimely cases that
are still open.
Yes (Y)/No (N) indicator of whether the request was
denied for lack of medical necessity. Answer NA if
the request was approved. Answer No if the request
was denied because it was untimely.
Yes (Y)/No (N) indicator of review by physician or
other appropriate health care professional if the
request 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 or dismissed).

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

If the request was
denied for lack of
medical necessity, was
the reconsideration
completed by a
physician other than
the person involved in
making the initial OD?
Date oral notification
provided to enrollee

CHAR
Always
Required

Yes (Y)/No (N) indicator of review by a different
physician than the original reviewer. Answer NA if
the request was not denied for lack of medical
necessity or the request was not denied (i.e.,
approved, auto-forwarded, or dismissed).

CHAR
Always
Required

Date oral notification provided to enrollee. Submit in
CCYY/MM/DD format (e.g., 2015/01/01). Answer
NA if no oral notification provided.

Date written
notification provided
to enrollee/provider

CHAR
Always
Required

Date service
authorization
entered/effectuated in
the sponsor's system
Date forwarded to IRE
if denied or untimely

CHAR
Always
Required

Date written notification provided to enrollee, or if
applicable the non-contract provider. The term
“provided” means when the letter left the sponsor’s
establishment by US Mail, fax, or electronic
communication. Do not enter the date when a letter is
generated or printed within the sponsor’s
organization. Submit in CCYY/MM/DD format (e.g.,
2015/01/01). Answer NA if no written notification
was provided.
Date authorization entered in the sponsor's system.
Submit in CCYY/MM/DD format (e.g., 2015/01/01).
Answer NA for denials and IRE auto-forwards.

CHAR
Always
Required

If request denied or
untimely, date enrollee
notified request has
been forwarded to IRE
AOR receipt date

CHAR
Always
Required

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Page 33 of 53

Date the sponsor forwarded request to the IRE if
request denied or untimely. Submit in
CCYY/MM/DD format (e.g., 2015/01/01). Answer
NA if approved or not forwarded to IRE.
Date enrollee notified that request was forwarded to
the IRE due to denial or untimely decision. Submit in
CCYY/MM/DD format (e.g., 2015/01/01). Answer
NA if approved or not forwarded to IRE.
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 NA if no AOR form was
required.
Insert the name of the First Tier, Downstream, and
Related Entity that processed the standard pre-service
reconsideration (e.g., Independent Physician
Association, Physicians Medical Group or Third Party
Administrator). Answer NA if not applicable.

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 6: Expedited Pre-service Reconsiderations (EREC) Record Layout
• Include all requests processed as expedited pre-service reconsiderations.
• Exclude all requests processed as standard reconsiderations, dismissals, reopenings and
withdrawn reconsideration 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

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Cardholder ID

Cardholder identifier used to identify the beneficiary.
This is assigned by the sponsor.

Contract ID

The contract number (e.g., H1234) of the
organization.

Plan ID

The plan number (e.g., 001) of the organization.

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Who made the
request?

CHAR
Always
Required

Provider Type

CHAR
Always
Required

Date the request was
received

CHAR
Always
Required

Time the request was
received

CHAR
Always
Required

Note: the term “provider” encompasses physicians
and facilities.
Indicate whether the provider performing the service
is a contract provider (CP) or non-contract provider
(NCP).
Provide the date the request was received by your
organization. Submit in CCYY/MM/DD format (e.g.,
2015/01/01).
Note: If the request was received as a standard
reconsideration request, but later expedited, enter the
date of the request to expedite the reconsideration.
Provide the time the request was received by your
organization. Submit in HH:MM:SS military time
format (e.g., 23:59:59).
Note: If the request was received as a standard
reconsideration request, but later expedited, enter the
time of the request to expedite the reconsideration.

Page 34 of 53

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Diagnosis

CHAR
Always
Required

100

Issue description and
type of service

CHAR
Always
Required

2,000

Level of service

CHAR
Always
Required

Provide the enrollee diagnosis/diagnoses ICD-10
codes related to this request. If the ICD codes are
unavailable, provide a description of the diagnosis, or
for drugs provide the 11-digit National Drug Code
(NDC) as well as the ICD-10 code related to the
request.
Provide a description of the service, medical supply
or drug requested and why it was requested (if
known). For denials, also provide an explanation of
why the expedited pre-service reconsideration was
denied.
Provide the level of service requested (e.g.,
inpatient/outpatient/ER/urgent care/point of sale
transaction).

Request for expedited
timeframe

CHAR
Always
Requested

Was a timeframe
extension taken?

If an extension was
taken, did the sponsor
notify the member of
the reason(s) for the
delay and of their right
to file an expedited
grievance?
Request Disposition

CHAR
Always
Required
CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the sponsor
notified the beneficiary of the delay. Answer NA if no
extension was taken.

CHAR
Always
Required

Date of sponsor
decision

CHAR
Always
Required

Time of sponsor
decision

CHAR
Always
Required

Page 35 of 53

If an expedited timeframe was requested, indicate
who requested the expedited reconsideration
timeframe: contract provider (CP), non-contract
provider (NCP), beneficiary (B), beneficiary’s
representative (BR) or sponsor (S). Answer BR if a
contract provider submitted the expedited
reconsideration request on behalf of an enrollee.
Yes (Y)/No (N) indicator of whether the Sponsor
extended the timeframe to make the determination.

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Was the request
denied for lack of
medical necessity?

CHAR
Always
Required

If denied for lack of
medical necessity, was
the review completed
by a physician or other
appropriate health care
professional?
If the request was
denied for lack of
medical necessity, was
the reconsideration
completed by a
physician other than
the person involved in
making the initial OD?
Date oral notification
provided to enrollee

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the request was
denied for lack of medical necessity. Answer NA if
the request was approved. Answer No if the request
was denied because it was untimely.
Yes (Y)/No (N) indicator of review by physician or
other appropriate health care professional if the
request 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 or dismissed).
Yes (Y)/No (N) indicator of review by a different
physician than the original reviewer. Answer NA if
the request was not denied for lack of medical
necessity or the request was not denied (i.e.,
approved, auto-forwarded, or dismissed).

CHAR
Always
Required

Date oral notification provided to enrollee. Submit in
CCYY/MM/DD format (e.g., 2015/01/01). Answer
NA if no oral notification was provided.

Time oral notification
provided to enrollee

CHAR
Always
Required

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.

Date written
notification provided
to enrollee

CHAR
Always
Required

Time written
notification provided
to enrollee

CHAR
Always
Required

Date service
authorization
entered/effectuated in
the sponsor's system
Time service
authorization
entered/effectuated in
the sponsor's system
Date forwarded to IRE
if denied or untimely

CHAR
Always
Required

Page 36 of 53

Date authorization entered/effectuated in the sponsor's
system. Submit in CCYY/MM/DD format (e.g.,
2015/01/01). Answer NA for denials and IRE autoforwards.
Time authorization entered/effectuated in the
sponsor's system. Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA for denials and
IRE auto-forwards.
Date the sponsor forwarded request to the IRE if
request denied or untimely. Submit in
CCYY/MM/DD format (e.g., 2015/01/01). Answer
NA if the request was approved.

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

CHAR
Always
Required

If request denied or
untimely, date enrollee
notified request has
been forwarded to IRE
AOR receipt date

CHAR
Always
Required

AOR receipt time

CHAR
Always
Required

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Date enrollee notified that request was forwarded to
the IRE due to denial or untimely decision. Submit in
CCYY/MM/DD format (e.g., 2015/01/01). Answer
NA if the request was approved.
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 NA if no AOR form was
required.
Time the Appointment of Representative (AOR)
form or other appropriate documentation received by
sponsor. Submit in HH:MM:SS military time format
(e.g., 23:59:59). Answer NA if no AOR form was
required.
Insert the name of the First Tier, Downstream, and
Related Entity that processed the expedited preservice reconsideration (e.g., Independent Physician
Association, Physicians Medical Group or Third Party
Administrator). Answer NA if not applicable.

Page 37 of 53

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 7: Requests for Payment Reconsiderations (PREC) Record Layout
• Include all requests processed as payment reconsiderations from non-contract providers.
• Exclude all requests processed as direct member reimbursements and direct member
reimbursement reconsideration requests, dismissals, reopenings, duplicate reconsideration
requests and payment adjustments to reconsideration requests, reopenings, reconsideration
requests denied for invalid billing codes, denied reconsideration requests for beneficiaries who
are not enrolled on the date of service and reconsideration requests denied due to recoupment of
payment.
• Submit payment reconsiderations based on the date the reconsideration was paid or denied, or
should have been paid or denied (the date the request was initiated may fall outside of the review
period).
• If a reconsideration request has more than one line item, include all of the request’s line items in a
single row and enter the multiple line items as a single request.
Column
ID

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Cardholder ID

Cardholder identifier used to identify the beneficiary.
This is assigned by the sponsor.

Contract ID

The contract number (e.g., H1234) of the
organization.

Plan ID

The plan number (e.g., 001) of the organization.

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Date the request was
received

CHAR
Always
Required

Diagnosis

CHAR
Always
Required

100

Issue description and
type of service

CHAR
Always
Required

2,000

Page 38 of 53

Provide the enrollee diagnosis/diagnoses ICD-10
codes related to this request. If the ICD codes are
unavailable, provide a description of the diagnosis, or
for drugs provide the 11-digit National Drug Code
(NDC) as well as the ICD-10 code related to the
request.
Provide a description of the service, medical supply
or drug requested and why it was requested (if
known). For denials, also provide an explanation of
why the claim reconsideration was denied.

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Level of service

Request Disposition

CHAR
Always
Required
CHAR
Always
Required

Provide the level of service requested (e.g.,
inpatient/outpatient/ER/urgent care/point of sale
transaction).
Status of the request. Valid values are: approved,
denied, denied with IRE auto forward or IRE autoforward due to untimely decision. Sponsors should
note any requests that are untimely and not yet
resolved (still outstanding) as denied.

Date the
reconsideration
request was paid or
denied

CHAR
Always
Required

Was interest paid on
the reconsideration
request?
Was the request
denied for lack of
medical necessity?

CHAR
Always
Required
CHAR
Always
Required

If denied for lack of
medical necessity, was
the review completed
by a physician or other
appropriate health care
professional?
Date written
notification provided
to provider

CHAR
Always
Required

Date forwarded to IRE
if denied or untimely

CHAR
Always
Required

WOL Receipt date

CHAR
Always
Required

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Page 39 of 53

All untimely and pending cases should be treated as
denials for the purposes of populating the rest of this
record layout’s fields.
Date the reconsideration request was paid or the date
the denied claim was upheld, which may be the IRE
auto-forward date. Submit in CCYY/MM/DD format
(e.g., 2015/01/01). Sponsors should answer NA for
untimely cases that are still open.
Yes (Y)/No (N) indicator of whether interest was paid
on the reconsideration request.
Yes (Y)/No (N) indicator of whether the request was
denied for lack of medical necessity. Answer NA if
the request was approved. Answer No if the request
was denied because it was untimely.
Yes (Y)/No (N) indicator of review by a physician or
other appropriate health care professional if the
request was denied for lack of medical necessity.
Answer NA if the reconsideration was approved or
not denied due to lack of medical necessity.
Date notification provided to the provider. 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.,
2015/01/01). Answer NA if no notification provided
or sent to provider.
Date the sponsor forwarded request to the IRE if
request denied or untimely. Submit in
CCYY/MM/DD format (e.g., 2015/01/01). Answer
NA if reconsideration was approved.
Date the Waiver of Liability (WOL) form received by
the sponsor. Submit in CCYY/MM/DD format (e.g.,
2015/01/01). Answer NA if no WOL form was
required.
Insert the name of the First Tier, Downstream, and
Related Entity that processed the payment
reconsideration (e.g., Independent Physician
Association, Physicians Medical Group or Third Party
Administrator). Answer NA if not applicable.

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 8: Pre-service IRE Cases Requiring Effectuation (IREEFF) Record Layout
• Include all requests processed as pre-service cases overturned by the IRE, including standard and
expedited cases (i.e., a favorable decision was rendered by the IRE).
• Exclude all requests processed as dismissals, requests for payment and unfavorable requests
where the IRE upheld the denial.
• Submit cases based on the date of receipt of the IRE overturn decision (the date the request was
initiated may fall outside of the review period).
Column
ID

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Cardholder ID

Cardholder identifier used to identify the beneficiary.
This is assigned by the sponsor.

Contract ID

The contract number (e.g., H1234) of the
organization.

Plan ID

The plan number (e.g., 001) of the organization.

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Diagnosis

CHAR
Always
Required

100

Issue description and
type of service

CHAR
Always
Required

2,000

The associated authorization number assigned by the
sponsor for this request. If an authorization number is
not available, please provide your internal tracking or
case number. Answer NA if there is no authorization
or other tracking number available.
Provide the enrollee diagnosis/diagnoses ICD-10
codes related to this request. If the ICD codes are
unavailable, provide a description of the diagnosis, or
for drugs provide the 11-digit National Drug Code
(NDC) as well as the ICD-10 code related to the
request.
Provide a description of the service, medical supply
or drug requested and why it was requested (if
known). For denials, also provide an explanation of
why the request was denied before going to the IRE.

Level of service

Request for expedited
timeframe

Date of receipt of IRE
decision

CHAR
Always
Required
CHAR
Always
Requested
CHAR
Always
Required

Page 40 of 53

Provide the level of service requested (e.g.,
inpatient/outpatient/ER/urgent care/point of sale
transaction).
Indicate whether the pre-service request was
processed under the expedited (E) timeframe or
standard (S) timeframe.
Date the sponsor received the IRE overturn decision.
Submit in CCYY/MM/DD format (e.g., 2015/01/01).

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Time of receipt of IRE
decision

CHAR
Always
Required

Provide the time the sponsor received the IRE
overturn decision. Submit in HH:MM:SS military
time format (e.g., 23:59:59). Answer NA if the
request was not expedited.

Date service
authorization
entered/effectuated in
the sponsor's system
Time service
authorization
entered/effectuated in
the sponsor's system
Date written
notification provided
to IRE

CHAR
Always
Required

Date the IRE determination was effectuated in the
sponsor's system. Submit in CCYY/MM/DD format
(e.g., 2015/01/01).

CHAR
Always
Required

Time effectuated in the sponsor's system. Submit in
HH:MM:SS military time format (e.g., 23:59:59).
Answer NA if the request was not expedited.

CHAR
Always
Required

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Date written notification of sponsor’s effectuation
sent to IRE. 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., 2015/01/01).
Insert the name of the First Tier, Downstream, and
Related Entity that processed the effectuation (e.g.,
Independent Physician Association, Physicians
Medical Group or Third Party Administrator).
Answer NA if not applicable.

Page 41 of 53

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 9: IRE Payment Cases Requiring Effectuation (IREClaimsEFF) Record Layout
• Include all requests overturned by the IRE that were processed as non-contract provider payment
or direct member reimbursement requests (i.e., a favorable decision was rendered by the IRE).
• Exclude all requests processed as dismissals, pre-service requests and unfavorable requests where
the IRE upheld the denial.
• Submit cases based on the date of receipt of the IRE overturn decision (the date the request was
initiated may fall outside of the review period).
Column
ID

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Cardholder ID

Cardholder identifier used to identify the
beneficiary. This is assigned by the sponsor.

Contract ID

The contract number (e.g., H1234) of the
organization.

Plan ID

The plan number (e.g., 001) of the organization.

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Diagnosis

CHAR
Always
Required

100

Issue description and
type of service

CHAR
Always
Required

2,000

Level of service

CHAR
Always
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 number available.
Provide the enrollee diagnosis/diagnoses ICD-10
codes related to this request. If the ICD codes are
unavailable, provide a description of the diagnosis,
or for drugs provide the 11-digit National Drug Code
(NDC) as well as the ICD-10 code related to the
request.
Provide a description of the service, medical supply
or drug requested and why it was requested (if
known). For denials, also provide an explanation of
why the request was denied before going to the IRE.
Provide the level of service requested (e.g.,
inpatient/outpatient/ER/urgent care/point of sale
transaction).

Was interest paid on
the claim or
reimbursement
request?
Date of receipt of IRE
decision

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether interest was
paid on the claim or reimbursement request.

CHAR
Always
Required

Date the sponsor received the IRE overturn decision.
Submit in CCYY/MM/DD format (e.g.,
2015/01/01).

Page 42 of 53

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Date service
authorization
entered/effectuated in
the sponsor's system
Date written
notification provided
to IRE

CHAR
Always
Required

Date the IRE overturn decision was effectuated in
the sponsor's system. Submit in CCYY/MM/DD
format (e.g., 2015/01/01).

CHAR
Always
Required

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Page 43 of 53

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 10: All Part C ALJ and MAC Cases Requiring Effectuation (ALJMACEFF) Record Layout
• Include all requests processed as overturned by the ALJ or MAC, including standard and
expedited cases, both pre-service and payment (i.e., a favorable decision was rendered by the ALJ
or MAC).
• Exclude all requests processed as dismissals and unfavorable requests where the ALJ or MAC
upheld the denial.
• Submit cases based on the date of receipt of the ALJ or MAC overturn decision (the date the
request was initiated may fall outside of the review period).
Column
ID

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Cardholder ID

Cardholder identifier used to identify the
beneficiary. This is assigned by the sponsor.

Contract ID

The contract number (e.g., H1234) of the
organization.

Plan ID

The plan number (e.g., 001) of the organization.

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Diagnosis

CHAR
Always
Required

100

Issue description and
type of service

CHAR
Always
Required

2,000

Level of service

Request for expedited
timeframe

CHAR
Always
Required
CHAR
Always
Requested

The associated authorization, claim or payment
request number assigned by the sponsor for this
request. If an authorization, claim or payment
request number is not available, please provide your
internal tracking or case number. Answer NA if
there is no authorization, claim, payment request or
other tracking number available.
Provide the enrollee diagnosis/diagnoses ICD-10
codes related to this request. If the ICD codes are
unavailable, provide a description of the diagnosis,
or for drugs provide the 11-digit National Drug Code
(NDC) as well as the ICD-10 code related to the
request.
Provide a description of the service, medical supply
or drug requested and why it was requested (if
known). For denials, also provide an explanation of
why the request was denied before going to the
ALJ/MAC.
Provide the level of service requested (e.g.,
inpatient/outpatient/ER/urgent care/point of sale
transaction).
Indicate whether the pre-service request was
processed under the expedited (E) timeframe or
standard (S) timeframe. Answer NA for payment
requests.

Page 44 of 53

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Was interest paid on
the claim or
reimbursement
request?

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether interest was
paid on the claim or reimbursement request. Answer
NA if a pre-service request.

Date of receipt of
ALJ/MAC decision

CHAR
Always
Required

Date the sponsor received the ALJ/MAC overturn
decision. Submit in CCYY/MM/DD format (e.g.,
2015/01/01).

Did sponsor appeal
ALJ decision to
MAC?

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the sponsor
appealed the ALJ decision to the MAC.

Date written
notification provided
to enrollee

CHAR
Always
Required

Date service
authorization
entered/effectuated in
the sponsor's system

CHAR
Always
Required

If sponsor appealed the ALJ’s decision to the MAC,
provide the 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
when a letter is generated or printed within the
sponsor’s organization. Submit in CCYY/MM/DD
format (e.g., 2015/01/01). Answer NA if the ALJ’s
decision was not appealed to the MAC.
Date the ALJ/MAC overturn decision was
effectuated in the sponsor's system. Submit in
CCYY/MM/DD format (e.g., 2015/01/01).

Date written
notification provided
to IRE

CHAR
Always
Required

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Page 45 of 53

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 11: Part C Oral & Written Standard Grievances (GRV_S) Record Layout
• Include all requests processed as standard oral and written grievances.
• Exclude all requests processed as expedited oral and written grievances, dismissals and CTM
complaints.
• Submit cases based on the date the resolution notification was issued or the date the resolution
notification should have been issued (the date the grievance was received may fall outside of the
review period).
Column
ID
A

Field Name

Field Type

Field
Length
50

Description

Beneficiary First
Name

Beneficiary Last
Name

Cardholder ID

Contract ID

Plan ID

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Last name of the beneficiary.

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.

Person who made the
request

CHAR
Always
Required

Indicate whether the grievance was submitted by a
beneficiary (B) or a beneficiary’s representative
(BR).

Date
Grievance/Complaint
was Received

CHAR
Always
Required

How was the
grievance/complaint
received?

CHAR
Always
Required

Date the grievance/complaint was received from the
beneficiary or their authorized representative.
Submit in CCYY/MM/DD format (e.g.,
2015/01/01).
Describe how the grievance/complaint was first
received from the beneficiary or authorized
representative. Valid values include: Oral or Written.

Category of the
grievance/complaint

CHAR
Always
Required

Grievance/complaint
Description

1,800

Was this a quality of
care grievance?

CHAR
Always
Required
CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the grievance
was a quality of care grievance.

Was a timeframe
extension taken?

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the Sponsor
extended the timeframe to respond to the
grievance/complaint.

Page 46 of 53

First name of the beneficiary.

Category of the grievance/complaint. At a minimum
categories must include each of the following:
Enrollment/Disenrollment, Benefit Package, Access,
Marketing, Customer Service, Organization
Determination and Reconsideration Process, Quality
of Care, Grievances Related to “CMS” Issues, and
Other.
Provide a description of the grievance/complaint
issue.

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST

Column
ID
M

Field Name

Field Type

Field
Length
2

Description

If an extension was
taken, did the sponsor
notify the member of
the reason(s) for the
delay?
If the extension was
taken because the
sponsor needed more
information, did the
notice include how the
delay was in the best
interest of the
enrollee?
Date oral notification
of resolution provided
to enrollee

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the sponsor
notified the beneficiary of how the extension of the
timeframe was in the interest of the beneficiary.
Answer NA if an extension was not taken.

CHAR
Always
Required

Date written
notification of
resolution provided to
enrollee

CHAR
Always
Required

Resolution Description

CHAR
Always
Required

1,800

Date oral notification of resolution provided to
enrollee. Submit in CCYY/MM/DD format (e.g.,
2015/01/01). Answer NA if no oral notification was
provided to the 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., 2015/01/01). Answer NA if no written
notification was provided to the enrollee.
Provide a full description of the grievance
resolution.

AOR receipt date

CHAR
Always
Required

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Page 47 of 53

Yes (Y)/No (N) indicator of whether the sponsor
notified the beneficiary of the delay. Answer NA if
an extension was not taken.

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 NA if no AOR form was
required.
Insert the name of the First Tier, Downstream, and
Related Entity that processed the
grievance/complaint (e.g., Independent Physician
Association, Physicians Medical Group or Third
Party Administrator). Answer NA if not applicable.

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 12: Part C Oral & Written Expedited Grievances (GRV_E) Record Layout
• Include all requests processed as expedited oral and written grievances.
• Exclude all requests processed as standard oral and written grievances, dismissals and CTM
complaints.
• Submit cases based on the date the resolution notification was issued or the date the resolution
notification should have been issued (the date the grievance was received may fall outside of the
review period).
Column
ID
A

Field Name

Field Type

Beneficiary First
Name

Beneficiary Last
Name

Cardholder ID

Contract ID

Plan ID

Person who made the
request

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Date
Grievance/Complaint
was Received

Field
Length
50

Description

Last name of the beneficiary.

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 grievance was submitted by a
beneficiary (B) or a beneficiary’s representative
(BR).

CHAR
Always
Required

Time
Grievance/Complaint
was Received

CHAR
Always
Required

How was the
grievance/complaint
received?
Category of the
grievance/complaint

CHAR
Always
Required
CHAR
Always
Required

Grievance/complaint
Description

CHAR
Always
Required

1,800

Date the grievance/complaint was received from the
beneficiary or their authorized representative.
Submit in CCYY/MM/DD format (e.g.,
2015/01/01).
Provide the time the grievance/complaint was
received from the beneficiary or their authorized
representative. Time is in HH:MM:SS military time
format (e.g., 23:59:59).
Describe how the grievance/complaint was first
received from the beneficiary or authorized
representative. Valid values include: Oral or Written.
Category of the grievance/complaint. Indicate
whether the expedited grievance was submitted by
the enrollee because the plan declined to process a
case on the expedited timeframe (ETD) or whether it
was submitted due to the enrollee’s dissatisfaction
with the plan taking a processing timeframe
extension (PTE).
Provide a description of the grievance/complaint
issue.

Page 48 of 53

First name of the beneficiary.

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
L

Field Name

Field Type

Date oral notification
of resolution provided
to enrollee

CHAR
Always
Required

Time oral notification
of resolution provided
to enrollee

CHAR
Always
Required

Date written
notification of
resolution provided to
enrollee

CHAR
Always
Required

Time written
notification of
resolution provided to
enrollee
Resolution Description

CHAR
Always
Required

1,800

AOR receipt date

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 NA if no AOR form was
required.

AOR receipt time

CHAR
Always
Required

Time the Appointment of Representative (AOR)
Form or other appropriate documentation received
by sponsor. Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA if no AOR form
was required.

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Insert the name of the First Tier, Downstream, and
Related Entity that processed the
grievance/complaint (e.g., Independent Physician
Association, Physicians Medical Group or Third
Party Administrator). Answer NA if not applicable.

Page 49 of 53

Field
Length
10

Description
Date oral notification of resolution provided to
enrollee. Submit in CCYY/MM/DD format (e.g.,
2015/01/01). Answer NA if no oral notification
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
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.,
2015/01/01). Answer NA if no written notification
was provided to enrollee.
Time written notification provided to enrollee.
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.

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 13: Dismissals Record Layout
• Include all requests processed as sponsor dismissals.
• Submit cases based on the dismissal date (the date the request was initiated may fall outside of
the review period), or based on the date the IRE requested information from the plan for a case
that was appealed to the IRE after it was dismissed by the plan.
Column
ID
A

Field Name

Field Type

Beneficiary First
Name

Beneficiary Last
Name

Cardholder ID

Contract ID

Plan ID

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Who made the
request?

CHAR
Always
Required

Type of Request

CHAR
Always
Required

Provider Type

CHAR
Always
Required

Date the request was
received

CHAR
Always
Required

Page 50 of 53

Field
Length
50

Description

Last name of the beneficiary.

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.

The associated authorization number assigned by the
sponsor for this request. If an authorization number
is not available, please provide your internal tracking
or case number. Answer NA if there is no
authorization or other tracking number available.
Indicate whether the request was made by a contract
provider (CP), non-contract provider (NCP),
beneficiary (B) or beneficiary’s representative (BR).

First name of the beneficiary.

Identify the type of request that was dismissed. Valid
values are: grievance, pre-service organization
determination, pre-service reconsideration, noncontract provider claim, direct member
reimbursement request, non-contract provider
payment reconsideration, or DMR reconsideration.
Indicate whether the provider who has or will be
performing the service is a contract provider (CP) or
non-contract provider (NCP). Answer NA for
grievances that do not involve providers or if a
request was dismissed before it was possible to
determine whether the provider was contract or noncontract provider.
Provide the date the request was received by your
organization. Submit in CCYY/MM/DD format (e.g.,
2015/01/01).

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
K

Field Name

Field Type

Field
Length
300

Description

Description of the
Issue

CHAR
Always
Required

Is this an expedited or
standard request?

CHAR
Always
Required

Answer E if request was an expedited request or S if
a request was a standard request.

Was a timeframe
extension taken?

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the sponsor
extended the timeframe before dismissing the
request.

Date the request was
dismissed

CHAR
Always
Required

Provide the date the request was dismissed by your
organization. Submit in CCYY/MM/DD format (e.g.,
2015/01/01).

Reason for Dismissal

CHAR
Always
Required

300

Provide a description of why the request was
dismissed.

Provide a description of the service requested, and
why it was requested (if known).

Valid values include, but are not limited to:
• No AOR form
• No WOL
• Untimely filing
Provide the date the dismissal notice was sent to the
enrollee or provider. 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., 2015/01/01).
Yes (Y) / No (N) indicator of whether the dismissal
was appealed to the IRE.

Date written
notification provided
to enrollee/provider

CHAR
Always
Required

Appealed to IRE?

CHAR
Always
Required

Date forwarded to IRE

CHAR
Always
Required

Provide the date the case file was forwarded to the
IRE. Submit in CCYY/MM/DD format (e.g.,
2015/01/01). Answer “NA” if the case was not
appealed to the IRE.

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Insert the name of the First Tier, Downstream, and
Related Entity that processed the dismissal (e.g.,
Independent Physician Association, Physicians
Medical Group or Third Party Administrator).
Answer NA if not applicable.

Page 51 of 53

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 14: Call Logs Part C (CLC) 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 calls received by your organization (or delegated entity) that relate to your Medicare
Part C line of business and are from beneficiaries or their representatives (i.e., calls to your
customer service line).
Exclude any calls not relating to your Part C business (e.g., Medicare Part D, commercial)
Submit calls by the date the call was received by either your organization or another entity based
on the following criteria:
o Plans with <50,000 enrollees: The review period for this universe will be the 4-week
period preceding, and including, the date of the audit engagement letter.
o Plans with >50,000 but <250,000 enrollees: The review period for this universe will be
the 3-week period preceding, and including, the date of the audit engagement letter.
o Plans with >250,000 enrollees: The review period for this universe will be the 2-week
period preceding, and including, the date of the audit engagement letter.

Column
ID

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Cardholder ID

Cardholder identifier used to identify the beneficiary.
This is assigned by the plan.

Contract ID

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Optional

The contract number (e.g., H1234) of the
organization.

Plan ID

CHAR
Optional

The plan number (e.g., 001) of the organization.

Date the call was
received

CHAR
Always
Required

Provide the date the call was received from the
beneficiary or their authorized representative. Submit
in CCYY/MM/DD format (e.g., 2015/01/01).

Time the call was
received

CHAR
Always
Required

Provide the 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).

Category of the call

CHAR
Optional

Provide a general category of the call issue(s) (e.g.,
inquiry, benefit dispute, enrollment, or service
question).

Description of the call

1,800

Provide a full description of the nature of the
incoming call.

Description of the
outcome of the call

CHAR
Always
Required
CHAR
Always
Required

1,800

Provide a full description of the call outcome and any
resolution. This should include whether a subsequent
action was started (OD, reconsideration or grievance)

Page 52 of 53

v. 10-2016

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST

Column
ID

Field Name

Field Type

Field
Length

Description

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Insert the name of the First Tier, Downstream,
and Related Entity that processed the dismissal
(e.g., Independent Physician Association,
Physicians Medical Group or Third Party
Administrator). Answer NA if not applicable.

Page 53 of 53

v. 10-2016

File Type	application/pdf
File Title	Attachment IV ODAG Audit Process and Data Request
Subject	ODAG, Audit Protocols, Program Audits
Author	NICHOLAS PROY
File Modified	2016-12-06
File Created	2016-10-05