Medicare Part C and Part D Data Validation (42 CFR 422.516(g) and 423.514(g))

DR-v1.1

Organization Determinations/Reconsiderations (Part C) 2017

Organization Name:
Contract Number:
Reporting Section:

Organization Determinations/Reconsiderations (Part C) 2017

Last Updated:

MM/DD/YYYY

Date of Site Visit:
Last name, First name

Name of Peer Reviewer:

Last name, First name

Standard/
Sub-standard
ID

Re
po
rti
n
Cr g Se
ite ct
ria ion
ID

Name of Reviewer:

1) In the "Data Sources and Review Results:" column, enter the review results and/or data sources
used for each standard or sub-standard.
2) Enter "Y" if the requirements for the standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met, enter "N". If any standard or substandard does not apply, enter "N/A".
3) For standards 1c, 1d, 1e, 1g, 1h, and 2e, enter 'Findings' as follows based on the five-point scale:
Select "1" if plan data has more than 20% error, select "2" if plan data has between 15.1% - 20.0%
error, select "3" if plan data has between 10.1% - 15.0% error, select "4" if plan data has between
5.1% - 10.0% error, select "5" if plan data has less than or equal to a 5% error. Enter "N/A" if standard
does not apply.

Data Sources and Review Results:
Enter review results and/or data sources

Standard/Sub-standard Description

A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans,
saved data queries, file layouts, process flows) indicates that all source documents accurately
capture required data fields and are properly documented.

Data Sources:

1.a

Source documents are properly secured so that source documents can be retrieved at any time
to validate the information submitted to CMS via CMS systems.

Review Results:

1.b

Source documents create all required data fields for reporting requirements.

Review Results:

1.c

Source documents are error-free (e.g., programming code and spreadsheet formulas have no
messages or warnings indicating errors, use correct fields, have appropriate data selection, etc.).

Review Results:

1.d

All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID,
rather than Field1 and maintain the same field name across data sets).

Review Results:

1.e

Data file locations are referenced correctly.

Review Results:

1.f

If used, macros are properly documented.

Review Results:

1.g

Source documents are clearly and adequately documented.

Review Results:

1.h

Titles and footnotes on reports and tables are accurate.

Review Results:

1

Enter 'Findings' using
the applicable choice
in the appropriate
cells. Cells marked with
an '*' should not be
edited.
*

1.i

Version control of source documents is appropriately applied.

Review Results:

2

A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans,
saved data queries, file layouts, process flows) and census or sample data, whichever is
applicable, indicates that data elements for each reporting section are accurately identified,
processed, and calculated.

Data Sources:

The appropriate date range(s) for the reporting period(s) is captured.

Review Results:

2.a

RSC-1

*

Organization reports data based on the periods of 1/1 through 3/31, 4/1 through 6/30, 7/1
through 9/30, and 10/1 through 12/31.

2.b

RSC-2

Data are assigned at the applicable level (e.g., plan benefit package or contract level).

Review Results:

Organization properly assigns data to the applicable CMS contract.

2.c

RSC-3

Review Results:

Appropriate deadlines are met for reporting data (e.g., quarterly).
Organization meets deadlines for reporting data to CMS by 2/26/2018.
[Note to reviewer: If the organization has, for any reason, re-submitted its data to CMS for this
reporting section, the reviewer should verify that the organization’s original data submissions
met the CMS deadline in order to have a finding of “yes” for this reporting section criterion.
However, if the organization re-submits data for any reason and if the re-submission was
completed by 3/31 of the data validation year, the reviewer should use the organization’s
corrected data submission(s) for the rest of the reporting section criteria for this reporting
section.]
Terms used are properly defined per CMS regulations, guidance and Reporting Requirements
Technical Specifications.

Data Sources:

2.d

RSC-4

2.d

RSC-4.a

Organization properly defines the term “Organization Determinations” in
accordance with 42 C.F.R Part 422, Subpart M and the Medicare
Managed Care Manual Chapter 13, Section 10. This includes applying all
relevant guidance properly when performing its calculations and
categorizations.

Review Results:

2.d

RSC-4.b

Organization properly defines the term “Reconsideration” in accordance
with 42 C.F.R. Part 422, Subpart M and the Medicare Managed Care
Manual Chapter 13, Sections 10 and 70. This includes applying all
relevant guidance properly when performing its calculations and
categorizations.

Review Results:

2.e

RSC-5

Organization data passes data integrity checks listed below:

Data Sources:

2.e

RSC-5.a

RSC-5.a: The number of organization determinations processed timely
(Data Element 6.2) does not exceed the total number of organization
determinations (Data Element 6.1). [Data Element 6.2]

Data Element 6.2

Review Results:

2.e

RSC-5.b

RSC-5.b: The total number of organization determinations (Data Element
6.1) is equal to sum of organization determinations by outcome (Data
Element 6.3 + Data Element 6.4 + Data Element 6.5 + Data Element 6.6 +
Data Element 6.7 + Data Element 6.8).

Data Elements 6.1,
6.3, 6.4, 6.5, 6.6, 6.7,
6.8

Review Results:

*

*

2.e

RSC-5.c

RSC-5.c: Number of reconsiderations processed timely (Data Element
6.12) does not exceed total number of reconsiderations (Data Element
6.11).
[Data Element 6.12]

Data Element 6.12

Review Results:

2.e

RSC-5.d

RSC-5.d: The total number of reconsiderations (Data Element 6.11) is
equal to sum of reconsiderations by outcome (Data Element 6.13 + Data
Element 6.14 + Data Element 6.15 + Data Element 6.16 + Data Element
6.17 + Data Element 6.18).

Data Elements 6.11,
6.13, 6.14, 6.15, 6.16,
6.17, 6.18

Review Results:

2.e

RSC-5.e

RSC-5.e: The total number of reopened decisions (Data Element 6.21) is
equal to the number of records reported in the data file with a
disposition of reopened. [Data Element 6.21]

Data Element 6.21

Review Results:

2.e

RSC-5.f

RSC-5.f: The date each case was reopened (Data Element 6.31) is after
the date of its original disposition (Data Element 6.26). [Data Element
6.31]

Data Element 6.31

Review Results:

2.e

RSC-5.g

RSC-5.g: The date of disposition for each reopening (Data Element 6.34)
is after the date of the original disposition (Data Element 6.26). [Data
Element 6.34]

Data Element 6.34

Review Results:

2.e

RSC-5.h

RSC-5.h: The date of disposition for each reopening (Data Element 6.34)
is after the date the case was reopened (Data Element 6.31). [Data
Element 6.34]

Data Element 6.34

Review Results:

2.e

RSC-5.i

RSC-5.i: The date of disposition for each reopening (Data Element 6.34) is
within the reporting quarter.
[Data Element 6.34]

Data Element 6.34

Review Results:

2.e

RSC-5.j

RSC-5.j: Verify that there is a valid value submitted for date of original
disposition as MM/DD/YYYY format (Data Element 6.26). [Data Element
6.26]

Data Element 6.26

Review Results:

2.e

RSC-5.k

RSC-5.k: Verify that there is a valid value submitted for case level
(Organization Determination or Reconsideration) (Data Element 6.25).
[Data Element 6.25]

Data Element 6.25

Review Results:

2.e

RSC-5.l

RSC-5.l: Verify that there is a valid value submitted for reopening
disposition (Fully Favorable; Partially Favorable, Adverse or Pending
(Data Element 6.35).
[Data Element 6.35]

Data Element 6.35

Review Results:

2.e

RSC-5.m

If the organization received a CMS outlier/data integrity notice validate
whether or not an internal procedure change was warranted or
resubmission through HPMS.

Data Elements 6.16.21, 6.25, 6.26, 6.27,
6.34, 6.35

Review Results:

2.e

RSC-6

The number of expected counts (e.g., number of members, claims, grievances, procedures) are
verified; ranges of data fields are verified; all calculations (e.g., derived data fields) are verified;
missing data have been properly addressed; reporting output matches corresponding source
documents (e.g., programming code, saved queries, analysis plans); version control of reported
data elements is appropriately applied; QA checks/thresholds are applied to detect outlier or
erroneous data prior to data submission.

Data Sources:

RSC-6: Organization accurately calculates the total number of organization determinations,
including the following criteria:
[Data Elements 6.1-6.8]
2.e

RSC-6.a

RSC-6.a: Includes all completed organization determinations (Part C only) Data Element 6.1
with a date of member notification of the final decision that occurs
during the reporting period, regardless of when the request for
organization determination was received.
[Data Elements 6.1-6.8]

Review Results:

2.e

RSC-6.a

Data Element 6.2

Review Results:

2.e

RSC-6.a

Data Element 6.3

Review Results:

2.e

RSC-6.a

Data Element 6.4

Review Results:

2.e

RSC-6.a

Data Element 6.5

Review Results:

2.e

RSC-6.a

Data Element 6.6

Review Results:

2.e

RSC-6.a

Data Element 6.7

Review Results:

2.e

RSC-6.a

Data Element 6.8

Review Results:

2.e

RSC-6.b

Data Element 6.1

Review Results:

2.e

RSC-6.b

Data Element 6.2

Review Results:

RSC-6.b: Includes adjudicated claims with a date of adjudication that
occurs during the reporting period.
[Data Elements 6.1-6.8]

*

2.e

RSC-6.b

Data Element 6.3

Review Results:

2.e

RSC-6.b

Data Element 6.4

Review Results:

2.e

RSC-6.b

Data Element 6.5

Review Results:

2.e

RSC-6.b

Data Element 6.6

Review Results:

2.e

RSC-6.b

Data Element 6.7

Review Results:

2.e

RSC-6.b

Data Element 6.8

Review Results:

2.e

RSC-6.c

Data Element 6.1

Review Results:

2.e

RSC-6.c

Data Element 6.2

Review Results:

2.e

RSC-6.c

Data Element 6.3

Review Results:

2.e

RSC-6.c

Data Element 6.4

Review Results:

2.e

RSC-6.c

Data Element 6.5

Review Results:

RSC-6.c: Includes all claims submitted for payment including those that
pass through the adjudication system that may not require
determination by the staff of the organization or its delegated entity.
[Data Elements 6.1-6.8]

2.e

RSC-6.c

Data Element 6.6

Review Results:

2.e

RSC-6.c

Data Element 6.7

Review Results:

2.e

RSC-6.c

Data Element 6.8

Review Results:

2.e

RSC-6.d

Data Element 6.1

Review Results:

2.e

RSC-6.d

Data Element 6.2

Review Results:

2.e

RSC-6.d

Data Element 6.3

Review Results:

2.e

RSC-6.d

Data Element 6.4

Review Results:

2.e

RSC-6.d

Data Element 6.5

Review Results:

2.e

RSC-6.d

Data Element 6.6

Review Results:

2.e

RSC-6.d

Data Element 6.7

Review Results:

2.e

RSC-6.d

Data Element 6.8

Review Results:

RSC-6.d: Includes decisions made on behalf of the organization by a
delegated entity.
[Data Elements 6.1-6.8]

2.e

RSC-6.e

RSC-6.e: Includes organization determinations that are filed directly with Data Element 6.1
the organization or its delegated entities (e.g., excludes all organization
determinations that are only forwarded to the organization from the
CMS Complaint Tracking Module (CTM) and not filed directly with the
organization or delegated entity). If a member requests an organization
determination directly with the organization and files an identical
complaint via the CTM, the organization includes only the organization
determination that was filed directly with the organization and excludes
the identical CTM complaint.
[Data Elements 6.1-6.8]

Review Results:

2.e

RSC-6.e

Data Element 6.2

Review Results:

2.e

RSC-6.e

Data Element 6.3

Review Results:

2.e

RSC-6.e

Data Element 6.4

Review Results:

2.e

RSC-6.e

Data Element 6.5

Review Results:

2.e

RSC-6.e

Data Element 6.6

Review Results:

2.e

RSC-6.e

Data Element 6.7

Review Results:

2.e

RSC-6.e

Data Element 6.8

Review Results:

2.e

RSC-6.f

Data Element 6.1

Review Results:

2.e

RSC-6.f

Data Element 6.2

Review Results:

2.e

RSC-6.f

Data Element 6.3

Review Results:

RSC-6.f: Includes all methods of organization determination request
receipt (e.g., telephone, letter, fax, in-person).
[Data Elements 6.1-6.8]

2.e

RSC-6.f

Data Element 6.4

Review Results:

2.e

RSC-6.f

Data Element 6.5

Review Results:

2.e

RSC-6.f

Data Element 6.6

Review Results:

2.e

RSC-6.f

Data Element 6.7

Review Results:

2.e

RSC-6.f

Data Element 6.8

Review Results:

2.e

RSC-6.g

RSC-6.g: Includes all organization determinations regardless of who filed Data Element 6.1
the request.
[Data Elements 6.1-6.8]

Review Results:

2.e

RSC-6.g

Data Element 6.2

Review Results:

2.e

RSC-6.g

Data Element 6.3

Review Results:

2.e

RSC-6.g

Data Element 6.4

Review Results:

2.e

RSC-6.g

Data Element 6.5

Review Results:

2.e

RSC-6.g

Data Element 6.6

Review Results:

2.e

RSC-6.g

Data Element 6.7

Review Results:

2.e

RSC-6.g

Data Element 6.8

Review Results:

2.e

RSC-6.h

RSC-6.h: Includes supplemental benefits (i.e., non- Medicare covered
Data Element 6.1
item or service) provided as a part of a plan’s Medicare benefit package.
[Data Elements 6.1-6.8]

Review Results:

2.e

RSC-6.h

Data Element 6.2

Review Results:

2.e

RSC-6.h

Data Element 6.3

Review Results:

2.e

RSC-6.h

Data Element 6.4

Review Results:

2.e

RSC-6.h

Data Element 6.5

Review Results:

2.e

RSC-6.h

Data Element 6.6

Review Results:

2.e

RSC-6.h

Data Element 6.7

Review Results:

2.e

RSC-6.h

Data Element 6.8

Review Results:

2.e

RSC-6.i

Data Element 6.1

Review Results:

RSC-6.i: Excludes dismissals and withdrawals.
[Data Elements 6.1-6.8]

2.e

RSC-6.i

Data Element 6.2

Review Results:

2.e

RSC-6.i

Data Element 6.3

Review Results:

2.e

RSC-6.i

Data Element 6.4

Review Results:

2.e

RSC-6.i

Data Element 6.5

Review Results:

2.e

RSC-6.i

Data Element 6.6

Review Results:

2.e

RSC-6.i

Data Element 6.7

Review Results:

2.e

RSC-6.i

Data Element 6.8

Review Results:

2.e

RSC-6.j

Data Element 6.1

Review Results:

2.e

RSC-6.j

Data Element 6.2

Review Results:

2.e

RSC-6.j

Data Element 6.3

Review Results:

2.e

RSC-6.j

Data Element 6.4

Review Results:

RSC-6.j: Excludes Independent Review Entity Decisions.
[Data Elements 6.1-6.8]

2.e

RSC-6.j

Data Element 6.5

Review Results:

2.e

RSC-6.j

Data Element 6.6

Review Results:

2.e

RSC-6.j

Data Element 6.7

Review Results:

2.e

RSC-6.j

Data Element 6.8

Review Results:

2.e

RSC-6.k

Data Element 6.1

Review Results:

2.e

RSC-6.k

Data Element 6.2

Review Results:

2.e

RSC-6.k

Data Element 6.3

Review Results:

2.e

RSC-6.k

Data Element 6.4

Review Results:

2.e

RSC-6.k

Data Element 6.5

Review Results:

2.e

RSC-6.k

Data Element 6.6

Review Results:

2.e

RSC-6.k

Data Element 6.7

Review Results:

RSC-6.k: Excludes Quality Improvement Organization (QIO) reviews of a
member’s request to continue Medicare-covered services (e.g., a SNF
stay).
[Data Elements 6.1-6.8]

Data Element 6.8

Review Results:

Data Element 6.1

Review Results:

RSC-6.l

Data Element 6.2

Review Results:

2.e

RSC-6.l

Data Element 6.3

Review Results:

2.e

RSC-6.l

Data Element 6.4

Review Results:

2.e

RSC-6.l

Data Element 6.5

Review Results:

2.e

RSC-6.l

Data Element 6.6

Review Results:

2.e

RSC-6.l

Data Element 6.7

Review Results:

2.e

RSC-6.l

Data Element 6.8

Review Results:

2.e

RSC-6.m

RSC-6.m: Excludes payment requests returned to a provider/supplier in Data Element 6.1
which a substantive decision (fully favorable, partially favorable or
adverse) has not yet been made due to error (e.g., payment requests or
forms that are incomplete, invalid or do not meet the requirements for a
Medicare claim).
[Data Elements 6.1-6.8]

Review Results:

2.e

RSC-6.m

Data Element 6.2

Review Results:

2.e

RSC-6.k

2.e

RSC-6.l

2.e

RSC-6.l: Excludes duplicate payment requests concerning the same
service or item.
[Data Elements 6.1-6.8]

2.e

RSC-6.m

Data Element 6.3

Review Results:

2.e

RSC-6.m

Data Element 6.4

Review Results:

2.e

RSC-6.m

Data Element 6.5

Review Results:

2.e

RSC-6.m

Data Element 6.6

Review Results:

2.e

RSC-6.m

Data Element 6.7

Review Results:

2.e

RSC-6.m

Data Element 6.8

Review Results:

2.e

RSC-7

2.e

Organization accurately calculates the number of organization determinations, including the
following criteria:

Data Sources:

RSC-7.a

RSC-7.a: Includes all service organization determinations for contract
and non-contract providers/suppliers.
[Data Element 6.1]

Data Element 6.1

Review Results:

2.e

RSC-7.b

RSC-7.b: Includes all payment (claim) organization determinations for
contract and non-contract providers/suppliers.
[Data Element 6.1]

Data Element 6.1

Review Results:

2.e

RSC-8

2.e

RSC-8.a

Organization accurately calculates the total number of organization determinations that were
processed in a timely manner including the following criteria:

Data Sources:

RSC-8.a: Includes all service organization determinations for contract
and non-contract providers/suppliers.
[Data Element 6.2]

Review Results:

Data Element 6.2

*

*

2.e

RSC-8.b

2.e

RSC-9

2.e

RSC-8.b: Includes all payment (claim) organization determinations for
contract and non-contract providers/suppliers.
[Data Element 6.2]

Data Element 6.2

Review Results:

RSC-9: Organization accurately calculates the number of fully favorable (e.g., approval of entire
request resulting in full coverage of the item or service organization determinations, including
the following criteria):

Data Sources:

RSC-9.a

RSC-9.a: Includes all fully favorable service organization determinations
for contract and non-contract providers/suppliers.
[Data Element 6.3]

Data Element 6.3

Review Results:

2.e

RSC-9.b

RSC-9.b: Includes all fully favorable payment (claim) organization
determinations made to contract and non-contract providers.
[Data Element 6.4]

Data Element 6.4

Review Results:

2.e

RSC-9.c

RSC-9.c: For instances when a request for payment is submitted to an
Data Element 6.3
organization concerning an item or service, and the organization has
already made a favorable organization determination (i.e., issued a fully
favorable service decision), includes the request for payment for the
same item or service as another, separate, fully favorable organization
determination.
[Data Elements 6.3-6.4]

Review Results:

2.e

RSC-9.c

Data Element 6.4

Review Results:

2.e

RSC-9.d

RSC-9.d: For instances when the organization approves an initial request Data Element 6.3
for an item or service (e.g., physical therapy services) and the
organization approves a separate additional request to extend or
continue coverage of the same item or service, includes the decision to
extend or continue coverage of the same item or service as another,
separate, fully favorable organization determination.
[Data Elements 6.3-6.4]

Review Results:

2.e

RSC-9.d

Data Element 6.4

Review Results:

2.e

RSC-9.e

RSC-9.e: Includes auto-adjudicated claims, service authorizations which Data Element 6.3
include prior-authorization (authorization that is issued prior to the
services being rendered), concurrent authorization for services rendered
in an office setting (authorization that is issued at the time the service is
being rendered) and post-authorization (authorization that is issued
after the services has already been provided) for contract and noncontract providers [Data Elements 6.3-6.4].

Review Results:

2.e

RSC-9.e

Data Element 6.4

Review Results:

2.e

RSC-10

Organization accurately calculates the number of partially favorable claim and favorable service
organization determinations (e.g., coverage denial of some items and coverage approval of some
items in a claim that has multiple line items) organization determinations, including the following
criteria:

Data Sources:

*

*

2.e

RSC-10.a

RSC-10.a: Includes all partially favorable service organization
determinations for contract and non-contract providers/suppliers.
[Data Element 6.5]

Data Element 6.5

Review Results:

2.e

RSC-10.b

RSC-10.b: Includes all partially favorable payment (claim) organization
determinations for contract and non-contract providers/suppliers.
[Data Element 6.6]

Data Element 6.6

Review Results:

2.e

RSC-11

2.e

Organization accurately calculates the number of adverse (e.g., denial of entire request resulting
in no coverage of the item or service) organization determinations, including the following
criteria:

Data Sources:

RSC-11.a

RSC-11.a: Includes all adverse service organization determinations for
contract and non-contract providers/suppliers.
[Data Element 6.7]

Data Element 6.7

Review Results:

2.e

RSC-11.b

RSC-11.b: Includes all adverse payment (claim) organization
Data Element 6.8
determinations that result in zero payment being made to contract and
non-contract providers.
[Data Element 6.8]

Review Results:

2.e

RSC-12

RSC-12: Organization accurately calculates “Withdrawn Organization Determination” according
to the following criteria:

Data Sources:

2.e

RSC-12.a

RSC-12.a: Includes an organization determination that is withdrawn
upon the enrollee’s request, the enrollee representative's request, or
the enrollee provider's request but excludes appeals that the
organization forwards to the IRE for dismissal.
[Data Element 6.9]

Review Results:

2.e

RSC-13

2.e

RSC-13.a

2.e

RSC-14

2.e

RSC-14.a

Data Element 6.9

Organization accurately calculates “Organization Determinations - Dismissals” according to the
following criteria:

Data Sources:

RSC-13.a: Includes dismissals that were processed according to
Reconsideration Dismissal Procedure as stated in guidance provided in
the September 10, 2013 HPMS memo regarding Part C reconsideration
dismissal procedures prior to issuing the dismissal as well as guidance
provided in Chapter 13 of the Medicare Managed Care Manual. [Data
Element 6.10]

Review Results:

Data Element 6.10

Organization accurately calculates the total number of reconsiderations, including the following
criteria:

Data Sources:

RSC-14.a: Includes all completed reconsiderations (Part C only) with a
Data Element 6.11
date of member notification of the final decision that occurs during the
reporting period, regardless of when the request for reconsideration was
received
[Data Elements 6.11-6.18]

Review Results:

*

*

*

*

2.e

RSC-14.a

Data Element 6.12

Review Results:

2.e

RSC-14.a

Data Element 6.13

Review Results:

2.e

RSC-14.a

Data Element 6.14

Review Results:

2.e

RSC-14.a

Data Element 6.15

Review Results:

2.e

RSC-14.a

Data Element 6.16

Review Results:

2.e

RSC-14.a

Data Element 6.17

Review Results:

2.e

RSC-14.a

Data Element 6.18

Review Results:

2.e

RSC-14.b

Data Element 6.11

Review Results:

2.e

RSC-14.b

Data Element 6.12

Review Results:

2.e

RSC-14.b

Data Element 6.13

Review Results:

2.e

RSC-14.b

Data Element 6.14

Review Results:

RSC-14.b: Includes decisions made on behalf of the organization by a
delegated entity
[Data Elements 6.11-6.18]

2.e

RSC-14.b

Data Element 6.15

Review Results:

2.e

RSC-14.b

Data Element 6.16

Review Results:

2.e

RSC-14.b

Data Element 6.17

Review Results:

2.e

RSC-14.b

Data Element 6.18

Review Results:

2.e

RSC-14.c

Data Element 6.11

Review Results:

2.e

RSC-14.c

Data Element 6.12

Review Results:

2.e

RSC-14.c

Data Element 6.13

Review Results:

2.e

RSC-14.c

Data Element 6.14

Review Results:

2.e

RSC-14.c

Data Element 6.15

Review Results:

2.e

RSC-14.c

Data Element 6.16

Review Results:

2.e

RSC-14.c

Data Element 6.17

Review Results:

RSC-14.c: Includes all methods of reconsideration request receipt (e.g.,
telephone, letter, fax, and in-person).
[Data Elements 6.11-6.18]

Data Element 6.18

Review Results:

Data Element 6.11

Review Results:

RSC-14.d

Data Element 6.12

Review Results:

2.e

RSC-14.d

Data Element 6.13

Review Results:

2.e

RSC-14.d

Data Element 6.14

Review Results:

2.e

RSC-14.d

Data Element 6.15

Review Results:

2.e

RSC-14.d

Data Element 6.16

Review Results:

2.e

RSC-14.d

Data Element 6.17

Review Results:

2.e

RSC-14.d

Data Element 6.18

Review Results:

2.e

RSC-14.e

RSC-14.e: Includes reconsiderations that are filed directly with the
Data Element 6.11
organization or its delegated entities (e.g., excludes all reconsiderations
that are only forwarded to the organization from the CMS Complaint
Tracking Module (CTM) and not filed directly with the organization or
delegated entity). If a member requests a reconsideration directly with
the organization and files an identical complaint via the CTM, the
organization includes only the reconsideration that was filed directly
with the organization and excludes the identical CTM complaint.
[Data Elements 6.11-6.18]

Review Results:

2.e

RSC-14.e

Data Element 6.12

Review Results:

2.e

RSC-14.c

2.e

RSC-14.d

2.e

RSC-14.d: Includes all reconsiderations regardless of who filed the
request. For example, if a non-contracted provider signs a waiver of
liability and submits a reconsideration request, a plan is to report this
reconsideration in the same manner it would report a member-filed
reconsideration.
[Data Elements 6.11-6.18]

2.e

RSC-14.e

Data Element 6.13

Review Results:

2.e

RSC-14.e

Data Element 6.14

Review Results:

2.e

RSC-14.e

Data Element 6.15

Review Results:

2.e

RSC-14.e

Data Element 6.16

Review Results:

2.e

RSC-14.e

Data Element 6.17

Review Results:

2.e

RSC-14.e

Data Element 6.18

Review Results:

2.e

RSC-14.f

RSC-14.f: Includes supplemental benefits (i.e., non- Medicare covered
Data Element 6.11
item or service) provided as a part of a plan’s Medicare benefit package.
[Data Elements 6.11-6.18]

Review Results:

2.e

RSC-14.f

Data Element 6.12

Review Results:

2.e

RSC-14.f

Data Element 6.13

Review Results:

2.e

RSC-14.f

Data Element 6.14

Review Results:

2.e

RSC-14.f

Data Element 6.15

Review Results:

2.e

RSC-14.f

Data Element 6.16

Review Results:

2.e

RSC-14.f

Data Element 6.17

Review Results:

2.e

RSC-14.f

Data Element 6.18

Review Results:

2.e

RSC-14.g

Data Element 6.11

Review Results:

2.e

RSC-14.g

Data Element 6.12

Review Results:

2.e

RSC-14.g

Data Element 6.13

Review Results:

2.e

RSC-14.g

Data Element 6.14

Review Results:

2.e

RSC-14.g

Data Element 6.15

Review Results:

2.e

RSC-14.g

Data Element 6.16

Review Results:

2.e

RSC-14.g

Data Element 6.17

Review Results:

2.e

RSC-14.g

Data Element 6.18

Review Results:

RSC-14.g: Excludes dismissals and withdrawals.
[Data Elements 6.11-6.18]

Data Element 6.11

Review Results:

RSC-14.h

Data Element 6.12

Review Results:

2.e

RSC-14.h

Data Element 6.13

Review Results:

2.e

RSC-14.h

Data Element 6.14

Review Results:

2.e

RSC-14.h

Data Element 6.15

Review Results:

2.e

RSC-14.h

Data Element 6.16

Review Results:

2.e

RSC-14.h

Data Element 6.17

Review Results:

2.e

RSC-14.h

Data Element 6.18

Review Results:

2.e

RSC-14.i

Data Element 6.11

Review Results:

2.e

RSC-14.i

Data Element 6.12

Review Results:

2.e

RSC-14.i

Data Element 6.13

Review Results:

2.e

RSC-14.h

2.e

RSC-14.h: Excludes Independent Review Entity Decisions.
[Data Elements 6.11-6.18]

RSC-14.i: Excludes QIO reviews of a member’s request to continue
Medicare-covered services (e.g., a SNF stay).
[Data Elements 6.11-6.18]

2.e

RSC-14.i

Data Element 6.14

Review Results:

2.e

RSC-14.i

Data Element 6.15

Review Results:

2.e

RSC-14.i

Data Element 6.16

Review Results:

2.e

RSC-14.i

Data Element 6.17

Review Results:

2.e

RSC-14.i

Data Element 6.18

Review Results:

2.e

RSC-14.j

Data Element 6.11

Review Results:

2.e

RSC-14.j

Data Element 6.12

Review Results:

2.e

RSC-14.j

Data Element 6.13

Review Results:

2.e

RSC-14.j

Data Element 6.14

Review Results:

2.e

RSC-14.j

Data Element 6.15

Review Results:

2.e

RSC-14.j

Data Element 6.16

Review Results:

RSC-14.j: Excludes duplicate payment requests concerning the same
service or item.
[Data Elements 6.11-6.18]

2.e

RSC-14.j

Data Element 6.17

Review Results:

2.e

RSC-14.j

Data Element 6.18

Review Results:

2.e

RSC-14.k

RSC-14.k: Excludes payment requests returned to a provider/supplier in Data Element 6.11
which a substantive decision (Fully Favorable, Partially Favorable or
Adverse) has not yet been made due to error (e.g., payment requests or
forms that are incomplete, invalid or do not meet the requirements for a
Medicare claim).
[Data Elements 6.11-6.18]

Review Results:

2.e

RSC-14.k

Data Element 6.12

Review Results:

2.e

RSC-14.k

Data Element 6.13

Review Results:

2.e

RSC-14.k

Data Element 6.14

Review Results:

2.e

RSC-14.k

Data Element 6.15

Review Results:

2.e

RSC-14.k

Data Element 6.16

Review Results:

2.e

RSC-14.k

Data Element 6.17

Review Results:

2.e

RSC-14.k

Data Element 6.18

Review Results:

2.e

RSC-15

Organization accurately calculates the total number of reconsiderations processed timely
according to the following criteria:

Data Sources:

*

2.e

RSC-15.a

RSC-15.a. Includes all -service reconsiderations for contract and noncontract providers/suppliers. [Data Element 6.12]

Data Element 6.12

Review Results:

2.e

RSC-15.b

RSC-15.b. Includes all payment (claim) reconsiderations for contract and Data Element 6.12
non-contract providers/suppliers. [Data Element 6.12]

Review Results:

2.e

RSC-16

Organization accurately calculates the number of fully favorable (item or service was covered in
full) reconsiderations, including the following criteria:

Data Sources:

2.e

RSC-16.a

RSC-16.a: Includes all fully favorable service reconsideration
determinations for contract and non-contract providers/suppliers.
[Data Element 6.13]

Data Element 6.13

Review Results:

2.e

RSC-16.b

RSC-16.b: Includes all fully favorable payment (claim) reconsideration
determinations for contract and non-contract providers/suppliers.
[Data Element 6.14]

Data Element 6.14

Review Results:

2.e

RSC-16.c

RSC-16.c: For instances when a reconsideration request for payment is Data Element 6.13
submitted to an organization concerning an item or service, and the
organization has already made a favorable service reconsideration
determination, includes the reconsideration request for payment for the
same item or service as another, separate, fully favorable
reconsideration determination.
[Data Elements 6.13, 6.14]

Review Results:

2.e

RSC-16.c

Data Element 6.14

Review Results:

2.e

RSC-17

2.e

Organization accurately calculates the number of partially favorable (e.g., coverage denial of
some items and coverage approval of some items in a claim that has multiple line items
reconsiderations, including the following criteria:

Data Sources:

RSC-17.a

RSC-17.a: Includes all partially favorable service reconsideration
determinations for contract and non-contract providers/suppliers.
[Data Element 6.15]

Data Element 6.15

Review Results:

2.e

RSC-17.b

RSC-17.b: Includes all partially favorable payment (claim)
reconsideration determinations for contract and non-contract
providers/suppliers. [Data Element 6.16]

Data Element 6.16

Review Results:

2.e

RSC-18

Organization accurately calculates the number of adverse (e.g., denial of entire request resulting
in no coverage of the item or service) reconsiderations, including the following criteria:

Data Sources:

*

*

*

2.e

RSC-18.a

RSC-18.a: Includes all adverse service reconsideration determinations for Data Element 6.17
contract and non-contract providers/suppliers. [Data Element 6.17]

Review Results:

2.e

RSC-18.b

RSC-18.b: Includes all adverse payment (claim) reconsideration
Data Element 6.18
determinations that result in zero payment being made to contract and
non-contract providers. [Data Element 6.18]

Review Results:

2.e

RSC-18.c

RSC-18.c: For instances when a reconsideration request for payment is Data Element 6.17
submitted to an organization concerning an item or service, and the
organization has already made an adverse service reconsideration
determination, includes the reconsideration request for payment for the
same item or service as another, separate, adverse reconsideration
determination.
[Data Element 6.17]

Review Results:

2.e

RSC-18.c

RSC-18.c: For instances when a reconsideration request for payment is Data Element 6.18
submitted to an organization concerning an item or service, and the
organization has already made an adverse service reconsideration
determination, includes the reconsideration request for payment for the
same item or service as another, separate, adverse reconsideration
determination.
[Data Element 6.18]

Review Results:

2.e

RSC-19

Organization accurately calculates “Withdrawn Reconsiderations” according to the following
criteria:

Data Sources:

2.e

RSC-19.a

RSC-19.a: Includes a Reconsideration that is withdrawn upon the
Data Element 6.19
enrollee’s request, the enrollee representatives request, or the enrollee
provider's request. [Data Element 6.19]

Review Results:

2.e

RSC-20

Organization accurately calculates “Reconsiderations Dismissals” according to the following
criteria:

Data Sources:

2.e

RSC-20.a

RSC-20.a: Includes reconsiderations dismissals that were processed
according to Reconsideration Dismissal Procedure as provided in the
September 10, 2013 HPMS memo and according to guidance provided
by Chapter 13 of the Medicare Managed Care Manual. [Data Element
6.20]

Review Results:

2.e

RSC-21

2.e

RSC-21.a

2.e

RSC-22

Data Element 6.20

Organization accurately calculates the total number of reopened decisions according to the
following criteria:

Data Sources:

RSC-21.a: Includes a remedial action taken to change a final
determination or decision even though the determination or decision
was correct based on the evidence of record.
[Data Element 6.21]

Review Results:

Data Element 6.21

The organization accurately reports the following information for each reopened case.

Data Sources:

*

*

*

*

2.e

RSC-22.a

RSC-22.a: Contract Number [Data Element 6.22]

Data Element 6.22

Review Results:

2.e

RSC-22.b

RSC-22.b: Plan ID [Data Element 6.23]

Data Element 6.23

Review Results:

2.e

RSC-22.c

RSC-22.c: Case ID [Data Element 6.24]

Data Element 6.24

Review Results:

2.e

RSC-22.d

RSC-22.d: Date of original disposition [Data Element 6.26]

Data Element 6.26

Review Results:

2.e

RSC-22.e

RSC-22.e: Original disposition (Fully Favorable; Partially Favorable; or
Adverse) [Data Element 6.27]

Data Element 6.27

Review Results:

2.e

RSC-22.f

RSC-22.f: Case Level (Organization Determination or Reconsideration)
[Data Element 6.25]

Data Element 6.25

Review Results:

2.e

RSC-22.g

RSC-22.g: Date case was reopened [Data Element 6.31]

Data Element 6.31

Review Results:

2.e

RSC-22.h

RSC-22.h: Reason (s) for reopening (Clerical Error, Other Error, New and Data Element 6.32
Material Evidence, Fraud or Similar Fault, or Other) [Data Element 6.32]

Review Results:

2.e

RSC-22.i

RSC-22.i: Date of reopening disposition (revised decision) [Data Element Data Element 6.34
6.34]

Review Results:

2.e

RSC-22.j

RSC-22.j: Reopening disposition (Fully Favorable; Partially Favorable,
Adverse, or Pending) [Data Element 6.35]

Review Results:

3

Data Element 6.35

Organization implements policies and procedures for data submission, including the following:

Data Sources:

*

Data Element 6.1

Review Results:

3.a

Data Element 6.2

Review Results:

3.a

Data Element 6.3

Review Results:

3.a

Data Element 6.4

Review Results:

3.a

Data Element 6.5

Review Results:

3.a

Data Element 6.6

Review Results:

3.a

Data Element 6.7

Review Results:

3.a

Data Element 6.8

Review Results:

3.a

Data Element 6.9

Review Results:

3.a

Data Element 6.10

Review Results:

3.a

Data Element 6.11

Review Results:

3.a

Data elements are accurately entered/uploaded into CMS systems and
entries match corresponding source documents.

3.a

Data Element 6.12

Review Results:

3.a

Data Element 6.13

Review Results:

3.a

Data Element 6.14

Review Results:

3.a

Data Element 6.15

Review Results:

3.a

Data Element 6.16

Review Results:

3.a

Data Element 6.17

Review Results:

3.a

Data Element 6.18

Review Results:

3.a

Data Element 6.19

Review Results:

3.a

Data Element 6.20

Review Results:

3.a

Data Element 6.21

Review Results:

3.a

Data Element 6.22

Review Results:

3.a

Data Element 6.23

Review Results:

3.a

Data Element 6.24

Review Results:

3.a

Data Element 6.25

Review Results:

3.a

Data Element 6.26

Review Results:

3.a

Data Element 6.27

Review Results:

3.a

Data Element 6.28

Review Results:

3.a

Data Element 6.29

Review Results:

3.a

Data Element 6.30

Review Results:

3.a

Data Element 6.31

Review Results:

3.a

Data Element 6.32

Review Results:

3.a

Data Element 6.33

Review Results:

3.a

Data Element 6.34

Review Results:

3.a

Data Element 6.35

Review Results:

All source, intermediate, and final stage data sets and other outputs relied upon to enter data
into CMS systems are archived.

Review Results:

4

Organization implements policies and procedures for periodic data system updates (e.g., changes
in enrollment, provider/pharmacy status, claims adjustments).

Review Results:

5

Organization implements policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).

Review Results:

6

If organization’s data systems underwent any changes during the reporting period (e.g., as a
result of a merger, acquisition, or upgrade): Organization provided documentation on the data
system changes and, upon review, there were no issues that adversely impacted data reported.

Review Results:

7

If data collection and/or reporting for this reporting section is delegated to another entity:
Organization regularly monitors the quality and timeliness of the data collected and/or reported
by the delegated entity or first tier/ downstream contractor.

Review Results:

3.b

GC-v1.1

Grievances (Part C) 2017

Organization Name:
Contract Number:
Reporting Section:

Grievances (Part C) 2017

Last Updated:

MM/DD/YYYY

Date of Site Visit:
Last name, First name

Name of Peer Reviewer:

Last name, First name

Standard/
Sub-standard
ID

Re
po
rti
n
Cr g Se
i t e ct
ria ion
ID

Name of Reviewer:

1) In the "Data Sources and Review Results:" column, enter the review results and/or data sources
used for each standard or sub-standard.
2) Enter "Y" if the requirements for the standard or sub-standard have been completely met. If any
requirement for the standard or sub-standard has not been met, enter "N". If any standard or substandard does not apply, enter "N/A".
3) For standards 1c, 1d, 1e, 1g, 1h, and 2e, enter 'Findings' as follows based on the five-point scale:
Select "1" if plan data has more than 20% error, select "2" if plan data has between 15.1% - 20.0%
error, select "3" if plan data has between 10.1% - 15.0% error, select "4" if plan data has between
5.1% - 10.0% error, select "5" if plan data has less than or equal to a 5% error. Enter "N/A" if standard
does not apply.

Data Sources and Review Results:
Enter review results and/or data sources

Standard/Sub-standard Description

1

A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans,
saved data queries, file layouts, process flows) indicates that all source documents accurately
capture required data fields and are properly documented.

Data Sources:

1.a

Source documents are properly secured so that source documents can be retrieved at any time
to validate the information submitted to CMS via CMS systems.

Review Results:

1.b

Source documents create all required data fields for reporting requirements.

Review Results:

1.c

Source documents are error-free (e.g., programming code and spreadsheet formulas have no
messages or warnings indicating errors, use correct fields, have appropriate data selection, etc.).

Review Results:

1.d

All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID,
rather than Field1 and maintain the same field name across data sets).

Review Results:

1.e

Data file locations are referenced correctly.

Review Results:

1.f

If used, macros are properly documented.

Review Results:

1.g

Source documents are clearly and adequately documented.

Review Results:

1.h

Titles and footnotes on reports and tables are accurate.

Review Results:

Enter 'Findings' using
the applicable choice
in the appropriate cells.
Cells marked with an '*'
should not be edited.
*

1.i

Version control of source documents is appropriately applied.

Review Results:

2

A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans,
saved data queries, file layouts, process flows) and census or sample data, whichever is
applicable, indicates that data elements for each reporting section are accurately identified,
processed, and calculated.

Data Sources:

The appropriate date range(s) for the reporting period(s) is captured.

Review Results:

2.a

RSC-1

*

Organization reports data based on the periods of 1/1 through 3/31, 4/1 through 6/30, 7/1
through 9/30, and 10/1 through 12/31.

2.b

RSC-2

Data are assigned at the applicable level (e.g., plan benefit package or contract level).

Review Results:

Organization properly assigns data to the applicable CMS contract.

2.c

2.d

RSC-3

RSC-4

Review Results:

Appropriate deadlines are met for reporting data (e.g., quarterly).
Organization meets deadlines for reporting data to CMS by 2/5/2018.
[Note to reviewer: If the organization has, for any reason, re-submitted its data to CMS for this
reporting section, the reviewer should verify that the organization’s original data submissions
met the CMS deadline in order to have a finding of “yes” for this reporting section criterion.
However, if the organization re-submits data for any reason and if the re-submission was
completed by 3/31 of the data validation year, the reviewer should use the organization’s
corrected data submission(s) for the rest of the reporting section criteria for this reporting
section.]
Terms used are properly defined per CMS regulations, guidance and Reporting Requirements
Technical Specifications.

Review Results:

Organization properly defines the term “Grievance” in accordance with 42 CFR §422.564 and
the Medicare Managed Care Manual Chapter 13, Sections 10 and 20. This includes applying all
relevant guidance properly when performing its calculations and categorizations. Requests for
organization determinations or appeals are not improperly categorized as grievances.
Data Sources:

2.e

RSC-5

Organization data passes data integrity checks listed below: 

2.e

RSC-5.a

RSC-5.a: Total grievances (Data Element A) is equal to the sum of
grievances by reason (Data Element F + Data Element H + Data Element J
+ Data Element L + Data Element N + Data Element P + Data Element R +
Data Element T+ Data Element V).

Data Elements A, F,
H, J, L, N, P, R, T, V

Review Results:

2.e

RSC-5.b

RSC-5.b: Total grievances in which timely notification was given (Data
Element B) is equal to the sum of grievances in which timely notification
was given by reason (Data Element G + Data Element I + Data Element K
+ Data Element M + Data Element O + Data Element Q + Data Element S
+ Data Element U + Data Element W).

Data Elements B, G,
I, K, M, O, Q, S, U, W

Review Results:

2.e

RSC-5.c

RSC-5.c: Number of expedited grievances (Data Element C) does not
exceed total grievances.
[Data Element A ] [Data Element C]

Data Element C

Review Results:

2.e

RSC-5.d

RSC-5.d: Number of expedited grievances in which timely notification
was given (Data Element D) does not exceed total grievances (Data
Element A).

Data Element D

Review Results:

*

2.e

RSC-5.e

RSC-5.e: Number of dismissed grievances (Data Element E)

Data Element E

Review Results:

2.e

RSC-5.f

RSC-5.f: Number of enrollment/disenrollment grievances in which timely
notification was given (Data Element G) does not exceed total
enrollment/disenrollment grievances (Data Element F).
[Data
Element G]

Data Element G

Review Results:

2.e

RSC-5.g

RSC-5.g: Number of benefit package grievances in which timely
notification was given (Data Element I) does not exceed total benefit
package grievances (Data Element H).
[Data Element I]

Data Element I

Review Results:

2.e

RSC-5.h

RSC-5.h: Number of access grievances in which timely notification was
given (Data Element K) does not exceed total access grievances (Data
Element J).
[Data Element K]

Data Element K

Review Results:

2.e

RSC-5.i

RSC-5.i: Number of marketing grievances in which timely notification
was given (Data Element M) does not exceed total marketing grievances
(Data Element L).
[Data Element M]

Data Element M

Review Results:

2.e

RSC-5.j

RSC-5.j: Number of customer service grievances in which timely
notification was given (Data Element O) does not exceed total customer
service grievances (Data Element N). [Data Element O]

Data Element O

Review Results:

2.e

RSC-5.k

RSC-5.k: Number of organization determination and reconsideration
process grievances in which timely notification was given (Data Element
Q) does not exceed total organization determination and
reconsideration process grievances (Data Element P).
[Data
Element Q]

Data Element Q

Review Results:

2.e

RSC-5.l

RSC-5.l: Number of quality of care grievances in which timely
notification was given (Data Element S) does not exceed total quality of
care grievances (Data Element R). [Data Element S]

Data Element S

Review Results:

2.e

RSC-5.m

RSC-5.m: Number of CMS issue grievances in which timely notification
was given (Data Element U) does not exceed total CMS issue grievances
(Data Element T). [Data Element U]

Data Element U

Review Results:

2.e

RSC-5.n

RSC-5.n: Number of other grievances in which timely notification was
given (Data Element W) does not exceed total other grievances (Data
Element V).
[Data Element W]

Data Element W

Review Results:

2.e

RSC-5.o

If the organization received a CMS outlier/data integrity notice validate Data Elements A-W
whether or not an internal procedure change was warranted or
resubmission through HPMS.

Review Results:

2.e

RSC-6

The number of expected counts (e.g., number of members, claims, grievances, procedures) are
verified; ranges of data fields are verified; all calculations (e.g., derived data fields) are verified;
missing data has been properly addressed; reporting output matches corresponding source
documents (e.g., programming code, saved queries, analysis plans); version control of reported
data elements is appropriately applied; QA checks/thresholds are applied to detect outlier or
erroneous data prior to data submission.

Data Sources:

Applicable Reporting Section Criteria:
RSC-6: Organization accurately calculates the total number of grievances, including the following
criteria:
RSC-6.a: Includes all grievances that were completed (i.e., organization Data Element A
has notified member of its decision) during the reporting period,
regardless of when the grievance was received.
[Data Elements A, F, H, J, L, N, P, R, T, V ]

Review Results:

2.e

RSC-6.a

2.e

RSC-6.a

Data Element F

Review Results:

2.e

RSC-6.a

Data Element H

Review Results:

2.e

RSC-6.a

Data Element J

Review Results:

2.e

RSC-6.a

Data Element L

Review Results:

2.e

RSC-6.a

Data Element N

Review Results:

2.e

RSC-6.a

Data Element P

Review Results:

2.e

RSC-6.a

Data Element R

Review Results:

2.e

RSC-6.a

Data Element T

Review Results:

2.e

RSC-6.a

Data Element V

Review Results:

*

RSC-6.b: Includes all grievances reported by or on behalf of members who were previously
eligible, regardless of whether the member was eligible on the date that the grievance was
reported to the organization.
[Data Elements A, F, H, J, L, N, P, R, T, V ]

Data Sources:

2.e

RSC-6.b

2.e

RSC-6.b

Data Element A

Review Results:

2.e

RSC-6.b

Data Element F

Review Results:

2.e

RSC-6.b

Data Element H

Review Results:

2.e

RSC-6.b

Data Element J

Review Results:

2.e

RSC-6.b

Data Element L

Review Results:

2.e

RSC-6.b

Data Element N

Review Results:

2.e

RSC-6.b

Data Element P

Review Results:

2.e

RSC-6.b

Data Element R

Review Results:

2.e

RSC-6.b

Data Element T

Review Results:

2.e

RSC-6.b

Data Element V

Review Results:

*

RSC-6.c: If a grievance contains multiple issues filed under a single complaint, each issue is
calculated as a separate grievance.
[Data Elements A, F, H, J, L, N, P, R, T, V ]

Data Sources:

2.e

RSC-6.c

2.e

RSC-6.c

Data Element A

Review Results:

2.e

RSC-6.c

Data Element F

Review Results:

2.e

RSC-6.c

Data Element H

Review Results:

2.e

RSC-6.c

Data Element J

Review Results:

2.e

RSC-6.c

Data Element L

Review Results:

2.e

RSC-6.c

Data Element N

Review Results:

2.e

RSC-6.c

Data Element P

Review Results:

2.e

RSC-6.c

Data Element R

Review Results:

2.e

RSC-6.c

Data Element T

Review Results:

2.e

RSC-6.c

Data Element V

Review Results:

*

RSC-6.d: If a member files a grievance and then files a subsequent grievance on the same issue
prior to the organization’s decision or the deadline for decision notification (whichever is
earlier), then the issue is counted as one grievance.
[Data Elements A, F, H, J, L, N, P, R, T, V ]

Data Sources:

2.e

RSC-6.d

2.e

RSC-6.d

Data Element A

Review Results:

2.e

RSC-6.d

Data Element F

Review Results:

2.e

RSC-6.d

Data Element H

Review Results:

2.e

RSC-6.d

Data Element J

Review Results:

2.e

RSC-6.d

Data Element L

Review Results:

2.e

RSC-6.d

Data Element N

Review Results:

2.e

RSC-6.d

Data Element P

Review Results:

2.e

RSC-6.d

Data Element R

Review Results:

2.e

RSC-6.d

Data Element T

Review Results:

2.e

RSC-6.d

Data Element V

Review Results:

*

RSC-6.e: If a member files a grievance and then files a subsequent grievance on the same issue
after the organization’s decision or deadline for decision notification (whichever is earlier), then
the issue is counted as a separate grievance.
[Data Elements A, F, H, J, L, N, P, R, T, V]

Data Sources:

2.e

RSC-6.e

2.e

RSC-6.e

Data Element A

Review Results:

2.e

RSC-6.e

Data Element F

Review Results:

2.e

RSC-6.e

Data Element H

Review Results:

2.e

RSC-6.e

Data Element J

Review Results:

2.e

RSC-6.e

Data Element L

Review Results:

2.e

RSC-6.e

Data Element N

Review Results:

2.e

RSC-6.e

Data Element P

Review Results:

2.e

RSC-6.e

Data Element R

Review Results:

2.e

RSC-6.e

Data Element T

Review Results:

2.e

RSC-6.e

Data Element V

Review Results:

*

RSC-6.f: Includes all methods of grievance receipt (e.g., telephone, letter, fax, in-person.
[Data Elements A, F, H, J, L, N, P, R, T, V ]

Data Sources:

2.e

RSC-6.f

2.e

RSC-6.f

Data Element A

Review Results:

2.e

RSC-6.f

Data Element F

Review Results:

2.e

RSC-6.f

Data Element H

Review Results:

2.e

RSC-6.f

Data Element J

Review Results:

2.e

RSC-6.f

Data Element L

Review Results:

2.e

RSC-6.f

Data Element N

Review Results:

2.e

RSC-6.f

Data Element P

Review Results:

2.e

RSC-6.f

Data Element R

Review Results:

2.e

RSC-6.f

Data Element T

Review Results:

2.e

RSC-6.f

Data Element V

Review Results:

*

RSC-6.g: Includes all grievances regardless of who filed the grievance (e.g., member or
appointed representative).
[Data Elements A, F, H, J, L, N, P, R, T, V ]

Data Sources:

2.e

RSC-6.g

2.e

RSC-6.g

Data Element A

Review Results:

2.e

RSC-6.g

Data Element F

Review Results:

2.e

RSC-6.g

Data Element H

Review Results:

2.e

RSC-6.g

Data Element J

Review Results:

2.e

RSC-6.g

Data Element L

Review Results:

2.e

RSC-6.g

Data Element N

Review Results:

2.e

RSC-6.g

Data Element P

Review Results:

2.e

RSC-6.g

Data Element R

Review Results:

2.e

RSC-6.g

Data Element T

Review Results:

2.e

RSC-6.g

Data Element V

Review Results:

*

RSC-6.h: Includes only grievances that are filed directly with the organization (e.g., excludes all
complaints that are only forwarded to the organization from the CMS Complaint Tracking
Module (CTM) and not filed directly with the organization). If a member files the same
complaint both directly with the organization and via the CTM, the organization includes only
the grievance that was filed directly with the organization and excludes the identical CTM
complaint.
[Data Elements A, F, H, J, L, N, P, R, T, V ]

Data Sources:

2.e

RSC-6.h

2.e

RSC-6.h

Data Element A

Review Results:

2.e

RSC-6.h

Data Element F

Review Results:

2.e

RSC-6.h

Data Element H

Review Results:

2.e

RSC-6.h

Data Element J

Review Results:

2.e

RSC-6.h

Data Element L

Review Results:

2.e

RSC-6.h

Data Element N

Review Results:

2.e

RSC-6.h

Data Element P

Review Results:

2.e

RSC-6.h

Data Element R

Review Results:

2.e

RSC-6.h

Data Element T

Review Results:

2.e

RSC-6.h

Data Element V

Review Results:

*

2.e

RSC-6.i

RSC-6.i: For MA-PD contracts: Includes only grievances that apply to the Data Element A
Part C benefit (If a clear distinction cannot be made for an MA-PD, cases
are reported as Part C grievances).
[Data Elements
A, F, H, J, L, N, P, R, T, V ]

Review Results:

2.e

RSC-6.i

Data Element F

Review Results:

2.e

RSC-6.i

Data Element H

Review Results:

2.e

RSC-6.i

Data Element J

Review Results:

2.e

RSC-6.i

Data Element L

Review Results:

2.e

RSC-6.i

Data Element N

Review Results:

2.e

RSC-6.i

Data Element P

Review Results:

2.e

RSC-6.i

Data Element R

Review Results:

2.e

RSC-6.i

Data Element T

Review Results:

2.e

RSC-6.i

Data Element V

Review Results:

2.e

RSC-6.j

Data Element A

Review Results:

RSC-6.j: Excludes withdrawn grievances.
Elements A, F, H, J, L, N, P, R, T, V ]

[Data

2.e

RSC-6.j

Data Element F

Review Results:

2.e

RSC-6.j

Data Element H

Review Results:

2.e

RSC-6.j

Data Element J

Review Results:

2.e

RSC-6.j

Data Element L

Review Results:

2.e

RSC-6.j

Data Element N

Review Results:

2.e

RSC-6.j

Data Element P

Review Results:

2.e

RSC-6.j

Data Element R

Review Results:

2.e

RSC-6.j

Data Element T

Review Results:

2.e

RSC-6.j

Data Element V

Review Results:

2.e

RSC-7

2.e

RSC-7.a

The number of expected counts (e.g., number of members, claims, grievances, procedures) are
verified; ranges of data fields are verified; all calculations (e.g., derived data fields) are verified;
missing data has been properly addressed; reporting output matches corresponding source
documents (e.g., programming code, saved queries, analysis plans); version control of reported
data elements is appropriately applied; QA checks/thresholds are applied to detect outlier or
erroneous data prior to data submission.
Applicable Reporting Section Criteria:
Organization accurately calculates the number of grievances by category, including the following
criteria:
RSC-7.a: Properly sorts the total number of grievances by grievance
Data Element F
category: Enrollment/Disenrollment; Benefit Package; Access;
Marketing; Customer Service; Organization Determination and
Reconsideration Process; Quality of Care; and "CMS Issues."
[Data Elements F, H, J, L, N, P, R, T, V ]

Data Sources:

Review Results:

*

2.e

RSC-7.a

Data Element H

Review Results:

2.e

RSC-7.a

Data Element J

Review Results:

2.e

RSC-7.a

Data Element L

Review Results:

2.e

RSC-7.a

Data Element N

Review Results:

2.e

RSC-7.a

Data Element P

Review Results:

2.e

RSC-7.a

Data Element R

Review Results:

2.e

RSC-7.a

Data Element T

Review Results:

2.e

RSC-7.a

Data Element V

Review Results:

2.e

RSC-7.b

2.e

RSC-7.b

2.e

RSC-8

RSC-7.b: Grievances not falling in a specific listed category are properly assigned to “Other
Grievances.”
[Data Elements V]

Data Element V

Organization accurately calculates the number of grievances for which it provided timely
notification of the decision, including the following criteria:
RSC-8a: Includes only grievances for which the member is notified of the decision according to
the following timelines:

Data Sources:

*

Review Results:

Data Sources:

*

2.e

RSC-8.a.i

RSC-8.a.i. For standard grievances: no later than 30 days after receipt of Data Element B
grievance.
[Data Elements B, G, I, K, M, O, Q, S, U, W ]

Review Results:

2.e

RSC-8.a.i

Data Element G

Review Results:

2.e

RSC-8.a.i

Data Element I

Review Results:

2.e

RSC-8.a.i

Data Element K

Review Results:

2.e

RSC-8.a.i

Data Element M

Review Results:

2.e

RSC-8.a.i

Data Element O

Review Results:

2.e

RSC-8.a.i

Data Element Q

Review Results:

2.e

RSC-8.a.i

Data Element S

Review Results:

2.e

RSC-8.a.i

Data Element U

Review Results:

2.e

RSC-8.a.i

Data Element W

Review Results:

2.e

RSC-8.a.ii

RSC-8.a.ii. For standard grievances with an extension taken: no later than 44 days after receipt
of grievance.
[Data Elements B, G, I, K, M, O, Q, S, U, W ]

Data Sources:

*

2.e

RSC-8.a.ii

Data Element B

Review Results:

2.e

RSC-8.a.ii

Data Element G

Review Results:

2.e

RSC-8.a.ii

Data Element I

Review Results:

2.e

RSC-8.a.ii

Data Element K

Review Results:

2.e

RSC-8.a.ii

Data Element M

Review Results:

2.e

RSC-8.a.ii

Data Element O

Review Results:

2.e

RSC-8.a.ii

Data Element Q

Review Results:

2.e

RSC-8.a.ii

Data Element S

Review Results:

2.e

RSC-8.a.ii

Data Element U

Review Results:

2.e

RSC-8.a.ii

Data Element W

Review Results:

2.e

RSC-8.a.iii

RSC-8.a.iii: For expedited grievances: no later than 24 hours after receipt of grievance.
[Data Elements B, D, G, I, K, M, O, Q, S, U, W]

Data Sources:

*

2.e

RSC-8.a.iii

Data Element B

Review Results:

2.e

RSC-8.a.iii

Data Element D

Review Results:

2.e

RSC-8.a.iii

Data Element G

Review Results:

2.e

RSC-8.a.iii

Data Element I

Review Results:

2.e

RSC-8.a.iii

Data Element K

Review Results:

2.e

RSC-8.a.iii

Data Element M

Review Results:

2.e

RSC-8.a.iii

Data Element O

Review Results:

2.e

RSC-8.a.iii

Data Element Q

Review Results:

2.e

RSC-8.a.iii

Data Element S

Review Results:

2.e

RSC-8.a.iii

Data Element U

Review Results:

2.e

RSC-8.a.iii

Data Element W

Review Results:

3

3.a

3.a

Organization implements policies and procedures for data submission, including the following:

Data Sources:

Data elements are accurately entered/uploaded into CMS systems and
entries match corresponding source documents.

Data Element A

Review Results:

Data Element B

Review Results:

3.a

Data Element C

Review Results:

3.a

Data Element D

Review Results:

3.a

Data Element E

Review Results:

3.a

Data Element F

Review Results:

3.a

Data Element G

Review Results:

3.a

Data Element H

Review Results:

3.a

Data Element I

Review Results:

3.a

Data Element J

Review Results:

*

3.a

Data Element K

Review Results:

3.a

Data Element L

Review Results:

3.a

Data Element M

Review Results:

3.a

Data Element N

Review Results:

3.a

Data Element O

Review Results:

3.a

Data Element P

Review Results:

3.a

Data Element Q

Review Results:

3.a

Data Element R

Review Results:

3.a

Data Element S

Review Results:

3.a

Data Element T

Review Results:

3.a

Data Element U

Review Results:

3.a

Data Element V

Review Results:

3.a

Data Element W

Review Results:

All source, intermediate, and final stage data sets and other outputs relied upon to enter data
into CMS systems are archived.

Review Results:

4

Organization implements policies and procedures for periodic data system updates (e.g.,
changes in enrollment, provider/pharmacy status, claims adjustments).

Review Results:

5

Organization implements policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).

Review Results:

6

If organization’s data systems underwent any changes during the reporting period (e.g., as a
result of a merger, acquisition, or upgrade): Organization provided documentation on the data
system changes and, upon review, there were no issues that adversely impacted data reported.

Review Results:

7

If data collection and/or reporting for this reporting section is delegated to another entity:
Organization regularly monitors the quality and timeliness of the data collected and/or reported
by the delegated entity or first tier/ downstream contractor.

Review Results:

3.b

SN-v1.0

Special Needs Plans (SNPs) Care Management 2017

Organization Name:
Contract Number:
Reporting Section:

Special Needs Plans (SNPs) Care Management 2017

Last Updated:

MM/DD/YYYY

Date of Site Visit:
Last name, First name

Name of Peer Reviewer:

Last name, First name

Standard/
Sub-standard
ID

Re
po
Cr rtin
i te g S
ria ec
ID tio
n

Name of Reviewer:

Standard/Sub-standard Description

1) In the "Data Sources and Review Results:" column, enter the review results and/or data
sources used for each standard or sub-standard.
2) Enter "Y" if the requirements for the standard or sub-standard have been completely met. If
any requirement for the standard or sub-standard has not been met, enter "N". If any standard or
sub-standard does not apply, enter "N/A".
3) For standards 1c, 1d, 1e, 1g, 1h, and 2e, enter 'Findings' as follows based on the five-point scale:
Select "1" if plan data has more than 20% error, select "2" if plan data has between 15.1% - 20.0%
error, select "3" if plan data has between 10.1% - 15.0% error, select "4" if plan data has between
5.1% - 10.0% error, select "5" if plan data has less than or equal to a 5% error. Enter "N/A" if
standard does not apply.

Data Sources and Review Results:
Enter review results and/or data sources

A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved
data queries, file layouts, process flows) indicates that all source documents accurately capture
required data fields and are properly documented.

Data Sources:

1.a

Source documents are properly secured so that source documents can be retrieved at any time to
validate the information submitted to CMS via CMS systems.

Review Results:

1.b

Source documents create all required data fields for reporting requirements.

Review Results:

1.c

Source documents are error-free (e.g., programming code and spreadsheet formulas have no
messages or warnings indicating errors, use correct fields, have appropriate data selection, etc.).

Review Results:

1.d

All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient_ID, rather
than Field1 and maintain the same field name across data sets).

Review Results:

1.e

Data file locations are referenced correctly.

Review Results:

1.f

If used, macros are properly documented.

Review Results:

1.g

Source documents are clearly and adequately documented.

Review Results:

1.h

Titles and footnotes on reports and tables are accurate.

Review Results:

1

Enter 'Findings' using
the applicable choice
in the appropriate
cells. Cells marked
with an '*' should not
be edited.
*

1.i

Version control of source documents is appropriately applied.

Review Results:

2

A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved
data queries, file layouts, process flows) and census or sample data, whichever is applicable, indicates
that data elements for each reporting section are accurately identified, processed, and calculated.

Data Sources:

The appropriate date range(s) for the reporting period(s) is captured.

Review Results:

2.a

RSC-1

*

Organization reports data based on the required reporting period of 1/1 through 12/31.

2.b

RSC-2

Data are assigned at the applicable level (e.g., plan benefit package or contract level).

Review Results:

Organization properly assigns data to the applicable CMS plan benefit package.

2.c

RSC-3

Review Results:

Appropriate deadlines are met for reporting data (e.g., quarterly).
Organization meets deadline for reporting annual data to CMS by 2/26/2018. [Note to reviewer: If the
organization has, for any reason, re-submitted its data to CMS for this reporting section, the reviewer
should verify that the organization’s original data submissions met the CMS deadline in order to have
a finding of “yes” for this reporting section criterion. However, if the organization re-submits data for
any reason and if the re-submission was completed by 3/31 of the data validation year, the reviewer
should use the organization’s corrected data submission(s) for the rest of the reporting section criteria
for this reporting section.]

2.d

2.e

RSC-4

Terms used are properly defined per CMS regulations, guidance and Reporting Requirements
Technical Specifications.

Review Results:

The number of expected counts (e.g., number of members, claims, grievances, procedures) are
verified; ranges of data fields are verified; all calculations (e.g., derived data fields) are verified;
missing data has been properly addressed; reporting output matches corresponding source
documents (e.g., programming code, saved queries, analysis plans); version control of reported data
elements is appropriately applied; QA checks/thresholds are applied to detect outlier or erroneous
data prior to data submission.

Data Sources:

Applicable Reporting Section Criteria:
2.e

RSC-4.a

RSC-4.a: Includes all new members who enrolled during the measurement
Data Element 13.1
year. Includes those members who may have enrolled as early as 90 days prior
to the effective enrollment date as they will be considered eligible for an initial
HRA for the year in which the effective enrollment date falls. [Data Element
13.1]

Review Results:

2.e

RSC-4.b

RSC-4.b: Includes members who have enrolled in the plan after dis-enrolling
from another plan (different sponsor or organization).
[Data Element 13.1]

Data Element 13.1

Review Results:

2.e

RSC-4.c

RSC-4.c: Includes members who dis-enrolled from and re-enrolled into the
Data Element 13.1
same plan if an initial HRA was not performed prior to dis-enrollment and
calculates the member’s eligibility date starting from the date of re-enrollment.
[Data Element 13.1]

Review Results:

2.e

RSC-4.d

RSC-4.d: Excludes continuously enrolled members with a documented initial
HRA that occurred under the plan during the previous year. These members,
and their HRAs, should be counted as new in the previous year.
[Data Element 13.1]

Review Results:

Data Element 13.1

*

RSC-4.e: Excludes members who received an initial HRA but were subsequently Data Element 13.1
deemed ineligible because they were never enrolled in the plan. [Data
Element 13.1]

Review Results:

RSC-5: Organization data passes data integrity checks listed below:

Data Sources:

2.e

RSC-4.e

2.e

RSC-5

2.e

RSC-5.a

RSC-5.a: The number of initial HRAs performed on new enrollees (Data
Element 13.3) does not exceed the number of new enrollees (Data Element
13.1).
[Data Element 13.3]

Data Element 13.3

Review Results:

2.e

RSC-5.b

RSC-5.b: The number of annual re-assessments performed (Data Element 13.6) Data Element 13.6
does not exceed number of enrollees eligible for annual HRA (Data Element
13.2).
[Data Element 13.6]

Review Results:

2.e

RSC-5.c

RSC-5.c: Number of initial HRAs refusals (Data Element 13.4) does not exceed
number of new enrollees (Data Element 13.1).
[Data Element 13.4]

Data Element 13.4

Review Results:

2.e

RSC-5.d

RSC-5.d: Number of annual reassessment refusals (Data Element 13.7) does
not exceed the number of enrollees eligible for an annual reassessment HRA
(Data Element 13.2).
[Data Element 13.7]

Data Element 13.7

Review Results:

2.e

RSC-5.e

RSC-5.e: Number of initial HRAs where SNP is unable to reach enrollees (Data Data Element 13.5
Element 13.5) does not exceed number of new enrollees (Data Element 13.1).
[Data Element 13.5]

Review Results:

2.e

RSC-5.f

RSC-5.f: Number of annual reassessments where SNP is unable to reach
Data Element 13.8
enrollee (Data Element 13.8) does not exceed number of enrollees eligible for
annual HRA (Data Element 13.2).
[Data Element 13.8]

Review Results:

2.e

RSC-5.g

RSC-5.g: If the organization received a CMS outlier/data integrity notice
validate whether or not an internal procedure change was warranted or
resubmission through HPMS.

Review Results:

2.e

RSC-6

RSC-6: Organization accurately calculates the number of members eligible for an annual health risk
reassessment during the reporting period, including the following criteria:

Data Sources:

2.e

RSC-6.a

RSC-6.a: Includes members who were enrolled in the same plan for more than Data Element 13.2
90 days after the effective date of enrollment in the same plan without
receiving an initial HRA.
[Data Element 13.2]

Review Results:

Data Element 13.1 13.8

*

*

2.e

RSC-6.b

RSC-6.b: Includes members who remained continuously enrolled in the same Data Element 13.2
plan for 365 days, starting from the initial day of enrollment if no initial HRA
had been performed, or from the date of their previous HRA. [Data Element
13.2]

Review Results:

2.e

RSC-6.c

RSC-6.c: Includes members who received a reassessment during the
measurement year within 365 days after their last HRA.
[Data Element 13.2]

Data Element 13.2

Review Results:

2.e

RSC-6.d

RSC-6.d: Includes members who dis-enrolled from and re-enrolled into the
Data Element 13.2
same plan if an initial HRA was performed within 90 days of re-enrollment and
the member has continuously enrolled in the same plan for up to 365 days
since the initial HRA.
[Data Element 13.2]

Review Results:

2.e

RSC-6.e

RSC-6.e: Includes members who dis-enrolled from and re-enrolled into the
Data Element 13.2
same plan if an initial HRA or reassessment was not performed within 90 days
of re-enrollment. The enrollee becomes eligible for a reassessment HRA the
day after the 90-day initial period expires.
[Data Element 13.2]

Review Results:

2.e

RSC-6.f

RSC-6.f. Excludes members who received a reassessment but were
Data Element 13.2
subsequently deemed ineligible because they were never enrolled in the plan.
[Data Element 13.2]

Review Results:

2.e

RSC-6.g

RSC-6.g: Excludes members who were not continuously enrolled in their same Data Element 13.2
health plan for 365 days after their last HRA and did not receive a
reassessment HRA.
[Data Element 13.2]

Review Results:

2.e

RSC-7

RSC-7: Organization accurately calculates the number of initial health risk assessments performed on
new members, including the following criteria
[Note to reviewer: CMS has not identified a standard tool that SNPs must use to complete initial and
annual health risk assessments. Reviewer should confirm that the SNP maintained documentation for
each reported assessment.]:

Data Sources:

2.e

RSC-7.a

RSC-7.a: Includes only initial HRAs performed on new members within 90 days Data Element 13.3
before or after the effective date of enrollment/re-enrollment. [Data Element
13.3]

Review Results:

2.e

RSC-7.b

RSC-7.b: The initial HRA is counted in the year that the effective date of
Data Element 13.3
enrollment occurred. For members who dis-enrolled from and re-enrolled into
the same plan, excludes any HRAs (initial or reassessment) performed during
their previous enrollment unless the re-enrollment occurred the day after the
disenrollment.
[Data Element 13.3]

Review Results:

2.e

RSC-7.c

RSC-7.c: For members who dis-enrolled from and re-enrolled into the same
plan, excludes any HRAs (initial or reassessment) performed during their
previous enrollment unless the re-enrollment occurred the day after the
disenrollment. [Data Element 13.3]

Data Element 13.3

Review Results:

2.e

RSC-7.d

RSC-7.d: Counts only one HRA for members who have multiple HRAs within 90 Data Element 13.3
days before or after the effective date of enrollment.
[Data Element 13.3]

Review Results:

*

2.e

RSC-7.e

2.e

RSC-8

2.e

RSC-7.e: Excludes HRAs completed for members who were subsequently
deemed ineligible because they were never enrolled in the plan.
[Data Element 13.3]

Data Element 13.3

Review Results:

Organization accurately calculates the number of initial health risk assessments refusals, including the
following criteria:

Data Sources:

RSC-8.a

RSC-8.a: Includes only initial HRAs that were not performed within 90 days
Data Element 13.4
before or after the effective date of enrollment/re-enrollment due to enrollee
refusal.
[Data Element 13.4]

Review Results:

2.e

RSC-8.b

RSC-8.b: Includes only initial HRA refusals for which the SNP has
documentation of enrollee refusal.
[Data Element 13.4]

Review Results:

2.e

RSC-9

2.e

Data Element 13.4

Organization accurately calculates the number of initial health risk assessments not performed due to
SNP not being able to reach the enrollee, including the following criteria:

Data Sources:

RSC-9.a

RSC-9.a: Includes only initial HRAs not performed for which the SNP has
documentation showing that enrollee did not respond to the SNP’s attempts
to reach him/her. Documentation must show that the SNP made at least 3
phone calls and sent a follow-up letter in its attempts to reach the enrollee.
[Data Element 13.5]

Data Element 13.5

Review Results:

2.e

RSC-9.b

RSC-9.b: Includes only those initial HRAs not performed where the SNP made
an attempt to reach the enrollee, at least within 90 days (before or after) of
the effective enrollment date. [Data Element 13.5]

Data Element 13.5

Review Results:

2.e

RSC-10

RSC-10: Organization accurately calculates the number of annual health risk reassessments performed
on members eligible for a reassessment, including the following criteria.
[Note to reviewer: CMS has not identified a standard tool that SNPs must use to complete initial and
annual health risk assessments. Reviewer should confirm that the SNP maintained documentation for
each reported assessment.]:

Data Sources:

2.e

RSC-10.a

RSC-10.a: Includes annual HRA reassessments that were completed within 365 Data Element 13.6
days of the member becoming eligible for a reassessment
[Data Element 13.6]

Review Results:

2.e

RSC-10.b

RSC-10.b: Includes annual HRA reassessments within 365 days of the
member's initial date of enrollment if the member did not receive an initial
HRA within 90 days before or after the effective date of enrollment.
[Data Element 13.6]

Data Element 13.6

Review Results:

2.e

RSC-10.c

RSC-10.c: Includes only HRAs that were performed between 1/1 and 12/31 of
the measurement year.
[Data Element 13.6]

Data Element 13.6

Review Results:

*

*

*

2.e

RSC-10.d

RSC-10.d: Counts only one HRA for members who have multiple reassessments Data Element 13.6
within 365 days of becoming eligible for a reassessment.
[Data Element 13.6]

Review Results:

2.e

RSC-10.e

RSC-10.e: Excludes HRAs completed for members who were subsequently
deemed ineligible because they were never enrolled in the plan. [Data
Element 13.6]

Review Results:

2.e

RSC-11

2.e

Data Element 13.6

Organization accurately calculates the number of annual health risk reassessments not performed on
members eligible for a reassessment due to enrollee refusal.

Data Sources:

RSC-11.a

RSC-11.a: Only includes annual reassessments not performed due to enrollee
refusal. [Data Element 13.7]

Data Element 13.7

Review Results:

2.e

RSC-11.b

RSC-11.b: Includes only annual reassessments refusals for which the SNP has
documentation of enrollee refusal. [Data Element 13.7]

Data Element 13.7

Review Results:

2.e

RSC-12

2.e

RSC-12.a

Organization accurately calculates the number of annual health risk reassessments not performed on
members eligible for a reassessment due to SNP not being able to reach enrollee.

Data Sources:

RSC-12.a: Only includes annual reassessments not performed for which the
Data Element 13.8
SNP has documentation showing that the enrollee did not respond to the
plan’s attempts to reach him/her. Documentation must show that the SNP
made at least 3 phone calls and sent a follow-up letter in its attempts to reach
the enrollee. [Data Element 13.8]

Review Results:

Organization implements policies and procedures for data submission, including the following:

Data Sources:

3.a

Data elements are accurately entered/uploaded into CMS systems and entries Data Element 13.1
match corresponding source documents.

Review Results:

3.a

Data Element 13.2

Review Results:

3.a

Data Element 13.3

Review Results:

3

*

*

*

3.a

Data Element 13.4

Review Results:

3.a

Data Element 13.5

Review Results:

3.a

Data Element 13.6

Review Results:

3.a

Data Element 13.7

Review Results:

3.a

Data Element 13.8

Review Results:

3.b

All source, intermediate, and final stage data sets and other outputs relied upon to enter data into
CMS systems are archived.

Review Results:

4

Organization implements policies and procedures for periodic data system updates (e.g., changes in
enrollment, provider/pharmacy status, claims adjustments).

Review Results:

5

Organization implements policies and procedures for archiving and restoring data in each data system
(e.g., disaster recovery plan).

Review Results:

6

If organization’s data systems underwent any changes during the reporting period (e.g., as a result of a
merger, acquisition, or upgrade): Organization provided documentation on the data system changes
and, upon review, there were no issues that adversely impacted data reported.

Review Results:

7

If data collection and/or reporting for this reporting section is delegated to another entity:
Organization regularly monitors the quality and timeliness of the data collected and/or reported by
the delegated entity or first tier/ downstream contractor.

Review Results:

MT-v1.1

Medication Therapy Management (MTM) Programs (Part D) 2017

Organization Name:
Contract Number:
Reporting Section:

Medication Therapy Management (MTM) Programs (Part D) 2017

Last Updated:

MM/DD/YYYY

Date of Site Visit:
Last name, First name

Name of Peer Reviewer:

Last name, First name

Standard/
Sub-standard
ID

Re
po
Cr rtin
it e g S
ria ec
ID tio
n

Name of Reviewer:

Standard/Sub-standard Description

1) In the "Data Sources and Review Results:" column, enter the review results and/or data
sources used for each standard or sub-standard.
2) Enter "Y" if the requirements for the standard or sub-standard have been completely met. If
any requirement for the standard or sub-standard has not been met, enter "N". If any standard
or sub-standard does not apply, enter "N/A".
3) For standards 1c, 1d, 1e, 1g, 1h, and 2e, enter 'Findings' as follows based on the five-point
scale: Select "1" if plan data has more than 20% error, select "2" if plan data has between 15.1% 20.0% error, select "3" if plan data has between 10.1% - 15.0% error, select "4" if plan data has
between 5.1% - 10.0% error, select "5" if plan data has less than or equal to a 5% error. Enter
"N/A" if standard does not apply.

Data Sources and Review Results:
Enter review results and/or data sources

Enter 'Findings' using
the applicable choice
in the appropriate
cells. Cells marked
with an '*' should not
be edited.

Note to reviewer: If the Part D sponsor has no MTM members, then it is not required to report this data and data validation is not required for this reporting section.
A review of source documents (e.g., programming code, spreadsheet formulas,
analysis plans, saved data queries, file layouts, process flows) indicates that all
source documents accurately capture required data fields and are properly
documented.

Data Sources:

1.a

Source documents are properly secured so that source documents can be retrieved
at any time to validate the information submitted to CMS via CMS systems.

Review Results:

1.b

Source documents create all required data fields for reporting requirements.

Review Results:

1.c

Source documents are error-free (e.g., programming code and spreadsheet formulas
have no messages or warnings indicating errors, use correct fields, have appropriate
data selection, etc.).

Review Results:

1.d

All data fields have meaningful, consistent labels (e.g., label field for patient ID as
Patient ID, rather than Field1 and maintain the same field name across data sets).

Review Results:

1.e

Data file locations are referenced correctly.

Review Results:

1.f

If used, macros are properly documented.

Review Results:

1.g

Source documents are clearly and adequately documented.

Review Results:

1

*

1.h

Titles and footnotes on reports and tables are accurate.

Review Results:

1.i

Version control of source documents is appropriately applied.

Review Results:

2

A review of source documents (e.g., programming code, spreadsheet formulas,
analysis plans, saved data queries, file layouts, process flows) and census or sample
data, whichever is applicable, indicates that data elements for each reporting section
are accurately identified, processed, and calculated.

Data Sources:

The appropriate date range(s) for the reporting period(s) is captured.

Review Results:

2.a

RSC-1

*

Organization reports data based on the required reporting period of 1/1 through
12/31.

2.b

RSC-2

Data are assigned at the applicable level (e.g., plan benefit package or contract
level).

Review Results:

Organization properly assigns data to the applicable CMS contract.

2.c

RSC-3

Appropriate deadlines are met for reporting data (e.g., quarterly).

Review Results:

Organization meets deadline for reporting annual data to CMS by 2/26/2018.
[Note to reviewer: If the organization has, for any reason, re-submitted its data to
CMS for this reporting section, the reviewer should verify that the organization’s
original data submissions met the CMS deadline in order to have a finding of “yes”
for this reporting section criterion. However, if the organization re-submits data for
any reason and if the re-submission was completed by 3/31 of the data validation
year, the reviewer should use the organization’s corrected data submission(s) for
the rest of the reporting section criteria for this reporting section.]
2.d

RSC-4

Terms used are properly defined per CMS regulations, guidance and Reporting
Requirements Technical Specifications.

Review Results:

Organization properly defines the MTM program services per CMS definitions, such
as Comprehensive Medication Review (CMR) with written summary and Targeted
Medication Review (TMR) in accordance with the annual MTM Program Guidance
and Submission memo posted on the CMS MTM web page. This includes applying all
relevant guidance properly when performing its calculations and categorizations.
Data Sources:

2.e

RSC-5

Organization data passes data integrity checks listed below:

2.e

RSC-5.a

RSC-5.a: Date of MTM program enrollment (Data Element I)
is within the reporting period (between 1/1/2017 and
12/31/2017).

Data Element I

Review Results:

2.e

RSC-5.b

RSC-5.b: One record is entered for each unique beneficiary
i.e. only one record exists for a unique HICN or RRB number.

Data Element B

Review Results:

*

2.e

RSC-5.c

RSC-5.c: Only reports beneficiaries enrolled in the contract
during the reporting period, i.e. HICN or RRB Number (Data
Element B) maps to a beneficiary enrolled at any point
during the reporting year for the given Contract Number
(Data Element A).

Data Element B

Review Results:

2.e

RSC-5.d

RSC-5.d: CMR received date (Data Element Q) is within the
beneficiary's MTM enrollment period.

Data Element Q

Review Results:

2.e

RSC-5.e

RSC - 5.e: If the beneficiary was identified as cognitively
impaired at time of CMS offer or delivery (Data Element H =
Yes), the beneficiary should have been offered a CMR (Data
Element M = Yes).

Data Element M

Review Results:

2.e

RSC-5.f

RSC-5.f: If beneficiary was offered or received a CMR (Data
Element M = Yes or Data Element O = Yes), the contract
should report if beneficiary was cognitively impaired at time
of CMR offer or delivery (Data Element H ≠ missing).

Data Element H

Review Results:

2.e

RSC-5.g

RSC-5.g: If beneficiary met the specified targeting criteria
per CMS-Part D Requirements (Data Element G = Yes), then
the contract should report the date the beneficiary met the
specified targeting criteria (Data Element J ≠ missing).

Data Element J

Review Results:

2.e

RSC-5.h

RSC-5.h: If beneficiary did not meet the specified targeting
criteria per CMS-Part D Requirements (Data Element G =
No), then the field for ‘date meets the specified targeting
criteria’ (Data Element J) should be missing.

Data Element J

Review Results:

2.e

RSC-5.i

RSC-5.i: If contract reports beneficiaries that were not
eligible according to CMS-Part D Requirements (Data
Element G = No), then Contract's MTM program submission
information should indicate that contract uses expanded
eligibility (Targeting Criteria for Eligibility in the MTMP ≠
Only enrollees who meet the specified targeting criteria per
CMS requirements).

Data Element G

Review Results:

2.e

RSC-5.j

RSC-5.j: If beneficiary opted out (Data Element K ≠ missing)
then contract should provide an opt-out reason (Data
Element L should not be missing).

Data Element L

Review Results:

2.e

RSC-5.k

RSC-5.k: If the beneficiary did not opt-out (Data Element K =
missing), the field for opt-out reason should be missing
(Data Element L = missing).

Data Element L

Review Results:

2.e

RSC-5.l

RSC-5.l: Date of MTM program opt-out (Data Element K)
should not be before the date of MTM program enrollment
(Data Element I).

Data Element K

Review Results:

2.e

RSC-5.m

RSC-5.m: Date of (initial) CMR offer (Data Element N) should
either be between the beneficiary’s MTM enrollment date
(Data Element I) and 12/31/2017 or the beneficiary’s opt out
date (Data Element K).

Data Element N

Review Results:

2.e

RSC-5.n

RSC-5.n: If a CMR was offered (Data Element M = Yes), there
is also a reported offer date (Data Element N ≠ missing).

Data Element N

Review Results:

2.e

RSC-5.o

RSC-5.o: If a CMR was not offered (Data Element M = No),
there is no reported offer date (Data Element N = missing).

Data Element N

Review Results:

2.e

RSC-5.p

RSC-5.p: If a CMR was received (Data Element O = Yes),
there is a reported number of CMRs (Data Element P ≠
missing or > 0).

Data Element P

Review Results:

2.e

RSC-5.q

RSC-5.q: If no CMRs were received (Data Element O = No),
there are no reported number for CMRs (Data Element P =
missing or 0).

Data Element P

Review Results:

2.e

RSC-5.r

RSC-5.r: If a CMR was received (Data Element O = Yes), there
is a reported delivery date(s) (Data Element Q ≠ missing)

Data Element Q

Review Results:

2.e

RSC-5.s

RSC-5.s: If a CMR was not received (Data Element O = No),
there are no reported delivery date(s) (Data Element Q =
missing).

Data Element Q

Review Results:

2.e

RSC-5.t

RSC-5.t: If a CMR was received, then the Number of CMRs
received (Data Element P) aligns with number of reported
dates of CMRs (Data Element Q) [ex: If Data Element P = 4
then Data Element Q reports 2 CMR dates].

Data Element P

Review Results:

2.e

RSC-5.u

RSC-5.u: If records indicate that beneficiary received CMR
(Data Element O = Yes), then indicator for CMR offered
(Data element M ≠ No).

Data Element M

Review Results:

2.e

RSC-5.v

RSC-5.v: CMR offer date (Data Element N) is before the CMR
received date (Data Element Q).

Data Element N

Review Results:

2.e

RSC-5.w

RSC-5.w: If a CMR was received (Data Element O = Yes),
there is a reported method of delivery (Data Element R ≠
missing).

Data Element R

Review Results:

2.e

RSC-5.x

RSC-5.x: If a CMR was not received (Data Element O = No),
there is no reported method of CMR delivery (Data Element
R = missing).

Data Element R

Review Results:

2.e

RSC-5.y

RSC-5.y: If a CMR was received Data Element (Data Element
O = Yes), there is a reported provider who performed the
CMR (Data Element S ≠ missing).

Data Element S

Review Results:

2.e

RSC-5.z

RSC-5.z: If a CMR was not received (Data Element O = No),
there is no reported provider who performed the CMR (Data
Element S = missing).

Data Element S

Review Results:

2.e

RSC-5.aa

RSC-5.aa: If a CMR was received (Data Element O = Yes),
there is reported recipient of CMR (Data Element T ≠
missing).

Data Element T

Review Results:

2.e

RSC-5.bb

RSC-5.bb: If a CMR was not received (Data Element O = No),
there is no reported recipient of CMR (Data Element T =
missing).

Data Element T

Review Results:

2.e

RSC-5.cc

RSC-5.cc: If the organization received a CMS outlier/data
integrity notice validate whether or not an internal
procedure change was warranted or resubmission through
HPMS.

Data Element A-T

Review Results:

2.e

RSC-6

2.e

RSC-6.a

2.e

RSC-6.a

The number of expected counts (e.g., number of members, claims, grievances,
procedures) are verified; ranges of data fields are verified; all calculations (e.g.,
derived data fields) are verified; missing data has been properly addressed;
reporting output matches corresponding source documents (e.g., programming
code, saved queries, analysis plans); version control of reported data elements is
appropriately applied; QA checks/thresholds are applied to detect outlier or
erroneous data prior to data submission.

Data Sources:

A
li blProperly
R
tiidentifies
S ti and
C itincludes
i
RSC-6.a:
members who
either met the specified targeting criteria per CMS Part D
requirements or other expanded plan-specific targeting
criteria at any time during the reporting period. [Data
Elements B, C, D, E, F, G, H, I, J]

Data Element B

Review Results:

Data Element C

Review Results:

*

2.e

RSC-6.a

Data Element D

Review Results:

2.e

RSC-6.a

Data Element E

Review Results:

2.e

RSC-6.a

Data Element F

Review Results:

2.e

RSC-6.a

Data Element G

Review Results:

2.e

RSC-6.a

Data Element H

Review Results:

2.e

RSC-6.a

Data Element I

Review Results:

2.e

RSC-6.a

Data Element J

Review Results:

2.e

RSC-6.b

RSC-6.b: Includes the ingredient cost, dispensing fee, sales Data Element G
tax, and the vaccine administration fee (if applicable) when
determining if the total annual cost of a member’s covered
Part D drugs is likely to equal or exceed the specified annual
cost threshold for MTM program eligibility. [Data Element
G]

Review Results:

2.e

RSC-6.c

RSC-6.c: Includes continuing MTM program members as well Data Element B
as members who were newly identified and auto-enrolled in
the MTM program at any time during the reporting period.
[Data Elements B, C, D, E, F, G, H, I, J]

Review Results:

2.e

RSC-6.c

Data Element C

Review Results:

2.e

RSC-6.c

Data Elements D

Review Results:

2.e

RSC-6.c

Data Elements E

Review Results:

2.e

RSC-6.c

Data Elements F

Review Results:

2.e

RSC-6.c

Data Element G

Review Results:

2.e

RSC-6.c

Data Element H

Review Results:

2.e

RSC-6.c

Data Element I

Review Results:

2.e

RSC-6.c

Data Element J

Review Results:

2.e

RSC-6.d

Data Element B

Review Results:

2.e

RSC-6.d

Data Element C

Review Results:

2.e

RSC-6.d

Data Element D

Review Results:

RSC-6.d: Includes and reports each targeted member,
reported once per contract year per contract file, based on
the member's most current HICN.
[Data
Elements B, C, D, E, F, G, H, I, J]

2.e

RSC-6.d

Data Element E

Review Results:

2.e

RSC-6.d

Data Element F

Review Results:

2.e

RSC-6.d

Data Element G

Review Results:

2.e

RSC-6.d

Data Element H

Review Results:

2.e

RSC-6.d

Data Element I

Review Results:

2.e

RSC-6.d

Data Element J

Review Results:

2.e

RSC-6.e

Data Element B

Review Results:

2.e

RSC-6.e

Data Element C

Review Results:

2.e

RSC-6.e

Data Element D

Review Results:

2.e

RSC-6.e

Data Element E

Review Results:

RSC-6.e: Excludes members deceased prior to their MTM
eligibility date. [Data Elements B, C, D, E, F, G, H, I, J]

2.e

RSC-6.e

Data Element F

Review Results:

2.e

RSC-6.e

Data Element G

Review Results:

2.e

RSC-6.e

Data Element H

Review Results:

2.e

RSC-6.e

Data Element I

Review Results:

2.e

RSC-6.e

Data Element J

Review Results:

2.e

RSC-6.f

RSC-6.f: Includes members who receive MTM services based Data Element B
on plan-specific MTM criteria defined by the plan. [Data
Elements B, C, D, E, F, G, H, I, J]

Review Results:

2.e

RSC-6.f

Data Element C

Review Results:

2.e

RSC-6.f

Data Element D

Review Results:

2.e

RSC-6.f

Data Element E

Review Results:

2.e

RSC-6.f

Data Element F

Review Results:

2.e

RSC-6.f

Data Element G

Review Results:

2.e

RSC-6.f

Data Element H

Review Results:

2.e

RSC-6.f

Data Element I

Review Results:

2.e

RSC-6.f

Data Element J

Review Results:

2.e

RSC-6.g

RSC-6.g: Properly identifies and includes members’ date of
MTM program enrollment (i.e., date they were
automatically enrolled) that occurs within the reporting
period. [Data Element I]

Data Element I

Review Results:

2.e

RSC-6.h

RSC-6.h: For those members who met the specified
targeting criteria per CMS Part D requirements, properly
identifies the date the member met the specified targeting
criteria. [Data Element J]

Data Element J

Review Results:

2.e

RSC-6.i

RSC-6.i: Includes members who moved between contracts in Data Element B
each corresponding file uploaded to Gentran. Dates of
enrollment, disenrollment elements, and other elements
(e.g., TMR/CMR data) are specific to the activity that
occurred for the member within each contract. [Data
Elements B, C, D, E, F, G, H, I, J]

Review Results:

2.e

RSC-6.i

Data Element C

Review Results:

2.e

RSC-6.i

Data Element D

Review Results:

2.e

RSC-6.i

Data Element E

Review Results:

2.e

RSC-6.i

Data Element F

Review Results:

2.e

RSC-6.i

Data Element G

Review Results:

2.e

RSC-6.i

Data Element H

Review Results:

2.e

RSC-6.i

Data Element I

Review Results:

2.e

RSC-6.i

Data Element J

Review Results:

2.e

RSC-6.j

Data Element B

Review Results:

2.e

RSC-6.j

Data Element C

Review Results:

2.e

RSC-6.j

Data Element D

Review Results:

2.e

RSC-6.j

Data Element E

Review Results:

2.e

RSC-6.j

Data Element F

Review Results:

RSC-6.j: Counts each member who disenrolls from and reenrolls in the same contract once.
[Data
Elements B, C, D, E, F, G, H, I, J]

2.e

RSC-6.j

Data Element G

Review Results:

2.e

RSC-6.j

Data Element H

Review Results:

2.e

RSC-6.j

Data Element I

Review Results:

2.e

RSC-6.j

Data Element J

Review Results:

2.e

RSC-7

2.e

RSC-7.a

2.e

RSC-8

2.e

Organization accurately identifies MTM eligible who are cognitively impaired at the
time of CMR offer or delivery of CMR and uploads it into Gentran, including the
following criteria:

Data Sources:

RSC-7.a: Properly identifies and includes whether each
Data Element H
member was cognitively impaired and reports this status as
of the date of the CMR offer or delivery of CMR. [Data
Element H]

Review Results:

RSC-8: Organization accurately identifies data on members who opted-out of
enrollment in the MTM program and uploads it into Gentran, including the following
criteria:

Data Sources:

RSC-8.a

RSC-8.a: Properly identifies and includes members' date of
MTM program opt-out that occurs within the reporting
period, but prior to 12/31. [Data Element K]

Data Element K

Review Results:

2.e

RSC-8.b

RSC-8.b: Properly identifies and includes the reason
Data Element L
participant opted-out of the MTM program for every
applicable member with an opt-out date completed (death,
disenrollment, request by member, other reason). [Data
Element L]

Review Results:

2.e

RSC-8.c

RSC-8.c: Excludes members who refuse or decline individual Data Elements K
services without opting-out (disenrolling) from the MTM
program. [Data Elements K,L]

Review Results:

*

*

2.e

RSC-8.c

Data Elements L

Review Results:

2.e

RSC-8.d

RSC-8.d: Excludes members who disenroll from and re-enroll Data Elements K
in the same contract regardless of the duration of if the gap
of MTM program enrollment [Data Elements K,L]

Review Results:

2.e

RSC-8.d

Data Elements L

Review Results:

2.e

RSC-9

2.e

RSC-9: Organization accurately identifies data on CMR offers and uploads it into
Gentran, including the following criteria:

Data Sources:

RSC-9.a

RSC-9.a: Properly identifies and includes MTM program
members who were offered a CMR per CMS Part D
requirements during the reporting period. [Data Element
M]

Data Element M

Review Results:

2.e

RSC-9.b

RSC-9.b: Properly identifies and includes members' date of Data Element N
initial offer of a CMR that occurs within the reporting period.
[Data Element N]

Review Results:

2.e

RSC-10

RSC-10 Organization accurately identifies data on CMR dates and uploads it into
Gentran, including the following criteria:

Data Sources:

2.e

RSC-10.a

RSC-10.a: Properly identifies and includes the number of
CMRs the member received, if applicable, with written
summary in CMS standardized format.
[Data
Elements O, P]

Data Elements O

Review Results:

2.e

RSC-10.a

Data Elements P

Review Results:

2.e

RSC-10.b

RSC-10.b: Properly identifies and includes the date(s) (up to Data Element Q
two) the member received a CMR, if applicable. The date
occurs within the reporting period, is completed for every
member with a “Y” entered for Field Name “Received annual
CMR with written summary in CMS standardized format,”
and if more than one comprehensive medication review
occurred, includes the date of the first CMR and last CMR.
[Data Element Q]

Review Results:

*

*

2.e

RSC-10.c

RSC-10.c: Properly identifies and includes the method of
Data Element R
delivery for the initial CMR received by the member; if more
than one CMR is received, the method of delivery for only
the initial CMR is reported. The method of delivery must be
reported as one of the following: Face-to-Face, Telephone,
Telehealth Consultation, or Other. [Data Element R]

Review Results:

2.e

RSC-10.d

Review Results:

2.e

RSC-10.e

RSC-10.d: Properly identifies and includes the qualified
Data Element S
provider who performed the initial CMR; if more than one
CMR is received, the qualified provider for only the initial
CMR is reported. The qualified provider must be reported as
one of the following: Physician, Registered Nurse, Licensed
Practical Nurse, Nurse Practitioner, Physician’s Assistant,
Local Pharmacist, LTC Consultant Pharmacist, Plan Sponsor
Pharmacist, Plan Benefit Manager (PBM) _Pharmacist, MTM
Vendor Local Pharmacist, MTM Vendor In-house Pharmacist,
Hospital Pharmacist, Pharmacist – Other, or Other. [Data
Element S]
RSC-10.e: Properly identifies the recipient of the annual
Data Element T
CMR; if more than one CMR is received, only the recipient of
the initial CMR is reported. The recipient of the CMR
interaction must be reported, not the recipient of the CMR
documentation. The recipient must be reported as one of
the following: Beneficiary, Beneficiary’s Prescriber,
Caregiver, or Other Authorized Individual. [Data Element T]

2.e

RSC-11

RSC-11: Organization accurately identifies data on MTM drug therapy problem
recommendations and uploads it into Gentran, including the following criteria:

Data Sources:

2.e

RSC-11.a

RSC-11.a: Properly identifies and includes all targeted
medication reviews within the reporting period for each
applicable member. [Data Element U]

Data Element U

Review Results:

2.e

RSC-11.b

RSC-11.b: Properly identifies and includes the number of
Data Element V
drug therapy problem recommendations made to
beneficiary's prescriber(s) as a result of MTM services
within the reporting period for each applicable member,
regardless of the success or result of the recommendations,
and counts these recommendations based on the number of
unique recommendations made to prescribers (e.g., the
number is not equal to the total number of prescribers that
received drug therapy problem recommendations from the
organization). Organization counts each individual drug
therapy problem identified per prescriber recommendation
(e.g., if the organization sent a prescriber a fax identifying 3
drug therapy problems for a member, this is reported as 3
recommendations). [Data Element V]

Review Results:

2.e

RSC-11.c

RSC-11.c: Properly identifies and includes the number of
Data Element W
drug therapy problem resolutions resulting from
recommendations made to beneficiary's prescriber(s) as a
result of MTM program services within the reporting period
for each applicable member. For reporting purposes, a
resolution is defined as a change or variation from the
beneficiary's previous drug therapy. Examples include, but
is not limited to Initiate drug, change drug (such as product
in different therapeutic class, dose, dosage form, quantity,
or interval), discontinue or substitute drug (such as
discontinue drug, generic substitution, or formulary
substitution), and Medication compliance/adherence .
[Note to reviewer: If the resolution was observed in the
calendar year after the current reporting period, but was
the result of an MTM recommendation made within the
current reporting period, the resolution may be reported for
the current reporting period. However, this resolution
cannot be reported again in the following reporting period.
[Data Element W]
Organization implements policies and procedures for data submission, including the
following:

Review Results:

3

Review Results:

Data Sources:

*

*

3.a

Data Element A

Review Results:

3.a

Data Element B

Review Results:

3.a

Data Element C

Review Results:

3.a

Data Element D

Review Results:

3.a

Data Element E

Review Results:

3.a

Data Element F

Review Results:

3.a

Data Element G

Review Results:

3.a

Data Element H

Review Results:

3.a

Data Element I

Review Results:

3.a

Data Element J

Review Results:

3.a

Data Element K

Review Results:

3.a

Data Element L

Review Results:

3.a

Data Element M

Review Results:

3.a

Data Element N

Review Results:

3.a

Data Element O

Review Results:

3.a

Data Element P

Review Results:

3.a

Data Element Q

Review Results:

3.a

Data Element R

Review Results:

3.a

Data Element S

Review Results:

3.a

Data Element T

Review Results:

3.a

Data Element U

Review Results:

3.a

Data Element V

Review Results:

3.a

Data Element W

Review Results:

3.b

All source, intermediate, and final stage data sets and other outputs relied upon to
enter data into CMS systems are archived.

Review Results:

4

Organization implements policies and procedures for periodic data system updates
(e.g., changes in enrollment, provider/pharmacy status, and claims adjustments).

Review Results:

5

Organization implements policies and procedures for archiving and restoring data in
each data system (e.g., disaster recovery plan).

Review Results:

6

If organization’s data systems underwent any changes during the reporting period
(e.g., as a result of a merger, acquisition, or upgrade): Organization provided
documentation on the data system changes and, upon review, there were no issues
that adversely impacted data reported.

Review Results:

7

If data collection and/or reporting for this reporting section is delegated to another
entity: Organization regularly monitors the quality and timeliness of the data
collected and/or reported by the delegated entity or first tier/ downstream
contractor.

Review Results:

GR-v1.1

Grievances (Part D) 2017

Organization Name:
Contract Number:
Reporting Section:

Grievances (Part D) 2017

Last Updated:

MM/DD/YYYY

Date of Site Visit:
Last name, First name

Name of Peer Reviewer:

Last name, First name

Standard/
Sub-standard
ID

Re
po
Cr rtin
it e g S
ria ec
ID tio
n

Name of Reviewer:

Standard/Sub-standard Description

1) In the "Data Sources and Review Results:" column, enter the review results and/or data
sources used for each standard or sub-standard.
2) Enter "Y" if the requirements for the standard or sub-standard have been completely
met. If any requirement for the standard or sub-standard has not been met, enter "N". If
any standard or sub-standard does not apply, enter "N/A".
3) For standards 1c, 1d, 1e, 1g, 1h, and 2e, enter 'Findings' as follows based on the five-point
scale: Select "1" if plan data has more than 20% error, select "2" if plan data has between
15.1% - 20.0% error, select "3" if plan data has between 10.1% - 15.0% error, select "4" if
plan data has between 5.1% - 10.0% error, select "5" if plan data has less than or equal to a
5% error. Enter "N/A" if standard does not apply.

Data Sources and Review Results:
Enter review results and/or data sources

A review of source documents (e.g., programming code, spreadsheet formulas,
analysis plans, saved data queries, file layouts, process flows) indicates that all
source documents accurately capture required data fields and are properly
documented.

Data Sources:

1.a

Source documents are properly secured so that source documents can be retrieved
at any time to validate the information submitted to CMS via CMS systems.

Review Results:

1.b

Source documents create all required data fields for reporting requirements.

Review Results:

1.c

Source documents are error-free (e.g., programming code and spreadsheet formulas
have no messages or warnings indicating errors, use correct fields, have appropriate
data selection, etc.).

Review Results:

1.d

All data fields have meaningful, consistent labels (e.g., label field for patient ID as
Patient_ID, rather than Field1 and maintain the same field name across data sets).

Review Results:

1.e

Data file locations are referenced correctly.

Review Results:

1.f

If used, macros are properly documented.

Review Results:

1.g

Source documents are clearly and adequately documented.

Review Results:

1

Enter 'Findings' using
the applicable choice in
the appropriate cells.
Cells marked with an '*'
should not be edited.
*

1.h

Titles and footnotes on reports and tables are accurate.

Review Results:

1.i

Version control of source documents is appropriately applied.

Review Results:

2

A review of source documents (e.g., programming code, spreadsheet formulas,
analysis plans, saved data queries, file layouts, process flows) and census or sample
data, whichever is applicable, indicates that data elements for each reporting section
are accurately identified, processed, and calculated.

Data Sources:

The appropriate date range(s) for the reporting period(s) is captured.

Review Results:

2.a

RSC-1

*

Organization reports data based on the periods of 1/1 through 3/31, 4/1 through
6/30, 7/1 through 9/30, and 10/1 through 12/31.

2.b

RSC-2

Data are assigned at the applicable level (e.g., plan benefit package or contract
level).

Review Results:

Organization properly assigns data to the applicable CMS contract.

2.c

RSC-3

Appropriate deadlines are met for reporting data (e.g., quarterly).

Review Results:

Organization meets deadlines for reporting data to CMS by 2/5/2018. [Note to
reviewer: If the organization has, for any reason, re-submitted its data to CMS for
this reporting section, the reviewer should verify that the organization’s original data
submissions met the CMS deadline in order to have a finding of “yes” for this
reporting section criterion. However, if the organization re-submits data for any
reason and if the re-submission was completed by 3/31 of the data validation year,
the reviewer should use the organization’s corrected data submission(s) for the rest
of the reporting section criteria for this reporting section.]
2.d

RSC-4

Terms used are properly defined per CMS regulations, guidance and Reporting
Requirements Technical Specifications.

Review Results:

Organization properly defines the term “Grievance” in accordance with 42 CFR
§423.564 and the Prescription Drug Benefit Manual Chapter 18, Sections 10 and 20.
This includes applying all relevant guidance properly when performing its
calculations and categorizations. Requests for coverage determinations, exceptions,
or redeterminations are not categorized as grievances.
Data Sources:

2.e

RSC-5

Organization data passes data integrity checks listed below:

2.e

RSC-5.a

RSC-5.a : Total grievances (Data Element A ) is equal to the
sum of grievances by reason (Data Element F + Data Element H
+ Data lement J + Data Element L + Data Element N + Data
Element P+ Data Element R + Data Element T + Data Element
V).

Data Elements A,
F, H, J, L, N, P, R, T,
V

Review Results:

2.e

RSC-5.b

RSC-5.b: Total grievances in which timely notification was
given (Data Element B) is equal to the sum of grievances in
which timely notification was given by reason (Data Element G
+ Data Element I + Data Element K + Data Element M + Data
Element O + Data Element Q + Data Element S + Data Element
U + Data Element W).

Data Elements B,
G, I, K, M, O, Q, S,
U, W

Review Results:

*

2.e

RSC-5.c

RSC-5.c: Number of expedited grievances (Data Element C)
does not exceed total grievances (Data Element A).

Data Element C

Review Results:

2.e

RSC-5.d

RSC-5.d: Number of expedited grievances in which timely
notification was given (Data Element D) does not exceed total
expedited grievances (Data Element C).

Data Element D

Review Results:

2.e

RSC-5.e

RSC-5.e: Number of dismissed grievances (Data Element E).

Data Element E

Review Results:

2.e

RSC-5.f

RSC-5.f: Number of enrollment/disenrollment grievances in
which timely notification was given (Data Element G) does not
exceed total enrollment/disenrollment grievances (Data
Element F).

Data Element G

Review Results:

2.e

RSC-5.g

RSC-5.g: Number of plan benefit grievances in which timely
notification was given (Data Element I) does not exceed total
plan benefit grievances (Data Element H).

Data Element I

Review Results:

2.e

RSC-5.h

RSC-5.h: Number of pharmacy access grievances in which
timely notification was given (Data Element K) does not exceed
total pharmacy access grievances (Data Element J).

Data Element K

Review Results:

2.e

RSC-5.i

RSC-5.i: Number of marketing grievances in which timely
notification was given (Data Element M) does not exceed total
marketing grievances (Data Element L).

Data Element M

Review Results:

2.e

RSC-5.j

RSC-5.j: Number of customer service grievances in which
timely notification was given (Data Element O) does not
exceed total customer service grievances (Data Element N).

Data Element O

Review Results:

2.e

RSC-5.k

RSC-5.k: Number of coverage determination and
redetermination process grievances in which timely
notification was given (Data Element Q) does not exceed total
coverage determination and redetermination process
grievances (Data Element P).

Data Element Q

Review Results:

2.e

RSC-5.l

RSC-5.l: Number of quality of care grievances in which timely
notification was given (Data Element S) does not exceed total
quality of care grievances (Data Element R).

Data Element S

Review Results:

2.e

RSC-5.m

RSC-5.m: Number of CMS issue grievances in which timely
notification was given (Data Element U) does not exceed total
CMS issue grievances (Data Element T).

Data Element U

Review Results:

2.e

RSC-5.n

RSC-5.n: Number of other grievances in which timely
notification was given (Data Element W) does not exceed total
other grievances (Data Element V).

Data Element W

Review Results:

2.e

RSC-5.o

RSC-5.o: If the organization received a CMS outlier/data
integrity notice validate whether or not an internal procedure
change was warranted or resubmission through HPMS.

Data Elements AW

Review Results:

2.e

RSC-6

2.e

RSC-6.a

2.e

RSC-6.a

Data Element B

Review Results:

2.e

RSC-6.a

Data Element C

Review Results:

2.e

RSC-6.a

Data Element D

Review Results:

2.e

RSC-6.a

Data Element E

Review Results:

2.e

RSC-6.a

Data Element F

Review Results:

The number of expected counts (e.g., number of members, claims, grievances,
procedures) are verified; ranges of data fields are verified; all calculations (e.g.,
derived data fields) are verified; missing data has been properly addressed;
reporting output matches corresponding source documents (e.g., programming
code, saved queries, analysis plans); version control of reported data elements is
appropriately applied; QA checks/thresholds are applied to detect outlier or
erroneous data prior to data submission.
RSC-5: Organization accurately calculates the total number of grievances, including
the following criteria:
RSC-6.a: Includes all grievances with a date of decision that
Data Element A
occurs during the reporting period, regardless of when the
grievance was received or completed (i.e., organization
notified member of its decision).
[Data Elements A-W]

Data Sources:

Review Results:

*

2.e

RSC-6.a

Data Element G

Review Results:

2.e

RSC-6.a

Data Element H

Review Results:

2.e

RSC-6.a

Data Element I

Review Results:

2.e

RSC-6.a

Data Element J

Review Results:

2.e

RSC-6.a

Data Element K

Review Results:

2.e

RSC-6.a

Data Element L

Review Results:

2.e

RSC-6.a

Data Element M

Review Results:

2.e

RSC-6.a

Data Element N

Review Results:

2.e

RSC-6.a

Data Element O

Review Results:

2.e

RSC-6.a

Data Element P

Review Results:

2.e

RSC-6.a

Data Element Q

Review Results:

2.e

RSC-6.a

Data Element R

Review Results:

2.e

RSC-6.a

Data Element S

Review Results:

2.e

RSC-6.a

Data Element T

Review Results:

2.e

RSC-6.a

Data Element U

Review Results:

2.e

RSC-6.a

Data Element V

Review Results:

2.e

RSC-6.a

Data Element W

Review Results:

2.e

RSC-6.b

RSC-6.b: If a grievance contains multiple issues filed by a single Data Element A
complainant, each issue is calculated as a separate grievance.
[Data Elements A-W]

Review Results:

2.e

RSC-6.b

Data Element B

Review Results:

2.e

RSC-6.b

Data Element C

Review Results:

2.e

RSC-6.b

Data Element D

Review Results:

2.e

RSC-6.b

Data Element E

Review Results:

2.e

RSC-6.b

Data Element F

Review Results:

2.e

RSC-6.b

Data Element G

Review Results:

2.e

RSC-6.b

Data Element H

Review Results:

2.e

RSC-6.b

Data Element I

Review Results:

2.e

RSC-6.b

Data Element J

Review Results:

2.e

RSC-6.b

Data Element K

Review Results:

2.e

RSC-6.b

Data Element L

Review Results:

2.e

RSC-6.b

Data Element M

Review Results:

2.e

RSC-6.b

Data Element N

Review Results:

2.e

RSC-6.b

Data Element O

Review Results:

2.e

RSC-6.b

Data Element P

Review Results:

2.e

RSC-6.b

Data Element Q

Review Results:

2.e

RSC-6.b

Data Element R

Review Results:

2.e

RSC-6.b

Data Element S

Review Results:

2.e

RSC-6.b

Data Element T

Review Results:

2.e

RSC-6.b

Data Element U

Review Results:

2.e

RSC-6.b

Data Element V

Review Results:

2.e

RSC-6.b

Data Element W

Review Results:

Data Element A

Review Results:

RSC-6.c

Data Element B

Review Results:

2.e

RSC-6.c

Data Element C

Review Results:

2.e

RSC-6.c

Data Element D

Review Results:

2.e

RSC-6.c

Data Element E

Review Results:

2.e

RSC-6.c

Data Element F

Review Results:

2.e

RSC-6.c

Data Element G

Review Results:

2.e

RSC-6.c

Data Element H

Review Results:

2.e

RSC-6.c

Data Element I

Review Results:

2.e

RSC-6.c

Data Element J

Review Results:

2.e

RSC-6.c

2.e

RSC-6.c: If a member files a grievance and then files a
subsequent grievance on the same issue prior to the
organization’s decision or deadline for decision notification
(whichever is earlier), then the issue is counted as one
grievance.
[Data Elements A-W]

2.e

RSC-6.c

Data Element K

Review Results:

2.e

RSC-6.c

Data Element L

Review Results:

2.e

RSC-6.c

Data Element M

Review Results:

2.e

RSC-6.c

Data Element N

Review Results:

2.e

RSC-6.c

Data Element O

Review Results:

2.e

RSC-6.c

Data Element P

Review Results:

2.e

RSC-6.c

Data Element Q

Review Results:

2.e

RSC-6.c

Data Element R

Review Results:

2.e

RSC-6.c

Data Element S

Review Results:

2.e

RSC-6.c

Data Element T

Review Results:

2.e

RSC-6.c

Data Element U

Review Results:

2.e

RSC-6.c

Data Element V

Review Results:

2.e

RSC-6.c

Data Element W

Review Results:

2.e

RSC-6.d

Data Element A

Review Results:

2.e

RSC-6.d

Data Element B

Review Results:

2.e

RSC-6.d

Data Element C

Review Results:

2.e

RSC-6.d

Data Element D

Review Results:

2.e

RSC-6.d

Data Element E

Review Results:

2.e

RSC-6.d

Data Element F

Review Results:

2.e

RSC-6.d

Data Element G

Review Results:

RSC-6.d: If a member files a grievance and then files a
subsequent grievance on the same issue after the
organization’s decision or deadline for decision notification
(whichever is earlier), then the issue is counted as a separate
grievance.
[Data Elements A-W]

2.e

RSC-6.d

Data Element H

Review Results:

2.e

RSC-6.d

Data Element I

Review Results:

2.e

RSC-6.d

Data Element J

Review Results:

2.e

RSC-6.d

Data Element K

Review Results:

2.e

RSC-6.d

Data Element L

Review Results:

2.e

RSC-6.d

Data Element M

Review Results:

2.e

RSC-6.d

Data Element N

Review Results:

2.e

RSC-6.d

Data Element O

Review Results:

2.e

RSC-6.d

Data Element P

Review Results:

2.e

RSC-6.d

Data Element Q

Review Results:

2.e

RSC-6.d

Data Element R

Review Results:

2.e

RSC-6.d

Data Element S

Review Results:

2.e

RSC-6.d

Data Element T

Review Results:

2.e

RSC-6.d

Data Element U

Review Results:

2.e

RSC-6.d

Data Element V

Review Results:

2.e

RSC-6.d

Data Element W

Review Results:

2.e

RSC-6.e

Data Element A

Review Results:

2.e

RSC-6.e

Data Element B

Review Results:

2.e

RSC-6.e

Data Element C

Review Results:

2.e

RSC-6.e

Data Element D

Review Results:

RSC-6.e: Includes all methods of grievance receipt (e.g.,
telephone, letter, fax, and in-person).
[Data
Elements A-W]

2.e

RSC-6.e

Data Element E

Review Results:

2.e

RSC-6.e

Data Element F

Review Results:

2.e

RSC-6.e

Data Element G

Review Results:

2.e

RSC-6.e

Data Element H

Review Results:

2.e

RSC-6.e

Data Element I

Review Results:

2.e

RSC-6.e

Data Element J

Review Results:

2.e

RSC-6.e

Data Element K

Review Results:

2.e

RSC-6.e

Data Element L

Review Results:

2.e

RSC-6.e

Data Element M

Review Results:

2.e

RSC-6.e

Data Element N

Review Results:

2.e

RSC-6.e

Data Element O

Review Results:

2.e

RSC-6.e

Data Element P

Review Results:

2.e

RSC-6.e

Data Element Q

Review Results:

2.e

RSC-6.e

Data Element R

Review Results:

2.e

RSC-6.e

Data Element S

Review Results:

2.e

RSC-6.e

Data Element T

Review Results:

2.e

RSC-6.e

Data Element U

Review Results:

2.e

RSC-6.e

Data Element V

Review Results:

2.e

RSC-6.e

Data Element W

Review Results:

2.e

RSC-6.f

Data Element A

Review Results:

RSC-6.f: Includes all grievances regardless of who filed the
grievance (e.g., member or appointed representative).
[Data Elements A-W]

2.e

RSC-6.f

Data Element B

Review Results:

2.e

RSC-6.f

Data Element C

Review Results:

2.e

RSC-6.f

Data Element D

Review Results:

2.e

RSC-6.f

Data Element E

Review Results:

2.e

RSC-6.f

Data Element F

Review Results:

2.e

RSC-6.f

Data Element G

Review Results:

2.e

RSC-6.f

Data Element H

Review Results:

2.e

RSC-6.f

Data Element I

Review Results:

2.e

RSC-6.f

Data Element J

Review Results:

2.e

RSC-6.f

Data Element K

Review Results:

2.e

RSC-6.f

Data Element L

Review Results:

2.e

RSC-6.f

Data Element M

Review Results:

2.e

RSC-6.f

Data Element N

Review Results:

2.e

RSC-6.f

Data Element O

Review Results:

2.e

RSC-6.f

Data Element P

Review Results:

2.e

RSC-6.f

Data Element Q

Review Results:

2.e

RSC-6.f

Data Element R

Review Results:

2.e

RSC-6.f

Data Element S

Review Results:

2.e

RSC-6.f

Data Element T

Review Results:

2.e

RSC-6.f

Data Element U

Review Results:

2.e

RSC-6.f

Data Element V

Review Results:

2.e

RSC-6.f

Data Element W

Review Results:

2.e

RSC-6.g

RSC-6.g: Excludes complaints received only by 1-800 Medicare Data Element A
or recorded only in the CMS Complaint Tracking Module
(CTM); however, complaints filed separately as grievances with
the organization are included.
[Data Elements A-W]

Review Results:

2.e

RSC-6.g

Data Element B

Review Results:

2.e

RSC-6.g

Data Element C

Review Results:

2.e

RSC-6.g

Data Element D

Review Results:

2.e

RSC-6.g

Data Element E

Review Results:

2.e

RSC-6.g

Data Element F

Review Results:

2.e

RSC-6.g

Data Element G

Review Results:

2.e

RSC-6.g

Data Element H

Review Results:

2.e

RSC-6.g

Data Element I

Review Results:

2.e

RSC-6.g

Data Element J

Review Results:

2.e

RSC-6.g

Data Element K

Review Results:

2.e

RSC-6.g

Data Element L

Review Results:

2.e

RSC-6.g

Data Element M

Review Results:

2.e

RSC-6.g

Data Element N

Review Results:

2.e

RSC-6.g

Data Element O

Review Results:

2.e

RSC-6.g

Data Element P

Review Results:

2.e

RSC-6.g

Data Element Q

Review Results:

2.e

RSC-6.g

Data Element R

Review Results:

2.e

RSC-6.g

Data Element S

Review Results:

2.e

RSC-6.g

Data Element T

Review Results:

2.e

RSC-6.g

Data Element U

Review Results:

2.e

RSC-6.g

Data Element V

Review Results:

2.e

RSC-6.g

Data Element W

Review Results:

2.e

RSC-6.h

2.e

RSC-6.h

Data Element A

Review Results:

2.e

RSC-6.h

Data Element B

Review Results:

2.e

RSC-6.h

Data Element C

Review Results:

2.e

RSC-6.h

Data Element D

Review Results:

Data Sources:

RSC-6.h: Excludes withdrawn Part D grievances.
[Data Elements A-W]

*

2.e

RSC-6.h

Data Element E

Review Results:

2.e

RSC-6.h

Data Element F

Review Results:

2.e

RSC-6.h

Data Element G

Review Results:

2.e

RSC-6.h

Data Element H

Review Results:

2.e

RSC-6.h

Data Element I

Review Results:

2.e

RSC-6.h

Data Element J

Review Results:

2.e

RSC-6.h

Data Element K

Review Results:

2.e

RSC-6.h

Data Element L

Review Results:

2.e

RSC-6.h

Data Element M

Review Results:

2.e

RSC-6.h

Data Element N

Review Results:

2.e

RSC-6.h

Data Element O

Review Results:

2.e

RSC-6.h

Data Element P

Review Results:

2.e

RSC-6.h

Data Element Q

Review Results:

2.e

RSC-6.h

Data Element R

Review Results:

2.e

RSC-6.h

Data Element S

Review Results:

2.e

RSC-6.h

Data Element T

Review Results:

2.e

RSC-6.h

Data Element U

Review Results:

2.e

RSC-6.h

Data Element V

Review Results:

2.e

RSC-6.h

Data Element W

Review Results:

2.e

RSC-6.i

RSC-6.i: For MA-PD contracts: Includes only grievances that apply to the Part D
benefit and were processed through the Part D grievance process. If a clear
distinction cannot be made for an MA-PD, cases are calculated as Part C grievances.
[Data Elements A-W]

Data Sources:

*

2.e

RSC-6.i

Data Element A

Review Results:

2.e

RSC-6.i

Data Element B

Review Results:

2.e

RSC-6.i

Data Element C

Review Results:

2.e

RSC-6.i

Data Element D

Review Results:

2.e

RSC-6.i

Data Element E

Review Results:

2.e

RSC-6.i

Data Element F

Review Results:

2.e

RSC-6.i

Data Element G

Review Results:

2.e

RSC-6.i

Data Element H

Review Results:

2.e

RSC-6.i

Data Element I

Review Results:

2.e

RSC-6.i

Data Element J

Review Results:

2.e

RSC-6.i

Data Element K

Review Results:

2.e

RSC-6.i

Data Element L

Review Results:

2.e

RSC-6.i

Data Element M

Review Results:

2.e

RSC-6.i

Data Element N

Review Results:

2.e

RSC-6.i

Data Element O

Review Results:

2.e

RSC-6.i

Data Element P

Review Results:

2.e

RSC-6.i

Data Element Q

Review Results:

2.e

RSC-6.i

Data Element R

Review Results:

2.e

RSC-6.i

Data Element S

Review Results:

2.e

RSC-6.i

Data Element T

Review Results:

2.e

RSC-6.i

Data Element U

Review Results:

2.e

RSC-6.i

Data Element V

Review Results:

2.e

RSC-6.i

Data Element W

Review Results:

2.e

RSC-6.j

2.e

RSC-6.j

Data Element A

Review Results:

2.e

RSC-6.j

Data Element B

Review Results:

2.e

RSC-6.j

Data Element C

Review Results:

2.e

RSC-6.j

Data Element D

Review Results:

2.e

RSC-6.j

Data Element E

Review Results:

2.e

RSC-6.j

Data Element F

Review Results:

RSC-6.j: Counts grievances for the contract to which the member belongs at the time
the grievance was filed, even if the beneficiary enrolled in a new contract before the
grievance is resolved (e.g., if a grievance is resolved within the reporting period for a
member that has disenrolled from a plan and enrolled in a new plan, then the
member’s previous plan is still responsible for investigating, resolving and reporting
the grievance). [Data Elements A-W]

Data Sources:

*

2.e

RSC-6.j

Data Element G

Review Results:

2.e

RSC-6.j

Data Element H

Review Results:

2.e

RSC-6.j

Data Element I

Review Results:

2.e

RSC-6.j

Data Element J

Review Results:

2.e

RSC-6.j

Data Element K

Review Results:

2.e

RSC-6.j

Data Element L

Review Results:

2.e

RSC-6.j

Data Element M

Review Results:

2.e

RSC-6.j

Data Element N

Review Results:

2.e

RSC-6.j

Data Element O

Review Results:

2.e

RSC-6.j

Data Element P

Review Results:

2.e

RSC-6.j

Data Element Q

Review Results:

2.e

RSC-6.j

Data Element R

Review Results:

2.e

RSC-6.j

Data Element S

Review Results:

2.e

RSC-6.j

Data Element T

Review Results:

2.e

RSC-6.j

Data Element U

Review Results:

2.e

RSC-6.j

Data Element V

Review Results:

2.e

RSC-6.j

Data Element W

Review Results:

2.e

RSC-7

2.e

2.e

Organization accurately calculates and uploads into HPMS the number of grievances
by category, including the following criteria:

Data Sources:

RSC-7.a

RSC-7.a: Properly sorts the total number of grievances by
Data Element F
grievance category: Enrollment/Disenrollment; Plan Benefit;
Pharmacy Access; Marketing; Customer Service; Coverage
Determination and Redetermination Process (e.g.; untimely
coverage decisions); Quality of Care; CMS Issues (which
includes grievances related to issues outside of the
organization’s direct control); and other grievances that do not
properly fit into the other listed categories. [Data Elements
F, H, J, L, N, P, R, T, V]

Review Results:

RSC-7.a

Data Element H

Review Results:

*

2.e

RSC-7.a

Data Element J

Review Results:

2.e

RSC-7.a

Data Element L

Review Results:

2.e

RSC-7.a

Data Element N

Review Results:

2.e

RSC-7.a

Data Element P

Review Results:

2.e

RSC-7.a

Data Element R

Review Results:

2.e

RSC-7.a

Data Element T

Review Results:

2.e

RSC-7.a

Data Element V

Review Results:

2.e

RSC-7.b

Data Element V

Review Results:

2.e

RSC-8

RSC-7.b: Assigns all additional categories tracked by
organization that are not listed above as Other.
[Data Element V]

Organization accurately calculates the number of grievances which the Part D
sponsor provided timely notification of the decision, including the following criteria:

Data Sources:

RSC-8.a: Includes only grievances for which the member is notified of decision
according to the following timelines:

2.e

RSC-8.a.i

RSC-8.a.i. For standard grievances: no later than 30 days after Data Element B
receipt of grievance. [Data Elements B, G, I, K, M, O, Q, S, U,
W]

Review Results:

*

2.e

RSC-8.a.i

Data Element G

Review Results:

2.e

RSC-8.a.i

Data Element I

Review Results:

2.e

RSC-8.a.i

Data Element K

Review Results:

2.e

RSC-8.a.i

Data Element M

Review Results:

2.e

RSC-8.a.i

Data Element O

Review Results:

2.e

RSC-8.a.i

Data Element Q

Review Results:

2.e

RSC-8.a.i

Data Element S

Review Results:

2.e

RSC-8.a.i

Data Element U

Review Results:

2.e

RSC-8.a.i

Data Element W

Review Results:

2.e

RSC-8.aii

RSC-8.aii: For standard grievances with an extension taken: no Data Element B
later than 44 days after receipt of grievance.
[Data Elements B, G, I, K, M, O, Q, S, U, W]

Review Results:

2.e

RSC-8.aii

Data Element G

Review Results:

2.e

RSC-8.aii

Data Element I

Review Results:

2.e

RSC-8.aii

Data Element K

Review Results:

2.e

RSC-8.aii

Data Element M

Review Results:

2.e

RSC-8.aii

Data Element O

Review Results:

2.e

RSC-8.aii

Data Element Q

Review Results:

2.e

RSC-8.aii

Data Element S

Review Results:

2.e

RSC-8.aii

Data Element U

Review Results:

2.e

RSC-8.aii

Data Element W

Review Results:

2.e

RSC-8.aiii

Data Element B

Review Results:

RSC-8.aiii: For expedited grievances: no later than 24 hours
after receipt of grievance.
[Data Elements B,
D, G, I, K, M, O, Q, S, U, W]

2.e

RSC-8.aiii

Data Element D

Review Results:

2.e

RSC-8.aiii

Data Element G

Review Results:

2.e

RSC-8.aiii

Data Element I

Review Results:

2.e

RSC-8.aiii

Data Element K

Review Results:

2.e

RSC-8.aiii

Data Element M

Review Results:

2.e

RSC-8.aiii

Data Element O

Review Results:

2.e

RSC-8.aiii

Data Element Q

Review Results:

2.e

RSC-8.aiii

Data Element S

Review Results:

2.e

RSC-8.aiii

Data Element U

Review Results:

2.e

RSC-8.aiii

Data Element W

Review Results:

Data Element B

Review Results:

RSC-8.b

Data Element D

Review Results:

2.e

RSC-8.b

Data Element G

Review Results:

2.e

RSC-8.b

Data Element I

Review Results:

2.e

RSC-8.b

Data Element K

Review Results:

2.e

RSC-8.b

Data Element M

Review Results:

2.e

RSC-8.b

Data Element O

Review Results:

2.e

RSC-8.b

Data Element Q

Review Results:

2.e

RSC-8.b

Data Element S

Review Results:

2.e

RSC-8.b

Data Element U

Review Results:

2.e

RSC-8.b

2.e

 RSC-8.b: Each number calculated is a subset of the total
number of grievances received for the applicable category.
[Data Elements B, D, G, I, K, M, O, Q, S,U, W]

2.e

RSC-8.b

Data Element W

Review Results:

Organization implements policies and procedures for data submission, including the
following:

Data Sources:

Data elements are accurately entered/uploaded into CMS
systems and entries match corresponding source documents.

Data Element A

Review Results:

3.a

Data Element B

Review Results:

3.a

Data Element C

Review Results:

3.a

Data Element D

Review Results:

3.a

Data Element E

Review Results:

3.a

Data Element F

Review Results:

3.a

Data Element G

Review Results:

3.a

Data Element H

Review Results:

3

3.a

*

3.a

Data Element I

Review Results:

3.a

Data Element J

Review Results:

3.a

Data Element K

Review Results:

3.a

Data Element L

Review Results:

3.a

Data Element M

Review Results:

3.a

Data Element N

Review Results:

3.a

Data Element O

Review Results:

3.a

Data Element P

Review Results:

3.a

Data Element Q

Review Results:

3.a

Data Element R

Review Results:

3.a

Data Element S

Review Results:

3.a

Data Element T

Review Results:

3.a

Data Element U

Review Results:

3.a

Data Element V

Review Results:

3.a

Data Element W

Review Results:

3.b

All source, intermediate, and final stage data sets and other outputs relied upon to
enter data into CMS systems are archived.

Review Results:

4

Organization implements policies and procedures for periodic data system updates
(e.g., changes in enrollment, provider/pharmacy status, and claims adjustments).

Review Results:

5

Organization implements policies and procedures for archiving and restoring data in
each data system (e.g., disaster recovery plan).

Review Results:

6

If organization’s data systems underwent any changes during the reporting period
(e.g., as a result of a merger, acquisition, or upgrade): Organization provided
documentation on the data system changes and, upon review, there were no issues
that adversely impacted data reported.

Review Results:

7

If data collection and/or reporting for this reporting section is delegated to another
entity: Organization regularly monitors the quality and timeliness of the data
collected and/or reported by the delegated entity or first tier/downstream
contractor.

Review Results:

AP-v1.1

Coverage Determinations and Redeterminations (Part D) 2017

Organization Name:
Contract Number:
Reporting Section:

Coverage Determinations and Redeterminations (Part D) 2017

Last Updated:

MM/DD/YYYY

Date of Site Visit:
Last name, First name

Name of Peer Reviewer:

Last name, First name

Standard/
Sub-standard
ID

Re
po
Cr rtin
i te g S
ria ec
ID tio
n

Name of Reviewer:

Standard/Sub-standard Description

1) In the "Data Sources and Review Results:" column, enter the review results and/or data
sources used for each standard or sub-standard.
2) Enter "Y" if the requirements for the standard or sub-standard have been completely
met. If any requirement for the standard or sub-standard has not been met, enter "N". If
any standard or sub-standard does not apply, enter "N/A".
3) For standards 1c, 1d, 1e, 1g, 1h, and 2e, enter 'Findings' as follows based on the fivepoint scale: Select "1" if plan data has more than 20% error, select "2" if plan data has
between 15.1% - 20.0% error, select "3" if plan data has between 10.1% - 15.0% error,
select "4" if plan data has between 5.1% - 10.0% error, select "5" if plan data has less than
or equal to a 5% error. Enter "N/A" if standard does not apply.

Data Sources and Review Results:
Enter review results and/or data sources

A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans,
saved data queries, file layouts, process flows) indicates that all source documents accurately
capture required data fields and are properly documented.

Data Sources:

1.a

Source documents are properly secured so that source documents can be retrieved at any time to
validate the information submitted to CMS via CMS systems.

Review Results:

1.b

Source documents create all required data fields for reporting requirements.

Review Results:

1.c

Source documents are error-free (e.g., programming code and spreadsheet formulas have no
messages or warnings indicating errors, use correct fields, have appropriate data selection, etc.).

Review Results:

1.d

All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient ID, rather
than Field1 and maintain the same field name across data sets).

Review Results:

1.e

Data file locations are referenced correctly.

Review Results:

1.f

If used, macros are properly documented.

Review Results:

1.g

Source documents are clearly and adequately documented.

Review Results:

1.h

Titles and footnotes on reports and tables are accurate.

Review Results:

1

Enter 'Findings' using
the applicable choice
in the appropriate
cells. Cells marked
with an '*' should not
be edited.
*

1.i

Version control of source documents is appropriately applied.

Review Results:

2

A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans,
saved data queries, file layouts, process flows) and census or sample data, whichever is applicable,
indicates that data elements for each reporting section are accurately identified, processed, and
calculated.

Data Sources:

The appropriate date range(s) for the reporting period(s) is captured.

Review Results:

2.a

RSC-1

*

Organization reports data based on the required reporting periods 1/1
through 3/31, 4/1 through 6/30, 7/1 through 9/30, and 10/1 through
12/31.

2.b

RSC-2

Review Results:

Data are assigned at the applicable level (e.g., plan benefit package or
contract level).
Organization properly assigns data to the applicable CMS contract.

2.c

RSC-3

Review Results:

Appropriate deadlines are met for reporting data (e.g., quarterly).
Organization meets deadlines for reporting data to CMS by 2/26/2018
[Note to reviewer: If the organization has, for any reason, re-submitted its
data to CMS for this reporting section, the reviewer should verify that the
organization’s original data submissions met the CMS deadline in order to
have a finding of “yes” for this reporting section criterion. However, if the
organization re-submits data for any reason and if the re-submission was
completed by 3/31 of the data validation year, the reviewer should use the
organization’s corrected data submission(s) for the rest of the reporting
section criteria for this reporting section.]

2.d

RSC-4

Review Results:

Terms used are properly defined per CMS regulations, guidance and
Reporting Requirements Technical Specifications.
1. Organization properly determines whether a request is subject to the
coverage determinations or the exceptions process in accordance with 42
CFR §423.566, §423.578, and the Prescription Drug Benefit Manual
Chapter 18, Sections 10 and 30. This includes applying all relevant
guidance properly when performing its calculations and categorizations for
the above-mentioned regulations in addition to 42 CFR §423.568,
§423.570, §423.572, §423.576 and the Prescription Drug Benefit Manual
Chapter 18, Sections 40, 50, and 130.
2. Organization properly defines the term “Redetermination” in
accordance with Title 42, Part 423, Subpart M §423.560, §423.580,
§423.582, §423.584, and §423.590 and the Prescription Drug Benefit
Manual Chapter 18, Section 10, 70, and 130. This includes applying all
relevant guidance properly when performing its calculations and
categorizations.
3. Refer to 42 CFR §423.1978-1986 and Chapter 18, section 120 of the
Medicare Prescription Drug Benefit Manual for additional information and
CMS requirements related to reopenings.
Organization data passes data integrity checks listed below:

Data Sources:

*

RSC-5.a

RSC-5.a: The following numbers do not exceed the total number of pharmacy transactions (Data
Element 1.A):

Data Sources:

*

RSC-5.ai

RSC-5.ai: Number of pharmacy transactions rejected due to non-formulary
status (Data Element 1.B).

Review Results:

2.e

RSC-5

2.e

2.e

Data Element 1.B

2.e

RSC-5.aii

RSC-5.aii: Number of pharmacy transactions rejected due to PA
requirements (Data Element 1.C).

Data Element 1.C

Review Results:

2.e

RSC-5.aiii

RSC-5.aiii: Number of pharmacy transactions rejected due to step therapy
requirements (Data Element 1.D).

Data Element 1.D

Review Results:

2.e

RSC-5.aiv

RSC-5.aiv: Number of pharmacy transactions rejected due to QL
requirements (Data Element 1.E).

Data Element 1.E

Review Results:

2.e

RSC-5.b

RSC-5.b: If a plan reported high cost edits in place for non-compounds
(Data Element 1.F =Yes), then corresponding cost threshold (Data Element
1.F) is greater than 0.

Data Element 1.F

Review Results:

2.e

RSC-5.c

RSC-5.c: If no high cost edits are reported for non-compounds (Data
Element 1.F = No), the plan did not report a corresponding cost threshold
(Data Element 1.F = blank).

Data Element 1.F

Review Results:

2.e

RSC-5.d

RSC-5.d: If the plan did not have high cost edits in place for noncompounds (Data Element 1.F = No), then the plan did not report claims
rejected due to high cost edits for non-compounds (Data Element 1.G = 0).

Data Element 1.G

Review Results:

2.e

RSC-5.e

RSC-5.e: The following numbers do not exceed the total number of pharmacy transactions rejected
(Data Element 1.A):

Data Sources:

2.e

RSC-5.e.i

RSC-5.e.i: Number of claims rejected due to high cost edits for noncompounds (Data Element 1.G).

Review Results:

2.e

RSC-5.f

RSC-5.f: The following numbers do not exceed the total number of coverage determinations
including exceptions (Data Element 2.A):

Data Sources:

2.e

RSC-5.fi

RSC-5.fi: Number of exception decisions made in the reporting period
(Data Element 2.J-2.AA).

Data Element 2.J-2.AA

Review Results:

2.e

RSC-5.f.ii

RSC-5.f.ii: Number of coverage determination decisions processed timely
(Data Element 2.B).

Data Element 2.B

Review Results:

Data Element 1.G

*

*

2.e

RSC-5.f.iii

RSC-5.f.iii: Number of coverage determinations decisions by outcome (Data
Element 2.E + Data Element 2.F + Data Element 2.G + Data Element 2.H +
Data Element 2.I) is equal to total number of coverage determinations
(Data Element 2.A).

Data Element 2.A

Review Results:

2.e

RSC-5.f.iv

RSC-5.f.iv: Number of coverage determination decisions not processed
timely (Data Element 2.C + Data Element 2.D)

Data Elements 2.C,
2.D

Review Results:

2.e

RSC-5.g

RSC-5.g: Number of redeterminations by outcome (Data Element 3.E +
Data Element 3.F + Data Element 3.G + Data Element H + Data Element I) is
equal to total number of redeterminations (Data Element 3.A).

Data Elements 3.A,
3.E, 3.F, 3.G, 3.H, 3.I

Review Results:

2.e

RSC-5.h

RSC-5.h: Number of redeterminations processed timely (Data Element 3.B)
does not exceed the total number of redeterminations made during the
reporting period (Data Element 3.A):

Data Element 3.B

Review Results:

2.e

RSC-5.i

RSC-5.i: Number of redetermination decisions not processed timely (Data
Element 3.C + Data Element 3.D)

Data Elements 3.C,
3.D

Review Results:

2.e

RSC-5.j

RSC-5.j: Total number of reopened (revised) decisions (Data Element 4.A)
is equal to the number of records reported in data file.

Data Element 4.A

Review Results:

2.e

RSC-5.k

RSC-5.k: Verify that the date of each reopening disposition (Data Element
4.B.11) is in the reporting quarter.) is in the reporting quarter.

Data Element 4.B.11

Review Results:

2.e

RSC-5.l

RSC-5.l: Verify that the date of disposition for each reopening (Data
Element 4.B.11) is after the date of original disposition (Data Element
4.B.5).

Data Element 4.B.11

Review Results:

2.e

RSC-5.m

RSC-5.m: Verify that the date of each reopening disposition (Data Element
4.B.11) is after the date that the case was reopened (Data Element 4.B.9).

Data Element 4.B.11

Review Results:

2.e

RSC-5.n

RSC-5.n: Verify that the date each case was reopened (Data Element 4.B.9)
is after the date of original disposition (Data Element 4.B.5).

Data Element 4.B.9

Review Results:

2.e

RSC-5.o

RSC-5.o: If the organization received a CMS outlier/data integrity notice
validate whether or not an internal procedure change was warranted or
resubmission through HPMS.

Data Elements 1.A –
1.G, 2.A – 2.AA, 3.A3.I 4.A – 4.B.9

Review Results:

2.e

RSC-6

The number of expected counts (e.g., number of members, claims, grievances, procedures) are
verified; ranges of data fields are verified; all calculations (e.g., derived data fields) are verified;
missing data has been properly addressed; reporting output matches corresponding source
documents (e.g., programming code, saved queries, analysis plans); version control of reported
data elements is appropriately applied; QA checks/thresholds are applied to detect outlier or
erroneous data prior to data submission.

Data Sources:

*

Applicable Reporting Section Criteria:
2.e

RSC-6.a

RSC-6.a: Includes pharmacy transactions for Part D drugs with a fill date
(not batch date) that falls within the reporting period.
[Data Element 1.A]

Data Element 1.A

Review Results:

2.e

RSC-6.b

RSC-6.b: Includes transactions with a final disposition of reversed.
[Data Element 1.A]

Data Element 1.A

Review Results:

2.e

RSC-6.c

RSC-6.c: Excludes pharmacy transactions for drugs assigned to an excluded Data Element 1.A
drug category.
[Data
Element 1.A]

Review Results:

2.e

RSC-6.d

RSC-6.d: If a prescription drug claim contains multiple transactions, each
transaction is calculated as a separate pharmacy transaction.
[Data Element 1.A]

Review Results:

2.e

RSC-7

2.e

Data Element 1.A

RSC-7: Organization accurately calculates the number of pharmacy transactions rejected due to
formulary restrictions, including the following criteria:

Data Sources:

RSC-7.a

RSC-7.a: Excludes rejections due to early refill requests. [Data Element
1.B]

Data Element 1.B

Review Results:

2.e

RSC-7.b

RSC-7.b: If a prescription drug claim contains multiple rejections, each
Data Element 1.B
rejection is calculated as a separate pharmacy transaction. [Data Element
1.B]

Review Results:

2.e

RSC-8

RSC-8: Organization accurately calculates the number of pharmacy transactions rejected due to
prior authorization (PA) requirements, including the following criteria:

Data Sources:

2.e

RSC-8.a

RSC-8.a: Excludes rejections due to early refill requests. [Data Element
1.C]

Data Element 1.C

Review Results:

2.e

RSC-8.b

RSC-8.b: If a prescription drug claim contains multiple rejections, each
Data Element 1.C
rejection is calculated as a separate pharmacy transaction. [Data Element
1.C]

Review Results:

*

*

RSC-9: Organization accurately calculates the number of pharmacy transactions rejected due to
step therapy requirements, including the following criteria:

Data Sources:

RSC-9.a

RSC-9.a: Excludes rejections due to early refill requests. [Data Element
1.D]

Data Element 1.D

Review Results:

2.e

RSC-9.b

RSC-9.b: If a prescription drug claim contains multiple rejections, each
Data Element 1.D
rejection is calculated as a separate pharmacy transaction. [Data Element
1.D]

Review Results:

2.e

RSC-10

RSC-10: Organization accurately calculates the number of pharmacy transactions rejected due to
quantity limits (QL) requirements, including the following criteria:

Data Sources:

2.e

RSC-10.a

RSC-10.a: Excludes rejections due to safety edits and early refill requests.
[Data Element 1.E]

Data Element 1.E

Review Results:

2.e

RSC-10.b

RSC-10.b: Includes all types of QL rejects, including but not limited to claim Data Element 1.E
rejections due to quantity limits or time rejections (e.g., a claim is
submitted for 20 tablets/10 days, but is only approved for 10 tablets/5
days). [Data Element 1.E]

Review Results:

2.e

RSC-10.c

RSC-10.c: If a prescription drug claim contains multiple rejections, each
Data Element 1.E
rejection is calculated as a separate pharmacy transaction. [Data Element
1.E]

Review Results:

2.e

RSC-11

RSC-11: Organization accurately reports data on high cost edits, including the following criteria:

Data Sources:

2.e

RSC-11.a

RSC-11.a: Indicates whether or not high cost edits for non-compounds
were in place during the reporting period. [Data Elements 1.F - 1.G]

Data Element 1.F

Review Results:

2.e

RSC-11.a

Data Element 1.G

Review Results:

2.e

RSC-11.b

RSC-11.b: If high cost edits for non-compounds were in place during the Data Element 1.F
reporting period, reports the cost threshold used. [Data Elements 1.F - 1.G]

Review Results:

2.e

RSC-9

2.e

*

*

*

2.e

RSC-11.b

Data Element 1.G

Review Results:

2.e

RSC-11.c

RSC-11.c: Includes the number of claims rejected due to high cost edits for Data Element 1.F
non-compounds. [Data Elements 1.F - 1.G]

Review Results:

2.e

RSC-11.c

Data Element 1.G

Review Results:

2.e

RSC-11.d

RSC-11.d: If a prescription drug claim contains multiple rejections, each
Data Element 1.F
rejection is calculated as a separate pharmacy transaction. [Data Elements
1.F - 1.G]

Review Results:

2.e

RSC-11.d

Data Element 1.G

Review Results:

2.e

RSC-12

2.e

RSC-12: Organization accurately calculates the number of coverage determinations (Part D only)
decisions made in the reporting period, including the following criteria:

Data Sources:

RSC-12.a

RSC-12.a: Includes all coverage determinations (including exceptions) with Data Element 2.A
a date of decision that occurs during the reporting period, regardless of
when the request for coverage determination was received. [Data Element
2.A]

Review Results:

2.e

RSC-12.b

RSC-12.b: Includes hospice-related coverage determinations. [Data
Element 2.A]

Data Element 2.A

Review Results:

2.e

RSC-12.c

RSC-12.c: Includes all methods of receipt (e.g., telephone, letter, fax, inperson).
[Data Element 2.A]

Data Element 2.A

Review Results:

2.e

RSC-12.d

RSC-12.d: Includes all coverage determinations (including exceptions)
regardless of who filed the request (e.g., member, appointed
representative, or prescribing physician).
[Data Element 2.A]

Data Element 2.A

Review Results:

2.e

RSC-12.e

RSC-12.e: Includes coverage determinations (including exceptions) from
delegated entities. [Data Element 2.A]

Data Element 2.A

Review Results:

*

2.e

RSC-12.f

RSC-12.f: Includes both standard and expedited coverage determinations
(including exceptions). [Data Element 2.A]

Data Element 2.A

Review Results:

2.e

RSC-12.g

RSC-12.g: Includes requests for coverage determinations (including
exceptions) that are withdrawn or dismissed.
[Data Element 2.A

Data Element 2.A

Review Results:

2.e

RSC-12.h

RSC-12.h: Includes each distinct dispute (i.e., multiple drugs) contained in Data Element 2.A
one coverage determination request as a separate coverage determination
request.
[Data Element 2.A]

Review Results:

2.e

RSC-12.i

RSC-12.i: Includes adverse coverage determination cases that were
forwarded to the Independent Review Entity (IRE) because the
organization made an untimely decision. [Data Element 2.A]

Data Element 2.A

Review Results:

2.e

RSC-12.j

RSC-12.j: Includes all coverage determination decisions that relate to Part
B versus Part D coverage (drugs covered under Part B are considered
adverse decisions under Part D). [Data Element 2.A]

Data Element 2.A

Review Results:

i. Point of Sale (POS) claims adjudications (e.g., a rejected claim for a drug
indicating a B v. D PA is required) are not included unless the plan
subsequently processed a coverage determination.
2.e

RSC-12.k

RSC-12.k: Includes Direct Member Reimbursements (DMRs) part of the
total number of exceptions if the plan processed the request under the
tiering or formulary exceptions process. [Data Elements 2.J, 2.P, 2.V]

Data Elements 2.J, 2.P,
2.V

Review Results:

2.e

RSC-12.l

RSC-12.l: Excludes coverage determinations (including exceptions)
regarding drugs assigned to an excluded drug category.
[Data Element 2.A]

Data Element 2.A

Review Results:

2.e

RSC-12.m

RSC-12.m: Excludes members who have UM requirements waived based
Data Element 2.A
on an exception decision made in a previous plan year or reporting period.
[Data Element 2.A]

Review Results:

2.e

RSC-12.n

RSC-12.n: Confirm that a coverage determination was denied for lack of
medical necessity based on review by a physician or other appropriate
health care professional. [Data Element 2.A]

Review Results:

2.e

RSC-13

2.e

RSC-13.a

Data Element 2.A

RSC-13: Organization accurately calculates the total number of UM, Formulary, and Tier exceptions
decisions made in the reporting period, including the following criteria:

Data Sources:

RSC-13.a. Includes all decisions made (fully favorable, partially favorable,
and adverse) with a date of decision that occurs during the reporting
period, regardless of when the exception decision was received. [Data
Elements 2. J, 2. P, 2.V]

Review Results:

Data Elements 2.J, 2.P,
2.V

*

2.e

RSC-13.b

RSC-13.b: Includes all methods of receipt (e.g., telephone, letter, fax, in
person).
[Data Elements 2.J, 2.P, 2.V]

Data Elements 2.J, 2.P,
2.V

Review Results:

2.e

RSC-13.c

RSC-13.c: Includes exception requests that were forwarded to the
Data Elements 2.J, 2.P,
Independent Review Entity (IRE) because the organization failed to make a 2.V
timely decision. [Data Elements 2.J, 2.P, 2.V]

Review Results:

2.e

RSC-13.d

RSC-13.d: Includes requests for exceptions from delegated entities. [Data
Elements 2.J, 2.P, 2.V]

Data Elements 2.J, 2.P,
2.V

Review Results:

2.e

RSC-13.e

RSC-13.e: Includes both standard and expedited exceptions. [Data
Elements 2.J, 2.P, 2.V]

Data Elements 2.J, 2.P,
2.V

Review Results:

2.e

RSC-13.f

RSC-13.f: Includes requests for exceptions that are withdrawn or
dismissed. [Data Elements 2.J, 2.P, 2.V]

Data Elements 2.J, 2.P,
2.V

Review Results:

2.e

RSC-13.g

RSC-13.g: Excludes requests for exceptions regarding drugs assigned to an Data Elements 2.J, 2.P,
excluded drug category. [Data Elements 2.J, 2.P, 2.V]
2.V

Review Results:

2.e

RSC-13.h

RSC-13.h: Excludes members who have UM requirements waived based on Data Elements 2.J, 2.P,
an exception decision made in a previous plan year or reporting period.
2.V
[Data Elements 2.J, 2.P, 2.V]

Review Results:

2.e

RSC-14

RSC-14: Organization accurately calculates the number of coverage determinations decisions
processed timely or not timely, including the following criteria:

Data Sources:

2.e

RSC-14.ai

RSC-14.ai:Included both standard coverage determinations and expedited Data Elements 2.B, 2.C,
coverage determinations. Includes only coverage determinations (including 2.D
exceptions) for which the member is notified of the decision according to
the following timelines.

Review Results:

2.e

2.e

RSC-14.aii

RSC-14.aiii

i. For standard coverage determinations: as expeditiously as the enrollee’s
health condition requires, but no later than 72 hours after receipt of the
request. Confirm that records that did not meet the timeliness criteria are
not included in the count for the number of standard coverage
determinations decisions processed timely.
RSC-14.aii: Included both standard coverage determinations and
Data Elements 2.B, 2.C,
expedited coverage determinations. Includes only coverage
2.D
determinations (including exceptions) for which the member is notified of
the decision according to the following timelines.
ii. For expedited coverage determinations: as expeditiously as the
enrollee’s health condition requires, but no later than 24 hours after
receipt of the request.
RSC-14.aiii: Included both standard coverage determinations and
Data Elements 2.B, 2.C,
2.D
expedited coverage determinations. Includes only coverage
determinations (including exceptions) for which the member is notified of
the decision according to the following timelines. [Data Elements 2.B, 2.C,
2.D]
iii. For reimbursement requests: as expeditiously as the enrollee’s health
condition requires, but no later than 14 days after receipt of the request.

Review Results:

Review Results:

*

2.e

RSC-14.bi

RSC-14.bi: Excludes favorable determinations in which the organization
did not authorize or provide the benefit or payment under dispute
according to the following timelines:
[Data Element 2.B, 2.C, 2.D]

Data Elements 2.B, 2.C,
2.D

Review Results:

RSC-14.bii

i. For standard coverage determinations: as expeditiously as the enrollee’s
health condition requires, but no later than 72 hours after receipt of the
request
RSC-14.bii: Excludes favorable determinations in which the organization Data Elements 2.B, 2.C,
2.D
did not authorize or provide the benefit or payment under dispute
according to the following timelines:
[Data Elements 2.B, 2.C, 2.D]

Review Results:

2.e

RSC-14.biii

ii.    For expedited coverage determinations: as expeditiously as the
enrollee’s health condition requires, but no later than 24 hours after
receipt of the request
RSC-14.biii: For reimbursement requests: as expeditiously as the enrollee’s Data Elements 2.B, 2.C,
2.D
health condition requires, but no later than 14 days after receipt of the
request. [Data Elements 2.B, 2.C, 2.D]

Review Results:

2.e

RSC-14.biv

RSC-14.biv: Includes fully favorable determinations where the enrollee was Data Elements 2.B, 2.C,
notified untimely but within 24 hours of the expiration of the adjudication 2.D
timeframe and thus not auto-forwarded to the IRE. [Data Elements 2.B,
2.C, 2.D]

Review Results:

2.e

RSC-14.c

RSC-14.c: Reflects if untimely cases were auto-forwarded to the IRE, or not. Data Elements 2.B, 2.C,
2.D
. [Data Elements 2.B, 2.C, 2.D]

Review Results:

2.e

RSC-15

RSC-15: Organization accurately calculates the number of coverage determinations decisions made
by final decision, including the following criteria:

Data Sources:

2.e

RSC-15.a

RSC-15.a: Properly categorizes the number of coverage determinations
Data Element 2.E
(including exceptions) by final decision: fully favorable, partially favorable,
or adverse. Verify that all cases included in the count for the total number
of coverage determinations made in the reporting period are identified as
one of the accepted disposition types. [Data Elements 2.E., 2.F., 2.G.]

Review Results:

2.e

RSC-15.a

Data Element 2.F

Review Results:

2.e

RSC-15.a

Data Element 2.G

Review Results:

2.e

RSC-15.b

RSC-15.b: Includes untimely coverage determinations decisions, regardless Data Element 2.E
if they were auto-forwarded to the IRE. [Data Elements.2.E., 2.F., 2.G.]

Review Results:

2.e

RSC-15.b

Data Element 2.F

Review Results:

2.e

RSC-15.b

Data Element 2.G

Review Results:

2.e

*

2.e

RSC-16

RSC-16: Organization accurately calculates the number of coverage determinations that were
withdrawn or dismissed, including the following criteria:

Data Sources:

2.e

RSC-16.a

RSC-16.a: Includes all withdrawals and dismissals on requests for coverage Data Element 2.H
determinations (including exceptions). This includes expedited coverage
determinations and exceptions that were withdrawn or dismissed for any
reason.
[Data Elements 2.H, 2.I]

Review Results:

2.e

RSC-16.a

2.e

RSC-16.b

2.e

RSC-16.b

2.e

RSC-17

RSC-17: Organization accurately calculates the total number of redeterminations (Part D only),
including the following criteria:

Data Sources:

2.e

RSC-17.a

RSC-17.a: Includes all redetermination decisions for Part D drugs with a
Data Element 3.A
date of final decision that occurs during the reporting period, regardless of
when the request for redetermination was received or when the member
was notified of the decision. [Data Element 3.A]

Review Results:

2.e

RSC-17.b

RSC-17.b: Includes all redetermination decisions, including fully favorable, Data Element 3.A
partially favorable, and unfavorable decisions. [Data Element 3.A]

Review Results:

2.e

RSC-17.c

RSC-17.c: Includes redetermination requests that were forwarded to the
IRE because the organization failed to make a timely decision. Verify that
all redetermination records from Universe 9 that are within the reporting
period and classified as auto-forwarded to the IRE are included in the
count for the total number of redeterminations [Data Element 3.A]

Data Element 3.A

Review Results:

2.e

RSC-17.d

RSC-17.d: Includes both standard and expedited redeterminations. [Data
Element 3.A]

Data Element 3.A

Review Results:

2.e

RSC-17.e

RSC-17.e: Includes all methods of receipt (e.g., telephone, letter, fax, inperson). [Data Element 3.A]

Data Element 3.A

Review Results:

RSC-16.b: Includes dismissals that are made where the procedural
requirements for a valid request are not met within the stipulated
timeframe. The plan should issue a dismissal only when the required
documentation was not received within a reasonable amount of time.
[Data Elements 2.H, 2.I]

Data Element 2.I

Review Results:

Data Element 2.H

Review Results:

Data Element 2.I

Review Results:

*

*

2.e

RSC-17.f

RSC-17.f: Includes all redeterminations regardless of who filed the request Data Element 3.A
(e.g., member, appointed representative, or prescribing physician). [Data
Element 3.A]

Review Results:

2.e

RSC-17.g

RSC-17.g: Includes Direct Member Reimbursements (DMRs) part of the
Data Element 3.A
total number of redeterminations if the plan processed the request under
the tiering or formulary exceptions process. Verify that all DMRs regardless
of request disposition type that were processed under the tiering or
formulary exception process should be included in the count of the total
number of redeterminations decisions made in the reporting period. [Data
Element 3.A]

Review Results:

2.e

RSC-17.h

RSC-17.h: Includes all redetermination decisions that relate to Part B
Data Element 3.A
versus Part D coverage (drugs covered under Part B are considered adverse
decisions under Part D). [Data Element 3.A]

Review Results:

2.e

RSC-17.i

RSC-17.i: Includes multiple distinct disputes contained in one
redetermination request (i.e., multiple drugs), as a separate
redetermination request. [Data Element 3.A]

Data Element 3.A

Review Results:

2.e

RSC-17.j

RSC-17.j: Includes dismissals and withdrawals. Verify that redetermination Data Element 3.A
requests that are withdrawn or dismissed are included in the count of total
redeterminations. [Data Element 3.A]

Review Results:

2.e

RSC-17.k

RSC-17.k: Excludes IRE decisions, as they are considered to be the second
level of appeal. [Data Element 3.A]

Data Element 3.A

Review Results:

2.e

RSC-17.l

RSC-17.l: Excludes redeterminations regarding excluded drugs.
Element 3.A]

Data Element 3.A

Review Results:

2.e

RSC-17.m

RSC-17.m: Limits reporting to just the redetermination level.
Element 3.A]

Data Element 3.A

Review Results:

2.e

RSC-17.n

RSC-17.n: Includes untimely redeterminations decisions, regardless if they Data Element 3.A
were auto-forwarded to the IRE. [Data Element 3.A]

Review Results:

2.e

RSC-18

RSC-18: Organization accurately calculates the number of redeterminations for which the Part D
sponsor processed timely, including the following criteria:

Data Sources:

*

2.e

RSC-18.a

RSC-18.a: Includes only redeterminations for which the member is notified of the decision
according to the following timelines:

Data Sources:

*

[Data

[Data

2.e

RSC-18.a.i

RSC-18.a.i: Includes only redeterminations for which the member is
notified of the decision according to the following timelines

Data Elements 3.B-3.D

Review Results:

Data Elements 3.B-3.D

Review Results:

Data Element 3.B-3.D

Review Results:

i.  i. For standard redeterminations: no later than 7 calendar days after
receipt of the request. [Data Elements 3.B-3.D]

2.e

RSC-18.a.ii

RSC-18.a.ii: Includes only redeterminations for which the member is
notified of the decision according to the following timelines:
ii.  For expedited redeterminations: no later than 72 hours after receipt of
the request. [Data Elements 3.B-3.D]

2.e

RSC-18.a.iii

RSC-18.a.iii: Includes only redeterminations for which the member is
notified of the decision according to the following timelines:
iii. For reimbursement requests: no later than 14 days after receipt of the
request.
[Data Element 3.B-3.D]

2.e

RSC-18.b

RSC-18.b: Excludes approvals in which the sponsor did not authorize or provide the benefit or
payment under dispute according to the following timelines:

Data Sources:

2.e

RSC-18.b.i

RSC-18.b.i: Excludes approvals in which the sponsor did not authorize or
provide the benefit or payment under dispute according to the following
timelines:

Data Elements 3.B-3.D

Review Results:

Data Elements 3.B-3.D

Review Results:

RSC-18.b.iii: Excludes approvals in which the sponsor did not authorize or Data Elements 3.B-3.D
provide the benefit or payment under dispute according to the following
timelines:

Review Results:

*

i.  For standard redeterminations: no later than 7 calendar days after
receipt of the request. [Data Elements 3.B-3.D]

2.e

RSC-18.b.ii

RSC-18.b.ii: Excludes approvals in which the sponsor did not authorize or
provide the benefit or payment under dispute according to the following
timelines:
ii. For expedited redeterminations: no later than 72 hours after receipt of
the request.
[Data Elements 3.B-3.D]

2.e

RSC-18.b.iii

iii. For reimbursement requests: no later than 14 days after receipt of the
request. [Data Elements 3.B-3.D]

RSC-18.c: Includes untimely redeterminations, regardless if they were auto- Data Elements 3.B-3.D
forwarded to the IRE.
[Data Elements 3.B-3.D]

Review Results:

RSC-19: Organization accurately calculates the number of redeterminations by final decision,
including the following criteria:

Data Sources:

RSC-19.a

RSC-19.a: Properly categorizes the total number of redeterminations by
final decision: fully favorable (e.g., fully favorable decision reversing the
original coverage determination, partially favorable (e.g., denial with a
“part” that has been approved) and adverse (e.g., the original coverage
determination decision was upheld). [Data Elements 3.E-3.G]

Data Elements 3.E-3.G

Review Results:

RSC-19.b

RSC-19.b: Excludes redetermination decisions made by the IRE.
Elements 3.E-3.G]

Data Elements 3.E-3.G

Review Results:

2.e

RSC-18.c

2.e

RSC-19

2.e

2.e

[Data

*

2.e

RSC-20

2.e

RSC-20.a

2.e

RSC-20.a

2.e

RSC-20.b

2.e

RSC-20.b

2.e

RSC-20.c

2.e

RSC-20.c

2.e

RSC-21

2.e

RSC-21.a

2.e

RSC-22

2.e

RSC-22.a

RSC-20: Organization accurately calculates the number of redeterminations that were withdrawn or
dismissed, including the following criteria:

Data Sources:

RSC-20.a: Includes all withdrawals and dismissals on requests for
Data Element 3.H
redeterminations. This includes redeterminations that were withdrawn or
dismissed for any reason. [Data Elements 3.H and 3.I]

Review Results:

Data Element 3.I

RSC-20.b: Includes dismissals that are made when the procedural
Data Element 3.H
requirements for a valid request are not met within the stipulated
timeframe. The plan should issue a dismissal only when the required
documentation has not been received within a reasonable amount of time.
[Data Elements 3.H and 3.I]

RSC-20.c: Each number calculated for requests for redeterminations that
were withdrawn (Data Element 3.H) and requests for redeterminations
that were dismissed (Data Element 3.I) is a subset of the number of
redeterminations decisions made (Data Element 3.A).
[Data Elements
3.H and 3.I]

Review Results:

Review Results:

Data Element 3.I

Review Results:

Data Element 3.H

Review Results:

Data Element 3.I

Review Results:

Organization accurately calculates the total number of reopened decisions according to the
following criteria:

Data Sources:

RSC-21.a: Includes a remedial action taken to change a final determination Data Element 4.A
or decision even though the determination or decision was correct based
on the evidence of record.
[Data Element 4.A]

Review Results:

Organization accurately reports the following information for each redetermination.

Data Sources:

RSC-22.a: Contract Number [Data Element 4.B.1]

Review Results:

Data Element 4.B.1

*

*

*

2.e

RSC-22.b

RSC-22.b: Plan ID

[Data Element 4.B.2]

Data Element 4.B.2

Review Results:

2.e

RSC-22.c

RSC-22.c: Case ID

[Data Element 4.B.3]

Data Element 4.B.3

Review Results:

2.e

RSC-22.d

RSC-22.d:Case level (Coverage Determination or Redetermination) [Data Data Element 4.B.4
Element 4.B.4]

Review Results:

2.e

RSC-22.e

RSC-22.e: Date of original disposition [Data Element 4.B.5]

Data Element 4.B.5

Review Results:

2.e

RSC-22.f

RSC-22.f: Original disposition (Fully Favorable; Partially Favorable; or
Adverse) [Data Element 4.B.6]

Data Element 4.B.6

Review Results:

2.e

RSC-22.g

RSC-22.g: Was case processed under expedited timeframe (Y/N) [Data
Element 4.B.7]

Data Element 4.B.7

Review Results:

2.e

RSC-22.h

RSC-22.h: Case type (Pre-Service; Payment) [Data Element 4.B.8]

Data Element 4.B.8

Review Results:

2.e

RSC-22.i

RSC-22.i: Date case was reopened

Data Element 4.B.9

Review Results:

2.e

RSC-22.j

RSC-22.j: Reason (s) for reopening (Clerical Error, Other Error, New and
Data Element 4.B.10
Material Evidence, Fraud or Similar Fault, or Other) [Data Element 4.B.10]

Review Results:

2.e

RSC-22.k

RSC-22.k: Date of reopening disposition (revised decision) [Data Element
4.B.11]

Data Element 4.B.11

Review Results:

2.e

RSC-22.l

RSC-22.l  Reopening disposition (Fully Favorable; Partially Favorable;
Adverse, or Pending). [Data Element 4.B.12]

Data Element 4.B.12

Review Results:

[Data Element 4.B.9]

Organization implements policies and procedures for data submission, including the following:

Data Sources:

Data elements are accurately entered/uploaded into CMS systems and
entries match corresponding source documents.

Data Element 1.A

Review Results:

3.a

Data Element 1.B

Review Results:

3.a

Data Element 1.C

Review Results:

3.a

Data Element 1.D

Review Results:

3.a

Data Element 1.E

Review Results:

3.a

Data Element 1.F

Review Results:

3.a

Data Element 1.G

Review Results:

3.a

Data Element 2.A

Review Results:

3.a

Data Element 2.B

Review Results:

3.a

Data Element 2.C

Review Results:

3

3.a

*

3.a

Data Element 2.D

Review Results:

3.a

Data Element 2.E

Review Results:

3.a

Data Element 2.F

Review Results:

3.a

Data Element 2.G

Review Results:

3.a

Data Element 2.H

Review Results:

3.a

Data Element 2.I

Review Results:

3.a

Data Element 2.J

Review Results:

3.a

Data Element 2.K

Review Results:

3.a

Data Element 2.L

Review Results:

3.a

Data Element 2.M

Review Results:

3.a

Data Element 2.N

Review Results:

3.a

Data Element 2.O

Review Results:

3.a

Data Element 2.P

Review Results:

3.a

Data Element 2.Q

Review Results:

3.a

Data Element 2.R

Review Results:

3.a

Data Element 2.S

Review Results:

3.a

Data Element 2.T

Review Results:

3.a

Data Element 2.U

Review Results:

3.a

Data Element 2.V

Review Results:

3.a

Data Element 2.W

Review Results:

3.a

Data Element 2.X

Review Results:

3.a

Data Element 2.Y

Review Results:

3.a

Data Element 2.Z

Review Results:

3.a

Data Element 2.AA

Review Results:

3.a

Data Element 3.A

Review Results:

3.a

Data Element 3.B

Review Results:

3.a

Data Element 3.C

Review Results:

3.a

Data Element 3.D

Review Results:

3.a

Data Element 3.E

Review Results:

3.a

Data Element 3.F

Review Results:

3.a

Data Element 3.G

Review Results:

3.a

Data Element 3.H

Review Results:

3.a

Data Element 3.I

Review Results:

3.a

Data Element 4.A

Review Results:

3.a

Data Element 4.B.1

Review Results:

3.a

Data Element 4.B.2

Review Results:

3.a

Data Element 4.B.3

Review Results:

3.a

Data Element 4.B.4

Review Results:

3.a

Data Element 4.B.5

Review Results:

3.a

Data Element 4.B.6

Review Results:

3.a

Data Element 4.B.7

Review Results:

3.a

Data Element 4.B.8

Review Results:

3.a

Data Element 4.B.9

Review Results:

3.a

Data Element 4.B.10

Review Results:

3.a

Data Element 4.B.11

Review Results:

3.a

Data Element 4.B.12

Review Results:

3.b

All source, intermediate, and final stage data sets and other outputs relied upon to enter data into
CMS systems are archived.

Review Results:

4

Organization implements policies and procedures for periodic data system updates (e.g., changes in
enrollment, provider/pharmacy status, and claims adjustments).

Review Results:

5

Organization implements policies and procedures for archiving and restoring data in each data
system (e.g., disaster recovery plan).

Review Results:

6

If organization’s data systems underwent any changes during the reporting period (e.g., as a result
of a merger, acquisition, or upgrade): Organization provided documentation on the data system
changes and, upon review, there were no issues that adversely impacted data reported.

Review Results:

7

If data collection and/or reporting for this reporting section is delegated to another entity:
Organization regularly monitors the quality and timeliness of the data collected and/or reported by
the delegated entity or first tier/ downstream contractor.

Review Results:

IM-v1.1

Improving Drug Utilization Review Controls (Part D) 2017

Organization Name:
Contract Number:
Reporting Section:

Improving Drug Utilization Review Controls (Part D) 2017

Last Updated:

MM/DD/YYYY

Date of Site Visit:
Last name, First name

Name of Peer Reviewer:

Last name, First name

Standard/
Sub-standard
ID

Re
po
Cr rtin
ite g S
ria ec
ID tio
n

Name of Reviewer:

Standard/Sub-standard Description

1) In the "Data Sources and Review Results:" column, enter the review results and/or data
sources used for each standard or sub-standard.
2) Enter "Y" if the requirements for the standard or sub-standard have been completely met. If
any requirement for the standard or sub-standard has not been met, enter "N". If any standard
or sub-standard does not apply, enter "N/A".
3) For standards 1c, 1d, 1e, 1g, 1h, and 2e, enter 'Findings' as follows based on the five-point
scale: Select "1" if plan data has more than 20% error, select "2" if plan data has between 15.1% 20.0% error, select "3" if plan data has between 10.1% - 15.0% error, select "4" if plan data has
between 5.1% - 10.0% error, select "5" if plan data has less than or equal to a 5% error. Enter
"N/A" if standard does not apply.

Data Sources and Review Results:
Enter review results and/or data sources

Enter 'Findings' using
the applicable choice
in the appropriate
cells. Cells marked
with an '*' should not
be edited.

Note to reviewer: This document corresponds to the CY 2017 Part D Improving Drug Utilization Review Controls File Record Layout in HPMS. If the Part D sponsor did not have a soft formulary-level cumulative opioid MED
edit POS, then pertaining parts of this reporting section is not required for data validation. If the Part D sponsor did not have a hard formulary-level cumulative opioid MED edit POS, then pertaining parts of this reporting
section is not required for data validation. CMS recommends that data sources are a documented on the FDCF.
1

A review of source documents (e.g., programming code, spreadsheet formulas, analysis
plans, saved data queries, file layouts, process flows) indicates that all source documents
accurately capture required data fields and are properly documented.

Data Sources:

1.a

Source documents are properly secured so that source documents can be retrieved at any
time to validate the information submitted to CMS via CMS systems.

Review Results:

1.b

Source documents create all required data fields for reporting requirements.

Review Results:

1.c

Source documents are error-free (e.g., programming code and spreadsheet formulas have
no messages or warnings indicating errors, use correct fields, have appropriate data
selection, etc.).

Review Results:

1.d

All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient ID,
rather than Field1 and maintain the same field name across data sets).

Review Results:

1.e

Data file locations are referenced correctly.

Review Results:

1.f

If used, macros are properly documented.

Review Results:

1.g

Source documents are clearly and adequately documented.

Review Results:

*

1.h

Titles and footnotes on reports and tables are accurate.

Review Results:

1.i

Version control of source documents is appropriately applied.

Review Results:

2

A review of source documents (e.g., programming code, spreadsheet formulas, analysis
plans, saved data queries, file layouts, process flows) and census or sample data, whichever
is applicable, indicates that data elements for each reporting section are accurately
identified, processed, and calculated.

Data Sources:

The appropriate date range(s) for the reporting period(s) is captured.

Review Results:

2.a

RSC-1

*

Organization reports data based on the required reporting period of 1/1 through 12/31.

2.b

RSC-2

Data are assigned at the applicable level (e.g., plan benefit package or contract level).

Review Results:

Organization properly assigns data to the applicable CMS contract.

2.c

RSC-3

Review Results:

Appropriate deadlines are met for reporting data (e.g., quarterly).
Organization meets deadline for reporting annual data to CMS by 2/26/2018.
[Note to reviewer: If the organization has, for any reason, re-submitted its data to CMS for
this reporting section, the reviewer should verify that the organization’s original data
submissions met the CMS deadline in order to have a finding of “yes” for this reporting
section criterion. However, if the organization re-submits data for any reason and if the resubmission was completed by 3/31 of the data validation year, the reviewer should use the
organization’s corrected data submission(s) for the rest of the reporting section criteria for
this reporting section.]

2.d

RSC-4

Terms used are properly defined per CMS regulations, guidance and Reporting
Requirements Technical Specifications.
Organization complies with drug utilization management (DUM) requirements of 42 C.F.R
§423.153 et seq. to prevent overutilization of opioids as well as other DUM requirements
according to guidelines specified by CMS. This includes but is not limited to: applying all
relevant guidance to properly establish and implement a soft and/or hard formulary-level
cumulative opioid morphine equivalent dose (MED) threshold edit at point of sale,
organization provides documentation that its soft and/or hard formulary-level cumulative
opioid MED POS edit was properly tested and validated prior to its implementation date,
etc...

Review Results:

2.e

RSC-5

Organization data passes data integrity checks listed below:

Data Sources:

2.e

RSC-5.a

RSC-5.a: The organization has either a soft and/or hard formulary
cumulative opioid MED POS edit in place (At least one of Data
Elements A and I must be 1 (Yes)).

2.e

RSC-5.b

RSC-5.b: If the organization has a soft formulary cumulative opioid MED POS edit (Data
Element A = 1), the following is true.

Data Element A
and/or I

*

Review Results:

Data Sources:

*

2.e

RSC-5.bi

RSC-5.bi: The number of soft edit claim rejections overridden by the
pharmacist at the pharmacy (G) does not exceed the number of
claims rejected due to the soft formulary-level cumulative opioid
MED edit at POS (E).

Data Element G

Review Results:

2.e

RSC-5.bii

RSC-5.bii: The cumulative MED threshold, the number of claims
rejected due to soft edits, and the number of unique beneficiary
rejected due to the soft formulary edits must be reported (Elements
B, E, F ≠ blank).

Data Elements B,E,F

Review Results:

2.e

RSC-5.biii

RSC-5.biii: The number of unique beneficiaries with at least one soft
edit claim rejection overridden by the pharmacist at the pharmacy
(H) does not exceed the number of unique beneficiaries with at least
one claim rejected due to the soft formulary-level cumulative opioid
MED edit at POS (F).

Data Element H

Review Results:

2.e

RSC-5.biv

RSC-5.biv: The number of unique beneficiaries with at least one
claim rejected due to the soft formulary-level cumulative opioid
MED edit at POS (data element F) is a value less than or equal to the
number of unique claims rejected (data element E).

Data Element F

Review Results:

2.e

RSC-5.c

RSC-5.c: If the organization does not have soft formulary
cumulative opioid MED POS edits (Data Element A = 2), data
elements B, C, D, E, F, G, and H should equal 0.

Data Elements: B, C,
D, E, F, G, H

Review Results:

2.e

RSC-5.d

RSC-5.d: If the organization had a hard formulary cumulative opioid MED POS edit (Data
Element I = 1), the following is true:

Data Sources:

2.e

RSC-5.di

RSC-5.di: The number of unique beneficiaries with coverage
determinations from hard edit rejections (Data Element O) does not
exceed the number of unique beneficiaries with hard edit rejections
(Data Element N).

Data Element O

Review Results:

2.e

RSC-5.dii

RSC-5.dii: The number of unique beneficiaries that had a claim
successfully processed (paid) (Data Element P) does not exceed the
number of unique beneficiaries with hard edit rejections (Data
Element N).

Data Element P

Review Results:

2.e

RSC-5.diii

RSC-5.diii: The cumulative MED threshold, the number of claims
rejected due to hard edit, and the number of claims rejected to due
to hard edits, and the number of unique beneficiary rejected due to
the hard formulary edit must be reported (Elements J, M, N ≠
blank).

Data ElementS: J, M,
N

Review Results:

2.e

RSC-5.div

RSC-5.div: The number of unique beneficiaries with at least one
claim rejected due to the hard formulary-level cumulative opioid
MED edit at POS (data element N) is a value less than or equal to the
number of claims rejected due to the hard formulary-level
cumulative opioid MED edit at POS (data element M).

Data Element N

Review Results:

2.e

RSC-5.dv

RSC-5.dv: The number of unique beneficiaries with at least one
claim rejected that also had a claim successfully processed (paid) for
an opioid drug subject to the hard opioid MED edit such as, but not
limited to, through favorable coverage determination (data element
P) is a value less than or equal to the number of unique beneficiaries
with at least one hard edit claim rejection that also had a coverage
determination request (data element O).

Data Element: P

Review Results:

*

2.e

RSC-5.e

RSC-5.e: If the organization does not have hard formulary
cumulative opioid MED POS edits (Data Element I = 2), data
elements J, K, L M, N, O, and P should equal 0.

Data ElementS: J, K,
L, M, N, O, P

Review Results:

2.e

RSC-5.f

RSC-5.f: If the organization received a CMS outlier/data integrity
Data Elements: B-H
and J-P
notice based on their soft/hard/provider/pharmacy formulary-level
cumulative opioid morphine equivalent dose (MED) threshold,
validate whether or not an internal procedure change was
warranted or resubmission through HPMS. Data elements: B-H and JP

Review Results:

2.e

RSC-6

RSC-6: Organization can accurately identify and create a Part D data set of POS claim rejects
related to its soft and/or hard formulary-level cumulative opioid morphine equivalent dose
(MED) edit(s) and correctly calculate and report counts to CMS via HPMS, including the
following criteria:

Data Sources:

*

2.e

RSC-6.a

RSC-6.a: Properly identifies and counts the number of POS rejects triggered and unique
beneficiaries by the established soft formulary-level cumulative MED threshold and if
applicable, a provider and pharmacy criterion

Data Sources:

*

2.e

RSC-6.ai

RSC-6.ai: Includes pharmacy transactions for Part D opioid drugs
with a fill date (not batch date) that falls within the reporting
period.

Data Element E

Review Results:

2.e

RSC-6.ai

RSC-6.ai: Includes pharmacy transactions for Part D opioid drugs
with a fill date (not batch date) that falls within the reporting
period.

Data Element F

Review Results:

2.e

RSC-6.aii

RSC-6.aii: The rejected opioid claim due to the soft formulary-level
cumulative opioid MED POS edit is not associated with an early refill
rejection transaction.

Data Element E

Review Results:

2.e

RSC-6.aii

RSC-6.aii: The rejected opioid claim due to the soft formulary-level
cumulative opioid MED POS edit is not associated with an early refill
rejection transaction.

Data Element F

Review Results:

2.e

RSC-6.aiii

RSC-6.aiii: Rejected opioid claims are counted at the unique
contract, beneficiary, prescriber, pharmacy, drug (strength and
dosage form), quantity, and date of service (DOS).

Data Element E

Review Results:

2.e

RSC-6.aiii

RSC-6.aiii: Rejected opioid claims are counted at the unique
contract, beneficiary, prescriber, pharmacy, drug (strength and
dosage form), quantity, and date of service (DOS).

Data Element F

Review Results:

2.e

RSC-6.aiv

RSC-6.aiv: Properly counts the number of unique beneficiaries by
contract that triggered the established soft formulary-level
cumulative MED threshold and if applicable, a provider and
pharmacy criterion.

Data Element E

Review Results:

RSC-6.aiv: Properly counts the number of unique beneficiaries by
contract that triggered the established soft formulary-level
cumulative MED threshold and if applicable, a provider and
pharmacy criterion.

Data Element F

Review Results:

2.e

RSC-6.aiv

2.e

RSC-6.b

RSC-6.b: Properly identifies and counts the number of POS rejects triggered and unique
beneficiaries by the established hard formulary-level cumulative MED threshold and if
applicable, a provider and pharmacy criterion.

Data Sources:

2.e

RSC-6.bi

RSC-6.bi: Includes pharmacy transactions for Part D opioid drugs
with a fill date (not batch date) that falls within the reporting
period.

Data Element M

Review Results:

2.e

RSC-6.bi

RSC-6.bi: Includes pharmacy transactions for Part D opioid drugs
with a fill date (not batch date) that falls within the reporting
period.

Data Element N

Review Results:

2.e

RSC-6.bii

RSC-6.bii: The rejected opioid claim due to the hard formulary-level
cumulative opioid MED POS edit is not associated with an early refill
rejection transaction.

Data Element M

Review Results:

2.e

RSC-6.bii

RSC-6.bii: The rejected opioid claim due to the hard formulary-level
cumulative opioid MED POS edit is not associated with an early refill
rejection transaction.

Data Element N

Review Results:

2.e

RSC-6.biii

RSC-6.biii: Rejected opioid claims are counted at the unique
contract, beneficiary, prescriber, pharmacy, drug (strength and
dosage form), quantity, and date of service (DOS).

Data Element M

Review Results:

2.e

RSC-6.biii

RSC-6.biii: Rejected opioid claims are counted at the unique
contract, beneficiary, prescriber, pharmacy, drug (strength and
dosage form), quantity, and date of service (DOS).

Data Element N

Review Results:

2.e

RSC-6.biv

RSC-6.biv: Properly counts the number of unique beneficiaries by
contract that triggered the established hard formulary-level
cumulative MED threshold and if applicable, a provider and
pharmacy criterion.

Data Element M

Review Results:

2.e

RSC-6.biv

RSC-6.biv: Properly counts the number of unique beneficiaries by
contract that triggered the established hard formulary-level
cumulative MED threshold and if applicable, a provider and
pharmacy criterion.

Data Element N

Review Results:

2.e

RSC-7

RSC-7 From the data set of POS rejects (RSC 6a) related to the soft formulary-level
cumulative opioid MED edit the organization accurately identifies and counts the number of
overridden rejected claims and correctly uploads the counts into HPMS, including the
following criteria:

Data Sources:

*

*

2.e

RSC-7.a

RSC-7.a: Properly identifies and counts the number of pharmacist overridden soft formularylevel cumulative opioid MED edit POS rejected claims.

Data Sources:

2.e

RSC-7.ai

RSC-7.ai: If a prescription drug claim contains multiple POS
rejections, each rejection is considered as a separate pharmacy
transaction and included in the data set.

Data Element G

Review Results:

2.e

RSC-7.ai

RSC-7.ai: If a prescription drug claim contains multiple POS
rejections, each rejection is considered as a separate pharmacy
transaction and included in the data set.

Data Element H

Review Results:

2.e

RSC-7.b

RSC-7.b: Properly identifies and counts the number of unique beneficiaries per contract with
at least one claim rejection due to its soft formulary-level cumulative opioid MED POS edit
and a pharmacist overridden soft formulary-level cumulative opioid MED POS edit rejected
claim (RSC 6a).

Data Sources:

2.e

RSC-7.bi

RSC-7.bi: If a prescription drug claim contains multiple POS
rejections, each rejection is considered as a separate pharmacy
transaction and included in the data set.

Data Element G

Review Results:

2.e

RSC-7.bi

RSC-7.bi: If a prescription drug claim contains multiple POS
rejections, each rejection is considered as a separate pharmacy
transaction and included in the data set.

Data Element H

Review Results:

2.e

RSC-8

2.e

RSC-8: From the data set of POS rejects (RSC 6b) related to the hard formulary-level
cumulative opioid morphine equivalent doses (MED) edits, the organization accurately
identifies claims leading to a coverage determination and correctly uploads the count into
HPMS including the following criteria:

Data Sources:

RSC-8.a

RSC-8.a: If a prescription drug claim contains multiple POS
rejections, each rejection is considered as a separate pharmacy
transaction.

Data Element O

Review Results:

2.e

RSC-8.b

RSC-8.b: Includes all methods of coverage determination receipt
(e.g., telephone, letter, fax, in-person).

Data Elements O

Review Results:

2.e

RSC-8.c

RSC-8.c: Includes all coverage determinations (fully favorable,
partially favorable, and adverse).

Data Elements O

Review Results:

2.e

RSC-9

RSC-9 From the subset of POS rejects (RSC 6b) related to the hard formulary-level
cumulative opioid morphine equivalent doses (MED) POS edits, the organization accurately
identifies the number of unique beneficiaries with at least one hard edit claim rejection due
to its hard formulary-level cumulative opioid MED POS edit that also had a claim successfully
processed (paid) for an opioid drug subject to the hard opioid MED edit such as, but not
limited to, through a favorable coverage determination or process and correctly uploads the
count, if the data set of POS rejects includes the complete reporting period, into HPMS
including the following criteria:

Data Sources:

*

*

*

*

2.e

3

3.a

RSC-9.a

RSC-9.a: The beneficiary’s opioid claim is also included in data
element O.

Data Element P

Organization implements policies and procedures for data submission, including the
following:

Data Element Zero
Enrollment

Review Results:

Data Sources:

Review Results:

3.a

Data Element A

Review Results:

3.a

Data Element B

Review Results:

3.a

Data Element C

Review Results:

3.a

Data Element D

Review Results:

3.a

Data Element E

Review Results:

3.a

Data Element F

Review Results:

3.a

Data Element G

Review Results:

3.a

Data Element H

Review Results:

*

3.a

Data Element I

Review Results:

3.a

Data Element J

Review Results:

3.a

Data Element K

Review Results:

3.a

Data Element L

Review Results:

3.a

Data Element M

Review Results:

3.a

Data Element N

Review Results:

3.a

Data Element O

Review Results:

3.a

Data Element P

Review Results:

3.b

All source, intermediate, and final stage data sets and other outputs relied upon to enter
data into CMS systems are archived.

Review Results:

4

Organization implements policies and procedures for periodic data system updates (e.g.,
changes in enrollment, provider/pharmacy status, and claims adjustments).

Review Results:

5

Organization implements policies and procedures for archiving and restoring data in each
data system (e.g., disaster recovery plan).

Review Results:

6

If organization’s data systems underwent any changes during the reporting period (e.g., as a
result of a merger, acquisition, or upgrade): Organization provided documentation on the
data system changes and, upon review, there were no issues that adversely impacted data
reported.

Review Results:

7

If data collection and/or reporting for this reporting section is delegated to another entity:
Organization regularly monitors the quality and timeliness of the data collected and/or
reported by the delegated entity or first tier/ downstream contractor.

Review Results: