| 2017 (old version) |
2019 (new version) |
Type of Change |
Reason for Change |
Burden Change |
| MTM H: Beneficiary in a long term care facility at the time of the first CMR offer? (Y (yes), N (no), or U (unknown)) |
MTM H: Beneficiary in a long term care facility at the time of the first CMR offer or delivery of CMR? (Y (yes), N (no), or U (unknown)) |
Rev |
Provide technical clarification. |
No |
| MTM O: If offered a CMR, recipient of (initial) offer |
MTM O: If offered a CMR, recipient of (initial) offer (Beneficiary, Beneficiary’s prescriber; Caregiver; or Other authorized individual). |
Rev |
Provide technical clarification. |
No |
Improving Drug Utilization Review Controls (DUR) A: A. Did the plan have a soft formulary-level cumulative opioid MME edit at POS in place during the time period above? (Y (yes) or N (no))
|
Improving Drug Utilization Review Controls (DUR) A: For the care coordination edit, the provider count criterion used, if applicable. |
Rev |
Revised data elements due to final CL provisions |
No |
| DUR B: If yes to element A, the cumulative MME threshold used. |
DUR B: For the care coordination edit, the pharmacy count criterion used, if applicable. |
Rev |
Revised data elements due to final CL provisions |
No |
| DUR C: If yes to element A, the provider count criterion used, if applicable. |
DUR C: The number of claims rejected due to the care coordination edit. |
Rev |
Revised data elements due to final CL provisions |
No |
| DUR D: If yes to element A, the pharmacy count criterion used, if applicable. |
DUR D: Of the total reported in element C, the number of care coordination edit claim rejections overridden by the pharmacist at the pharmacy. |
Rev |
Revised data elements due to final CL provisions |
No |
| DUR E: If yes to element A, the number of claims rejected due to the soft formulary-level cumulative opioid MMD edit at POS. |
DUR E: The number of unique beneficiaries with at least one claim rejected due to the care coordination edit. |
Rev |
Revised data elements due to final CL provisions |
No |
| DUR F: If yes to element A, the number of unique beneficiaries with at least one claim rejected due to the soft formulary-level cumulative opioid MME edit at POS. |
DUR F: Of the total reported in element E, the number of unique beneficiaries with at least one care coordination edit claim rejection overridden by the pharmacist at the pharmacy. |
Rev |
Revised data elements due to final CL provisions |
No |
| DUR G: Of the total reported in element E, the number of soft edit claim rejections overridden by the pharmacist at the pharmacy. |
DUR G: Of the total reported in element E, the number of unique beneficiaries with at least one care coordination edit claim rejection overridden by the pharmacist at the pharmacy that also had an opioid claim successfully processed at POS. |
Rev |
Revised data elements due to final CL provisions |
No |
| DUR H: Of the total reported in element F, the number of unique beneficiaries with at least one soft edit claim rejection overridden by the pharmacist at the pharmacy. |
DUR H: Did the plan have a hard MME edit in place during the time period above? (Y (yes) or N (no)). |
Rev |
Revised data elements due to final CL provisions |
No |
| DUR I: Did the plan have a hard formulary-level cumulative opioid MME edit at POS in place during the time period above? (Y (yes) or N (no)). |
DUR I: If yes to element H, the cumulative MME threshold used. |
Rev |
Revised data elements due to final CL provisions |
No |
| DUR J: If yes to element I, the cumulative MME threshold used. |
DUR J: If yes to element H, the provider count criterion used, if applicable. |
Rev |
Revised data elements due to final CL provisions |
No |
| DUR K: If yes to element I, the provider count criterion used, if applicable. |
DUR K: If yes to element H, the pharmacy count criterion used, if applicable. |
Rev |
Revised data elements due to final CL provisions |
No |
| DUR L: If yes to element I, the pharmacy count criterion used, if applicable. |
DUR L: If yes to element H, the number of claims rejected due to the hard MME edit. |
Rev |
Revised data elements due to final CL provisions |
No |
| DUR M: If yes to element I, the number of claims rejected due to the hard formulary-level cumulative opioid MME edit at POS. |
DUR M: If yes to element H, the number of unique beneficiaries with at least one claim rejected due to the hard MME edit. |
Rev |
Revised data elements due to final CL provisions |
No |
| DUR N: If yes to element I, the number of unique beneficiaries with at least one claim rejected due to the hard formulary-level cumulative opioid MED edit at POS. |
DUR N: Of the total reported in element M, the number of unique beneficiaries with at least one hard MME edit claim rejection that also had an opioid claim successfully processed at POS other than through a favorable coverage determination or appeal, such as pharmacist communication and/or plan override. |
Rev |
Revised data elements due to final CL provisions |
No |
| DUR O: Of the total reported in element N, the number of unique beneficiaries with at least one hard edit claim rejection that also had a coverage determination request for an opioid drug subject to the hard opioid MED edit. |
DUR O: Of the total reported in element M, the number of unique beneficiaries with at least one hard MME edit claim rejection that also had a coverage determination or appeal request for an opioid drug subject to the edit. |
Rev |
Provide technical clarification. |
No |
| DUR P: Of the total reported in element N, the number of unique beneficiaries with a favorable coverage determination. |
DUR P: Of the total reported in element M, the number of unique beneficiaries with at least one hard MME edit claim rejection with a coverage determination or appeal request for an opioid drug subject to the edit that had a favorable (either full or partial) coverage determination or appeal. |
Rev |
Provide technical clarification. |
No |
| DUR Q: Of the total reported in element N, the number of unique beneficiaries with at least one rejected opioid claim due to the hard opioid MME POS edit that also had an opioid claim successfully processed through a favorable coverage determination. |
DUR Q: Of the total reported in element M, the number of unique beneficiaries with at least one hard MME edit claim rejection with a favorable (either full or partial) coverage determination or appeal that also had an opioid claim successfully processed at POS. |
Rev |
Provide technical clarification. |
No |
| N/A |
DUR R: The look-back period used to identify an initial opioid prescription fill for the treatment of acute pain for the opioid naïve days supply edit. |
Add |
Added data collection |
Yes |
| N/A |
DUR S: The number of claims rejected due to the opioid naïve days supply edit. |
Add |
Added data collection |
Yes |
| N/A |
DUR T: The number of unique beneficiaries with at least one claim rejected due to the opioid naïve days supply edit. |
Add |
Added data collection |
Yes |
| N/A |
DUR U: Of the total reported in element T, the number of unique beneficiaries with at least one rejected opioid claim due to the hard opioid naïve POS edit that also had an opioid claim successfully processed at POS other than through a favorable coverage determination or appeal, such as, through pharmacist communication and plan override. |
Add |
Added data collection |
Yes |
| N/A |
DUR V: Of the total reported in element T, the number of unique beneficiaries with at least one opioid naïve days supply edit claim rejection that also had a coverage determination or appeal request for an opioid drug subject to the edit. |
Add |
Added data collection |
Yes |
| N/A |
DUR W: Of the total reported in element T, the number of unique beneficiaries with at least one opioid naïve days supply edit claim rejection with a coverage determination or appeal request for an opioid drug subject to the edit that had a favorable (either full or partial) coverage determination or appeal. |
Add |
Added data collection |
Yes |
| N/A |
DUR X: Of the total reported in element T, the number of unique beneficiaries with at least one opioid naïve days supply safety edit claim rejection with a favorable (either full or partial) coverage determination or appeal that also had an opioid claim successfully processed at POS. |
Add |
Added data collection |
Yes |