Cms-10191 Snp-moc Audit Process And Data Request

Special Needs Plan
Model of Care (SNPMOC)
Program Area
AUDIT PROCESS AND DATA REQUEST

Expires: TBD

Special Needs Plan Model of Care (SNP-MOC)
AUDIT PROCESS AND DATA REQUEST

Table of Contents
Audit Purpose and General Guidelines .................................................................................................. 3
Universe Preparation & Submission ...................................................................................................... 5
Sample Selection .................................................................................................................................... 7
Audit Elements ....................................................................................................................................... 8
I. Population to be Served – Enrollment Verification ....................................................................... 8
II. Care Coordination ........................................................................................................................ 10
III. Plan Performance Monitoring and Evaluation of the MOC...................................................... 13
Appendix .............................................................................................................................................. 15
Appendix A – Special Needs Plan Model of Care (SNP MOC) Record Layouts ............................ 15
Table 1: Special Needs Plan Enrollees (SNPE) Record Layout ................................................... 15
Table 2: Plan Performance Monitoring and Evaluation (PPME) Record Layout ........................ 19

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Audit Purpose and General Guidelines
1. Purpose: To evaluate sponsor implementation and performance in the three areas outlined in this
protocol related to Special Needs Plan (SNP) model of care (MOC). The Centers for Medicare &
Medicaid Services (CMS) will perform its audit activities using these instructions (unless
otherwise noted).
2. Review Period: The review period for SNPs that have been operational for at least a year, will be
the (13) thirteen month period preceding and including the date of the audit engagement letter (for
example, for an engagement letter sent on January 25, 2017, the universe review period would be
December 1, 2015 through January 25, 2017) CMS reserves the right to expand the universe
request as needed. Sponsors that have operated for more than one year, but have a new/updated
MOC that has been implemented for less than a year, will be assessed using the previous MOC.
3. Responding to Documentation Requests: The sponsor is expected to present its supporting
documentation during the audit and take screen shots or otherwise upload the supporting
documentation, as requested, to the secure site using the designated naming convention and
within the timeframe specified by the CMS Audit Team.
4. Sponsor Disclosed Issues: Sponsors will be asked to provide a list of all disclosed issues of noncompliance that are relevant to the program areas being audited and may be detected during the
audit. A disclosed issue is one that has been reported to CMS prior to the receipt of the audit start
notice (which is also known as the “engagement letter”). Issues identified by CMS through ongoing monitoring or other account management/oversight activities during the plan year are not
considered disclosed.
Sponsors must provide a description of each disclosed issue as well as the status of correction and
remediation using the Pre-Audit Issue Summary template. This template is due within 5 business
days after the receipt of the audit start notice. The sponsor’s Account Manager will review the
summary to validate that “disclosed” issues were known to CMS prior to receipt of the audit start
notice.
When CMS determines that a disclosed issue was promptly identified, corrected (or is actively
undergoing correction), and the risk to beneficiaries has been mitigated, CMS will not apply the
ICAR condition classification to that condition.
5. Impact Analysis (IA): An impact analysis must be submitted as requested by CMS. The impact
analysis must identify all beneficiaries subjected to or impacted by the issue of non-compliance.
Sponsors will have up to 10 business days to complete the requested impact analysis templates.
CMS may validate the accuracy of the impact analysis submission(s). In the event an impact
analysis cannot be produced, CMS will report that the scope of non-compliance could not be fully
measured and impacted an unknown number of beneficiaries across all contracts audited.
6. Calculation of Score: CMS will determine if each condition cited is an Observation (0 points),
Corrective Action Required (CAR) (1 point) or an Immediate Corrective Action Required (ICAR)

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(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 SNP MOC audit score. Some elements and
program areas may not apply to certain sponsors and therefore will not be considered when
calculating program area and overall audit scores. Observations will be recorded in the draft and
final reports, but will not be scored and therefore will not be included in the program area and
audit scores.
7. Informing Sponsor of Results: CMS will provide daily updates regarding conditions discovered
that day (unless the case has been pended for further review. CMS will provide a preliminary
summary of its findings at the exit conference. The CMS Audit team will do its best to be as
transparent and timely as possible in its communication of audit findings. Sponsors will also
receive a draft audit report which they may formally comment on and then a final report will be
issued after consideration of a sponsor’s comments on the draft.

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Universe Preparation & Submission
1. Responding to Universe Requests: The sponsor is expected to provide accurate and timely
universe submissions within 15 business days of the engagement letter date. CMS may request a
revised universe if data issues are identified. The resubmission request may occur before and/or
after the entrance conference depending on when the issue was identified. Sponsors will have a
maximum of 3 attempts to provide complete and accurate universes, whether these attempts all
occur prior to the entrance conference or they include submissions prior to and after the entrance
conference. However, 3 attempts may not always be feasible depending on when the data issues
are identified and the potential for impact to the audit schedule. When multiple attempts are
made, CMS will only use the last universe submitted.
If the sponsor fails to provide accurate and timely universe submissions twice, CMS will
document this as an observation in the sponsor’s program audit report. After the third failed
attempt, or when the sponsor determines after fewer attempts that they are unable to provide an
accurate universe within the timeframe specified during the audit, the sponsor will be cited an
Invalid Data Submission (IDS) condition relative to each element that cannot be tested, grouped
by the type of case.
2. Pull Universes and Submit Background Information: The universes collected for this
program area tests the sponsor’s performance in processing enrollments, care coordination, and
plan performance monitoring and evaluation of the MOC.
The sponsor will provide a universe consisting of all SNP beneficiaries who have been enrolled in
any of the sponsoring organization’s SNPs, with no breaks in enrollment (i.e. continuously
enrolled) for a period of at least 13 months as of the engagement letter date. Members may have
switched from one SNP plan to another so long as they did not experience a break in enrollment.
The sponsor will also submit quality measurement and performance improvement metrics utilized
by your organization to monitor and evaluate the effectiveness of the MOC. All applicable fields
of the plan performance monitoring and evaluation record layout should be completed; a separate
record layout should be submitted for each unique MOC. Sponsors may opt to submit one
workbook with a separate tab for each unique MOC.
The universes should be compiled using the appropriate SNP-MOC record layout as described in
Appendix A. These record layouts include:
•
•

Special Needs Plan Enrollees (PE) Record Layout (Table 1)
Plan Performance Monitoring and Evaluation (PPME) Record Layout (Table 2)

NOTE: For SNPE, the sponsor should include all cases that match the description for that
universe for all applicable SNP contracts and PBPs in its organization as identified in the audit
engagement letter (i.e., for all beneficiaries enrolled in your organization’ SNPs during the
review period).
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The sponsor will provide the following background information documentation that is
applicable to the audit timeframe:
•
•
•
•
•

•
•
•

Copies of all approved Models of Care (MOC) and any (red-lined) updates to the original
submissions
Copies of the CMS-approved Health Risk Assessment Tool(s) (HRA) used by the SNP
Copies of any pre-enrollment eligibility verification tools for C-SNPs & I-SNPs
Copies of policies and procedures related to enrollment and eligibility verification
Copies of policies and procedures for administration of the Health Risk Assessment Tool,
the development of the Individual Care Plan, the composition and functions of the
Interdisciplinary Care Team, and the coordination of members’ transitioning across care
settings
Copies of policies and procedures on the monitoring and evaluation of the MOC
Copies of performance monitoring/evaluation report(s) submitted to MOC/quality oversight
staff and/or Board
Listing of FDRs that assist with the MOC and their functions/deliverables

This documentation will have the same submission deadline as the universe. The auditors will
conduct a desk review of these materials prior to the audit start date to gain an understanding of
the criteria and protocols the organization’s SNPs implement. The background information to be
submitted may have been implemented outside of the audit period, but must be in effect during
the audit period.
There will be no pass or fail determinations made based on the review of these documents prior to
the audit.
3. Submit Universes to CMS: Sponsors should submit each universe in a Microsoft Excel (.xlsx)
or Comma Separated Values (.csv) file format with a header row following the record layouts
shown in Appendix A, Tables 1 and 2. The sponsor should submit its universes in whole and not
separately for each contract and PBP. The sponsor should submit all background information and
additional documentation with its universes.

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Sample Selection
1. Select Sample Cases: CMS will select a sample of 30 beneficiaries from the sponsor-submitted
universe as follows:
•
•
•

% selected = % of D-SNP beneficiaries
% selected = % of I-SNP beneficiaries
% selected = % of C-SNP beneficiaries

CMS will sample proportionally, with a minimum of 5 as applicable, for each existing SNP
type represented in the universe to obtain a total sample size of 30. The same sample will be
evaluated for the first two elements of the audit (referenced in the purpose section). The sample
selection will be provided to the sponsor by the close of business on the Thursday before the
Monday of the audit week.

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Audit Elements
I. Population to be Served – Enrollment Verification
1. Review Sample Case Documentation: CMS will sample all case file documentation to
determine correct processing of SNP enrollments and involuntary disenrollments. Enrollment
documentation should be uploaded by sponsor to HPMS by the end of the Entrance Conference.
For each case, the sponsor must produce all relevant documentation during the live audit webinar
including, but not limited to:
1.1. For All Beneficiaries:
•
Documentation of the length of the period of deemed continued eligibility (e.g.,
language used to describe the grace period in the EOC).
•
Screen print of enrollment effective date shown in sponsor’s internal system(s) and key
to interpreting the screen print.
•
Documentation of receipt of the enrollment request (by whichever medium the
enrollment is received, e.g., paper, telephonic, online).
•
Documentation showing sponsor’s verification of SNP eligibility prior to submission of
the enrollment to CMS.
•
Documentation of the completed enrollment request.
1.2. C-SNP Plan beneficiaries:
•
Treating provider verification that the enrollee has the qualifying condition.
•
The date(s) on which the verification was received.
•
The tool used to document eligibility.
1.3. For I-SNP Plan beneficiaries:
•
Confirmation that the individual requires an institutional (skilled nursing facility (SNF),
nursing facility (NF), intermediate care facility for the mentally retarded (ICF/MR) or
inpatient psychiatric facility) level-of-care and that the need for an institutional level-ofcare has lasted 90 days or longer.
•
If the institutional SNP opts to enroll special needs individuals prior to a 90 day lengthof-stay, the needs-assessment (pre-approved by CMS) must show that the individual’s
condition makes it likely that the length-of-stay (or need for an institutional level-ofcare) will be at least 90 days.
•
If the I-SNP elects to enroll community based beneficiaries into the I-SNP, the State
approved Level of Care Assessment administered by a third party will be required.
1.4. For D-SNP beneficiaries:
• Documentation of both Medicare and Medicaid eligibility prior to enrollment.
• Documentation of beneficiary attestation of eligibility for the election period submitted
by the sponsor.
• Documentation showing sponsor’s ongoing verification of SNP eligibility.

2. 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 SNP MOC requirements not being met.
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2.1. All Special Needs Plans (SNPs):
2.1.1. Was the appropriate eligibility verification completed?
2.2. D-SNPs and I-SNPs:
2.2.1. Is there evidence of re-verification of eligibility, when required?
3. Sample Case Results: CMS will test each of the 30 cases. If there is lack of evidence that the
sponsor is implementing its MOC and 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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II. Care Coordination
1. Review Sample Case Documentation: CMS will sample all case file documentation for
sponsors implementation of care coordination in relation to its MOC in the following areas:
Health Risk Assessments (HRAs) administration; Individual Care Plans (ICPs) appropriateness
and implementation; Interdisciplinary Care Team (ICT) appropriateness, development and
implementation of enrollee’s ICPs; and coordination of members transitions across care settings.
For each case, the sponsor must produce all relevant documentation during the live audit webinar
including, but not limited to:
•
•
•

•
•
•

Completed beneficiary Health Risk Assessment(s)
Copy of the beneficiary’s Individualized Care Plan (ICP).
Care and case management documentation associated with the ICP (including claims,
encounters and Prescription Drug Events) submitted for the beneficiary since the last HRA
was completed. Specific documentation will be selected by the audit team based on the
content of the ICP.
Membership in the ICT with evidence of appropriate credentials
Information of sponsor’s process to confirm MOC training for network providers and ICT
members.
Evidence that sponsor confirmation has occurred for MOC training of network providers and
ICT members.

2. 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 SNP-MOC requirements not being met.
2.1. Health Risk Assessment:
2.1.1. Did the sponsor conduct an initial HRA?
2.1.2. Did the sponsor conduct the initial HRA either 90 days before or after the
enrollment effective date?
2.1.3. Did the completed HRA include a comprehensive initial assessment and
reassessment(s) of the needs of the beneficiary including, for example, the medical,
psychosocial, cognitive, functional, and mental health needs?
2.1.4. Did the Sponsor conduct the annual HRA within 1 year of the initial assessment/1
year of the previous HRA?

2.2. Individual Care Plan:
2.2.1. Did the sponsor complete the individualized care plan (ICP) according to its
MOC?
2.2.2. Did the sponsor develop a comprehensive ICP designed to address needs
identified in the HRA, consistent with the MOC?

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2.2.3. Did the ICP include measurable outcomes in accordance with the MOC?
2.2.4. Was the ICP reviewed/revised based on the beneficiary’s health condition and in
accordance with the SNP’s most recently approved MOC?
2.2.5. Did the sponsor provide documentation to verify the implementation of the ICP,
such as proof of claims and/or documentation of social services provided?
2.2.6. Did the sponsor facilitate beneficiary and/or caregiver participation when
developing the beneficiary’s ICP?
2.2.7. For the ICP, did the sponsor coordinate communication among sponsor’s
personnel, providers, and beneficiaries?

2.3. Interdisciplinary Care Team:
2.3.1. Does documentation demonstrate that member care was managed by an
interdisciplinary care team (ICT) comprised of appropriate clinical disciplines
according to the SNP’s approved MOC?
2.4. Care Transitions:
2.4.1. Did the sponsor plan & implement care transition protocols to maintain
member’s continuity of care as defined in the MOC?
2.5. Administrative Processes & Training/Credentialing:
2.5.1. Did the personnel who reviewed, analyzed and stratified the HRA possess
appropriate professional knowledge and credentials, as defined in the MOC?
2.5.2. Does the sponsor utilize a contracted vendor that administers the HRA? If so,
does the vendor have Policies and Procedures that match the MOC goals and
comply with CMS requirements?
2.5.3. Did the personnel who reviewed the ICP possess professional knowledge and
credentials, as defined in the MOC?
2.5.4. Did all members of the sponsor’s staff that serve on the ICT receive training on
the MOC? Does the sponsor have documentation of this training?
2.5.5. Did the sponsor provide evidence of conducting outreach, training to educate
network providers about the MOC?

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3. Sample Case Results: CMS will test each of the 30 cases. If there is lack of evidence that the
sponsor is implementing its MOC and 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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III.

Plan Performance Monitoring and Evaluation of the MOC

1. Review Documentation: CMS will review all documentation for appropriateness of the
sponsor’s monitoring and evaluation of their MOC. The sponsor must produce all relevant
documentation during the live audit webinar including, but not limited to:
•
•
•
•
•
•
•
•
•

Sponsor’s methodology for collecting, analyzing, reporting and evaluating their MOC’s
performance.
Information regarding the personnel having responsibility for overseeing the MOC’s
monitoring and evaluation.
Evidence of data collection/results of internal analysis/evaluation, including reports
generated based on findings from internal analysis (i.e., progress toward goals/objectives,
areas for improvement, etc.).
Corrective Action Plans developed and implemented as a result of internal analysis and the
results of the CAPs, if applicable.
Copy of the most recent evaluation of the MOC.
Communication to stakeholders regarding results of monitoring or improvements to the
MOC.
Board Meeting minutes showing approval of the QI work plan and MOC, CAPs
performance outcomes
MOC versions: Updated and approved by CMS
QI/PI Meeting minutes for the audit period, CAP, Performance progress/Outcomes

NOTE: This evidence will vary by plan based on the provisions of the sponsor’s approved MOC.
The evidence to be obtained will be more specific after CMS has completed the desk review of
the background information that was submitted with the universe.
2. Apply Compliance Standard: At a minimum, CMS will evaluate the MOC against the
following criteria. CMS may review factors not specifically addressed in these questions if it is
determined that there are other related SNP MOC requirements not being met.
2.1. Did the sponsor collect, analyze, and evaluate the MOC (e.g., specific data sources,
specific performance and outcome measures, etc.)?
2.2. Did the sponsor use the analyzed results of performance measures to improve the MOC
(e.g., internal committee and other structured mechanism)?
2.3. When necessary, did the sponsor develop and implement corrective actions?
2.4. Did the sponsor show evidence of communicating performance monitoring results and
improvements to stakeholders and/or leadership, in accordance with the MOC?
2.5. Are the appropriate personnel responsible for oversight of the MOC’s evaluation and
monitoring process?
2.6. Does the sponsor’s Organizational chart properly reflect the personnel administering
the MOC program and their reporting structure?

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3. Model of Care Review Results: CMS will review documentation of MOC monitoring and
evaluations conducted by the sponsor utilizing metrics identified in the MOC. If there is lack of
evidence that the sponsor is implementing its MOC and if CMS requirements are not met,
conditions (findings) are cited. If CMS requirements are met, no conditions (findings) are cited.

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Appendix
Appendix A – Special Needs Plan Model of Care (SNP MOC) Record Layouts
The universes for the Special Needs Plan Model of Care (SNP MOC) program area must be
submitted as a Microsoft Excel (.xlsx) or Comma Separated Values (.csv) file with 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.
NOTE: There is a maximum of 4000 characters per record row. Therefore, should additional
characters be needed for a response, enter this information on the next record at the appropriate start
position.
Table 1: Special Needs Plan Enrollees (SNPE) Record Layout

Column
ID
A

Field Name

Field Type

Beneficiary First Name

B

Beneficiary Last Name

C

First Tier, Downstream, and
Related Entity

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

D

Cardholder ID

E

Contract ID

F

Plan ID

G

Plan Type

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

Field
Length
50

Description

50

Last name of the beneficiary.

70

First Tier, Downstream, and Related
Entity assigned to the beneficiary (e.g.,
Independent Physician Association,
Physicians Medical Group or Third
Party Administrator, any/all third
party, downstream, or related
organizations that the Sponsor
contracts with in order to implement
and/or manage the Model of Care).

20

5

First name of the beneficiary.

Enter NA if not applicable
Cardholder identifier used to identify
the beneficiary. This is assigned by
the plan.
The contract number (e.g., H1234) of
the organization.

3

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

10

Type of SNP. Valid values are:
• D-SNP (for dual-eligible
beneficiaries)
• C-SNP (for beneficiaries in a
chronic needs plan)
• I-SNP (for beneficiaries in an
institutional care setting)

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Column
ID
H

Field Name

Field Type

Enrollment Mechanism

CHAR
Always
Required

Field
Length
10

I

Date sponsor received
completed enrollment
request

CHAR
Always
Required

10

J

Enrollment Effective Date

CHAR
Always
Required

10

K

Was an initial HRA
completed 90 days before or
after the enrollment effective
date?

CHAR
Always
Required

3

Description
Enrollment mechanism for the
beneficiary. Enter one of the
following descriptions: Paper,
Electronic, Telephonic, Passive or
Seamless.
Only enter “Seamless” if the
beneficiary was already enrolled in
other health plans offered by Sponsor,
such as commercial or Medicaid plans,
and was seamlessly enrolled into the
Medicare plan.
Date a completed enrollment request
was received by the sponsor. Submit
in CCYY/MM/DD format (e.g.,
2013/01/01).
Effective date of enrollment for the
beneficiary. Submit in
CCYY/MM/DD format (e.g.,
2013/01/01).
Beneficiaries should receive a Health
Risk Assessment (HRA) within 90
days (before or after) their effective
date of enrollment. (Yes/No)
Enter Yes if the sponsor completed an
initial HRA within 90 days before or
after the member's effective date of
enrollment.

L

Date initial HRA was
completed?

CHAR
Always
Required

10

M

Did the sponsor conduct a
HRA during the current
audit period?

CHAR
Always
Required

3

N

Date of completion for HRA
conducted during current
audit period

CHAR
Always
Required

10

Enter No if the member did not have
an initial HRA within 90 days before
or after his/her effective date of
enrollment.
Date of the beneficiary’s first HRA
after enrolling. Submit in
CCYY/MM/DD format (e.g.,
2013/01/01).
Enter NA if no HRA was completed
Enter Yes if the sponsor completed
an HRA within the 13-month audit
period.
Enter No if the beneficiary did not
have an HRA completed within the
audit period.
Submit in CCYY/MM/DD format
(e.g., 2013/01/01).
If no HRA was conducted during
current audit period, please enter NA.

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Column
ID
O

Field Name

Field Type

Date of previous
HRA/reassessment?

CHAR
Always
Required

Field
Length
10

Description
Submit in CCYY/MM/format
(e.g. 2016/01/01)
If previous HRA/reassessment was not
conducted please enter NA

P

Was an ICP completed?

CHAR
Always
Required

3

Enter Yes if the beneficiary received a
comprehensive, Individualized Care
Plan (ICP).
Enter No if the beneficiary did not
receive an ICP.
Enter the total dollar amount for all
paid claims with dates of service
during the audit review period (e.g.,
$430,265). This field is not to be
populated with the number of claims.
Sponsors should exclude data related
to the types of claims cited; duplicate
claims and payment adjustments to
claims, claims that are denied for
invalid billing codes, billing errors,
denied claims for bundled or not
separately payable items, denied
claims for beneficiaries who are not
enrolled on the date of service and
claims denied due to recoupment of
payment.

Q

Cumulative Dollar Amount
of Parts C and D Claims
Paid

CHAR
Always
Required
(Currency)

30

R

Cumulative Dollar Amount
of Parts C and D Claims
Denied

CHAR
Always
Required
(Currency)

30

Enter the total dollar amount for all
denied claims with dates of service
during the audit review period (e.g.,
$99,782). This field is not to be
populated with the number of claims.
Sponsors should exclude data related
to the types of claims cited; duplicate
claims and payment adjustments to
claims, claims that are denied for
invalid billing codes, billing errors,
denied claims for bundled or not
separately payable items, denied
claims for beneficiaries who are not
enrolled on the date of service and
claims denied due to recoupment of
payment.

S

Cumulative # of Parts C and
D Claims Paid

CHAR
Always
Required

20

Enter the number of all paid claims
with dates of service during the audit
review period (e.g., 10,000). This field
is not to be populated with a dollar
amount. Sponsors should exclude data
related to the types of claims cited;
duplicate claims and payment

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Column
ID

Field Name

Field Type

Field
Length

Description
adjustments to claims, claims that are
denied for invalid billing codes, billing
errors, denied claims for bundled or
not separately payable items, denied
claims for beneficiaries who are not
enrolled on the date of service and
claims denied due to recoupment of
payment.

T

Cumulative # of Parts C and
D Claims Denied

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CHAR
Always
Required

20

Enter the number of all denied claims
with dates of service during the audit
review period (e.g., 2,000). This field
is not to be populated with a dollar
amount. Sponsors should exclude data
related to the types of claims cited;
duplicate claims and payment
adjustments to claims, claims that are
denied for invalid billing codes, billing
errors, denied claims for bundled or
not separately payable items, denied
claims for beneficiaries who are not
enrolled on the date of service and
claims denied due to recoupment of
payment.

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Table 2: Plan Performance Monitoring and Evaluation (PPME) Record Layout
• Submit one universe for each unique Model of Care administered.
Column
ID
A

Field Name

Field Type

Metric

CHAR
Always
Required

Field
Length
250

B

What is the duration of the
baseline period?

CHAR
Always
Required

30

C

Baseline Period Start Date

CHAR
Always
Required

10

D

Baseline Period End Date

CHAR
Always
Required

10

E

Baseline Result

CHAR
Always
Required

10

F

Target Goal

CHAR
Always
Required

10

G

Data Source

CHAR
Always
Required

250

Description
Sponsor should identify the goal,
objective or metric being measured.
Example:
Improving access to preventive health
services— Increase the percentage of
members vaccinated annually against
seasonal influenza.
Sponsor should enter the number of
months used to establish the baseline
performance against which future
performance is assessed (e.g., 4
months, 12 months, etc.).
Sponsor should indicate the start date
for the baseline period used to
establish the baseline performance
against which future performance is
assessed.
Submit in CCYY/MM/DD format
(e.g., 2013/01/01).
Sponsor should indicate the end date
of the baseline period used to
establish the baseline performance
against which future performance is
assessed.
Submit in CCYY/MM/DD format
(e.g., 2013/03/31).
Sponsors should enter the baseline
result value (e.g., percentage 66.6%,
ratio 33:50, etc.).
Enter NA if no baseline information
was collected/available.
Sponsor should enter the target goal
value (e.g., percentage 95%, ratio
49:50, etc.).

Sponsor should indicate data source
for the measurements (goals,
objectives, and metrics) reported in
the baseline rate and target rate
columns.
Example: Claims data, HPMS,
CAHPS, HEDIS

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Special Needs Plan Model of Care (SNP-MOC)
AUDIT PROCESS AND DATA REQUEST

Column
ID
H

Field Name

Field Type

How often is performance
assessed (after the baseline
period)?

CHAR
Always
Required

I

Measurement Period 1 Start
Date

CHAR
Always
Required

Field
Length
30

Description

10

Sponsor will report data for the 2
most recently conducted data
measurement/ assessments.

Indicate how often performance is
assessed after the baseline period
(e.g., monthly, quarterly, yearly).

Enter the start date of the 1st
measurement period. Submit in
CCYY/MM/DD format (e.g.,
2014/03/31).
Example: if the 1st of the 2 most
recent measurement periods began on
January 1, 2014, then enter
2014/01/01.

J

Measurement Period 1 End
Date

CHAR
Always
Required

10

If no measurement was conducted
enter NA.
Enter the end date of the 1st
measurement period. Submit in
CCYYMMDD format (e.g.,
2014/03/31).
Example: if the 1st of the 2 most
recent measurement periods ended on
March 31, 2014, then enter
2014/03/31.

K

L

Measurement Period 1 Result

Goal Met/Not Met

CHAR
Always
Required

CHAR
Always
Required

10

If no measurement was conducted
enter NA.
Sponsor should enter the value of the
result for measurement period 1 (e.g.,
percentage 70.6%, ratio 29:50.)

3

If no measurement was conducted
enter NA.
Determination of whether the target
value was met after the 1st
measurement period. (Yes/No)
Enter Yes if the goal was met.
Enter No if the goal was not met.
Enter NA if no information was
collected/available.

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Special Needs Plan Model of Care (SNP-MOC)
AUDIT PROCESS AND DATA REQUEST

Column
ID
M

Field Name

Field Type

Corrective Action Plan
(CAP)

CHAR
Always
Required

Field
Length
3

Description
Indicate whether a Corrective Action
Plan (CAP) was developed when
sponsor goals were not met (Yes, No,
NA).
Enter Yes if a CAP was developed
when the sponsor’s goal was not met.
Enter No if a CAP was not developed
when the sponsor’s goal was not met.

N

Measurement Period 2 Start
Date

CHAR
Always
Required

10

Enter NA if the goal was met (no
CAP necessary).
Sponsor will report data for the 2
most recently conducted data
measurement/ assessments.
Enter the start date of the 2nd
measurement period. Submit in
CCYY/MM/DD format (e.g.,
2014/04/01).
Example: if the 2nd of the 2 most
recent measurement periods began on
April 1, 2014, then enter 2014/04/01.

O

Measurement Period 2 End
Date

CHAR
Always
Required

10

If no measurement was conducted
enter NA.
Enter the end date of the 2nd
measurement period. Submit in
CCYY/MM/DD format (e.g.,
2014/06/30).
Example: if the 2nd of the 2 most
recent measurement periods ended on
June 30, 2014, then enter 2014/06/30.

P

Measurement Period 2 Result

CHAR
Always
Required

10

If no measurement was conducted
enter NA.
Sponsor should enter the value of the
result for measurement period 1 (e.g.,
percentage 86.6%, ratio 42:50).
If no measurement was conducted
enter NA.

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Special Needs Plan Model of Care (SNP-MOC)
AUDIT PROCESS AND DATA REQUEST

Column
ID
Q

Field Name

Field Type

Goal Met/Not Met

CHAR
Always
Required

Field
Length
3

Description
Determination of whether the target
value was met after the 2nd
measurement period. (Yes/No)
Enter Yes if the goal was met.
Enter No if the goal was not met.
Enter NA if no information was
collected/available.

R

Corrective Action Plan
(CAP)

CHAR
Always
Required

3

Indicate whether a Corrective Action
Plan (CAP) was developed when
sponsor goals were not met (Yes, No,
NA).
Enter Yes if a CAP was developed
when the sponsor’s goal was not met.
Enter No if a CAP was not developed
when the sponsor’s goal was not met.
Enter NA if the goal was met (no
CAP necessary).

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