Response to 60-day Comments

CMS Responses to 60 day comments for CMS-10261 (OMB 0938-1054)
Subsequent to the publication of the 60 day Federal Register notice, CMS received over 40 comments on the Part C Reporting
Requirements. The majority were germane to the new ODR reporting requirements. Specifically, many commenters questioned the
new ODR data reporting elements for contract and non-contract providers. In response to many of the comments, CMS revised the
requirement to capture enrollee/representative claims submitted data instead of contract and non-contract provider data. This change
was made because contract provider appeal rights fall outside the Subpart M Medicare appeals process. However, the cumulative total
number of data elements collected for ODR reporting remains unchanged. CMS believes the collection of this data is important
because it will demonstrate how often enrollees are submitting reimbursement requests and the outcome of plan decisions, and will
show better alignment with the Independent Review Entity (IRE) data.
There were also many comments about the file layout in the Plan Reporting Module in HPMS. Specifically, many commenters were
concerned the reformatting of the ODR Plan Reporting Module from its current numbering system for data elements to an alpha listing
of elements would cause confusion. CMS initially made this change to be consistent with Part D reporting but in response to the
public comments, CMS revised the format to include numbered subsections with an alpha listing under each subsection. The revisions
are included in the 30 day document.
The split between the Part C Reporting Requirements and the Part C Technical Specifications caused some concern about technical
information being released in a timely manner to enable plans sufficient time to develop reporting mechanisms with CMS Reporting.
CMS response is that critical information will be disseminated to plans early in the reporting year to allow sufficient time to develop
reporting mechanisms that are consistent with CMS expectations. Once the Part C Reporting Requirements are approved by OMB, the
technical specifications will be posted concurrently with the Part C Reporting Requirements. This process is consistent with Part D
Reporting. The split between the two documents enables CMS to make timely adjustments to the technical specifications in response
to feedback received through the Part C mailbox.
Finally there were many specific questions about the existing Part C Reporting Requirements which are akin to questions we receive
through the Part C mailbox and were not germane to the reporting changes. We have include those questions below.

Organization

Reporting Section

Description of Issue(s) or
Question

Commenters’
Recommendations

CMS Response

Fresenius
Health Partners

Grievances

The SO is asking if plan
organizations report a
grievance in the quarter in
which the plan makes the
final decision or in the
quarter in which the plan
has notified the enrollee of
its decision.
How is timely notification
determined in terms of
reporting grievances?

Include data element
detail, “notes,” and
further context
regarding what is
required for accurate
reporting for each
reporting section.

Report grievances in the quarter
in which the plan has notified
the enrollee of the decision.
CMS will consider adding more
detail to the technical
specifications.

N/A

No

Are Expedited Grievances
and Dismissals included in
the “Total Grievances”
calculation, or should these
categories instead only be
reported separately?
Should “the total number of
organization determinations
made in the reporting
period” exclude withdrawals
and dismissals? In general,
please define how this field
should be calculated (i.e.
which elements do we
include in the total?)

N/A

Timely notification is based on
when the plan has notified the
enrollee of the decision. Please
refer to CMS Regulations and
Guidance: 42 CFR Part 22,
Subpart M and Chapter 13 of
the Medicare Managed Care
Manual.
Expedited grievances are
included in the total. Dismissed
grievances are not.

For withdrawals, if a plan issues a
timely decision, but the request is
then withdrawn, the case should
be counted in the total count. If
the request is withdrawn prior to
a decision being issued, the case
is not included in the total count.
Dismissals are not included in the
total.

No

#1k2-92yjf6y9

Fresenius
Health Partners

Grievances

#1k2-92yjf6y9

Fresenius
Health Partners

Grievances

#1k2-92yjf6y9
Fresenius
Health Partners

1k2-92yj-f6y9

ODR

N/A

Revised
/Not
Revised
No

No

Organization

Reporting Section

Description of Issue(s) or
Question

Commenters’
Recommendations

CMS Response

Fresenius
Health Partners

ODR

Will this reporting section
[ODR] be based on quarters
as seen in previous reporting
years?
Should the plan report an
organization determination
or redetermination to CMS
once the plan makes the
final decision or once the
plan has notified the
enrollee of its decision?
Are the new elements
“contract provider” and
“non-contract provider”
determined by the
requesting provider or the
servicing provider?

N/A

Yes, the ODR reporting section
reports periods will continue to
be based on quarters of the
current CY.
Report an O/D or R when the
No
enrollee is notified of its
decision. These guidelines are in
the Technical Specifications.

With the split between the
Part C RR and the Technical
Specifications, the
commenter is stressing that
it is critical that this
information is disseminated
to plans early in the
reporting year to allow
sufficient time to develop
reporting mechanisms that
are consistent with CMS
expectations.

N/A

1k2-92yj-f6y9
Fresenius
Health Partners

ODR

1k2-92yj-f6y9

Fresenius
Health Partners

ODR

1k2-92yj-f6y9

Kaiser
Permanente

1k2-9318-he68

General

N/A

N/A

We have revised the data
elements to address this
question. You report who
requested the service in
subsection #1 in the appropriate
data element. You report the
disposition of the request and
by whom in subsection #2.
Critical information is
disseminated to plans early in
the reporting year to allow
sufficient time to develop
reporting mechanisms that are
consistent with CMS
expectations.

Revised
/Not
Revised
No

Yes

No

Organization

Reporting Section

Description of Issue(s) or
Question

Commenters’
Recommendations

CMS Response

Medica

ODR

Element E is described as:
Number of Organization
Determinations submitted
by Enrollee/Representative.
Our organization does not
have a reportable field
within the claims processing
system to indicate if the
request was submitted by an
enrollee or representative.
This will be very labor
intensive to report on
accurately.
Element G is described as:
Number of Organization
Determinations submitted
by Provider. Our
organization does not have a
reportable field within the
claims processing system to
indicate if the request
was submitted by the
provider. There is concern
that the provider counts
may inaccurately include
claims that were submitted
by an enrollee or
representative.
The commenter is
concerned about CMS’s
massive data collection

N/A

The impact of this change will
require the plans to reclassify
data that should already be
collected. This data is currently
collected during audits as well
as part of the timeliness
monitoring project. This data is
important because there are
different appeal rights and
different appeal paths. It will
also show better alignment with
the Independent Review Entity
(IRE) data.
We amended the language to
clarify that we are expecting
here the number of ODRs
reported that are submitted by
a non-contract provider.
However, as stated in the
previous comment, plans should
already be collecting this data
since it is currently collected
during audits as well as the
timeliness monitoring project.

1k2-931t-6taw

Medica

ODR

1k2-931t-6taw

BlueCross
BlueShield
Association

EGWP

N/A

BCBSA wishes to ask
CMS to demonstrate
that this information

Requesting this information on
an ad hoc basis would not
permit us to see potential

Revised
/Not
Revised
No

No

No

Organization

Reporting Section

1k2-939r-f0yw

BlueCross
BlueShield
Association

1k2-939r-f0yw

Provider Payments

Description of Issue(s) or
Question

Commenters’
Recommendations

CMS Response

effort for the agency to
obtain information on
employer group plans
(EGWPs) and in the absence
of a lack of purpose or
objective.

is of value to the
agency and how it will
be used.

trends and could also require
more resources depending on
where information may be
accessed.

The commenter asks
whether the alternative
payment arrangement data
is being used to support the
other payer advanced APMs,
as described in the recently
releases CY 2019 Final Rate
notice. The commenter
states it is not clear to
BCBSA, putting together
what is in the final Rate
Notice on APMs and the
language used in that
section, whether this data is
being used for that purpose.
The commenter states that
the purpose of the section in
the PRA is, “to determine
how broadly MA
organizations are using

They suggest an
alternative that entails
CMS asking for
specific information
upon request and not
collect this data
annually.
BCBSA requests CMS
clarify the relationship
between this data
collection and the
determination of
other payer advanced
APM statuses. They
recommend if these
new proposed data
sets do not apply,
then they should not
be collected.

CMS confirms this data
collection is used to determine
how broadly MA organizations
are using alternative payment
arrangements. It is not used to
determine whether physicians
qualify under other payer
advanced APMs. CMS
appreciates your input and will
take your recommendation in
the consideration in future
updates to the Part C reporting
requirements.

Revised
/Not
Revised

No

Organization

BlueCross
BlueShield
Association

Reporting Section

Grievances

1k2-939r-f0yw

Capitol BCBS

ODR

1k2-939v-j0s5

Capitol BCBS

1k2-93b6-x02t

alternative payment
arrangements”, rather than
to determine whether
physicians qualify under
other payer advanced APMs
CMS notes that Plan Benefit
grievances will be removed,
but is silent on the Benefit
Package category. The
commenter is concerned
this may create confusion as
Plan Benefit is a Part D
category and Benefit
Package is missing from the
Part C list.
The commenter is
concerned the reformatting
of the ORD Plan Reporting
Module from its current
numbering system to an
alpha listing of elements
would cause confusion.

Commenters’
Recommendations

CMS Response

The commenter
requests/recommends
that CMS remove Plan
Benefit and add
Benefit Package to the
deletion list.

Both Part C and D reporting
No
requirements have removed all
Grievance categories leaving five
(5) remaining.

The commenter
recommends CMS
retain the current
data element
numbering system.

Please see revised document for
clarification.

Yes

A crosswalk of changes was
provided as part of the 60 day
PRA package.
A revised crosswalk will be
provided as part of the 30 day
package.
MA organizations no longer are
required to report timeliness

No

60 day Crosswalk

For Part C Reporting
Requirements, CMS should
provide a crosswalk of
changes, as they did for the
Part D Requirements.

Please provide Part C
Crosswalk

ODR

Element B, subsection 1

Is the removal of the
timeliness element an

1k2-939v-j0s5

Cigna

Description of Issue(s) or
Question

Revised
/Not
Revised

No

Organization

Cigna

Reporting Section

ODR

1k2-93b6-x02t

Aetna

1k2-93ce-hvsp

ODR

Description of Issue(s) or
Question

Commenters’
Recommendations

CMS Response

Revised
/Not
Revised

(Org Deter) CMS has deleted
Elements 6.2, yet there does
not seem to be any request
for counts of
Timeliness in any of the
elements now.
The commenter is
concerned the reformatting
of the ORD Plan Reporting
Module from its current
numbering system to an
alpha listing of elements
would cause confusion.
For organization
determinations for service
requests, we believe plans
will need more specific
direction in order to
accurately capture the
contracting information that
CMS is seeking. For prior
authorizations, the
requesting provider may be
different from the provider
who will provide the service.
Plans generally capture both
providers in their prior
authorization
documentation at the time
that the service is
requested. Should plans

oversight, or do we no
longer need to report
timeliness?

elements for ODR reporting
section.

The commenter
strongly recommends
that this confusion be
addressed.

Please see revised document for
clarification.

Yes

Please see revised document for
clarification.

Yes

Organization

Aetna

Reporting Section

ODR

1k2-93ce-hvsp

Aetna

1k2-93ce-hvsp

ODR

Description of Issue(s) or
Question
report the contracting status
of the requesting provider or
the status of the provider
who will be performing the
service?
In the reconsideration
section, CMS requires the
contracting status of the
provider. Per Section 40.2.3
Notice Requirements for
Non-contract Providers in
Chapter 13 of the Medicare
Manage Care Manual, in the
situation of a denial of a
claim payment, only noncontracting providers have
CMS appeal rights.
Contracted providers are
afforded plan-specific
appeal rights relative to
claims denials and this
activity would not captured
in CMS reporting.
The commenter is
concerned the reformatting
of the ORD Plan Reporting
Module from its current
numbering system to an
alpha listing of elements
would cause confusion.

Commenters’
Recommendations

CMS Response

Revised
/Not
Revised

Recommends that
CMS remove the
Reconsideration
elements related to
claims from
contracted providers

CMS agrees and has revised the
data elements to capture

Yes

The commenter
recommends that
CMS use the previous
formatting for ODR
reporting.

Please see revised document for
clarification.

Yes

enrollee/representative
claims submitted data instead
of contract and non-contract
provider data.

Organization

Reporting Section

Description of Issue(s) or
Question

Commenters’
Recommendations

CMS Response

Fallon Health

General

The commenter is
concerned about the split
between the Part C RR and
the Technical Specifications
because the latter assists
organizations in preparing
and submitting accurate
datasets to CMS.

CMS expects to release the Part
C technical specifications when
the Part C Reporting
Requirements are approved by
OMB. Both will be posted
concurrently on the CMS.gov
website. This is consistent with
Part D reporting.

ODR

CMS should provide
clarification on pre-service
cases for Part C Organization
Determinations reporting.

General Comment

The current method of
providing the reporting
requirements and technical
specifications on CMS.gov
and the file layouts on HPMS
is confusing and hampers
the review and response
times. Additionally, it would
be beneficial if all of the
applicable draft versions
were issued at the same
time so that these could be
reviewed at the same time

Can CMS let plans
know when the
when Part C Technical
Specifications are
released? Will there
be any opportunity for
plans to comment
on them before their
implementation?
Clarify if all pre-service
cases for Part C
Organization
Determinations
reporting are to be
reported based on
date of notification to
the enrollee or
decision date.
We recommend that
CMS provide the
details regarding the
reporting (the
Reporting
Requirements, the
Technical
Specifications, and the
File layouts) in one
location. Preferably on
the CMS.gov website
rather than HPMS.

1k2-93ce-iais

CVS Health

1k2-93ce-rm1r

CVS

1k2-93ce-rm1r

Revised
/Not
Revised
No

You report based on date of
notification to the enrollee. This
information will be provided in
the Tech Specs.

No

We believe that technical
specifications germane to HPMS
reporting is appropriately
posted on HPMS. All approved
technical and reporting
requirements for Part C
Reporting are appropriately
placed on the CMS.gov website.

No

Organization

Reporting Section

UCARE
1k2-93cg-anrq

General

UCARE
1k2-93cg-anrq

Grievances

Description of Issue(s) or
Question
and taken as a whole,
allowing comments to be
more meaningful as
reviewers will have the full
picture of the reporting ask.
Since the forthcoming
Technical Specifications
document will provide
important details about the
data elements, UCare
requests that CMS allow
plans an opportunity to
review and comment on the
document before it is
finalized.
The Grievances section,
page 4 states: "When
categorizing grievances into
core categories,
organizations may report
based on their investigations
subsequent to the enrollees’
filing of the grievances."
Since CMS will no longer
require plans to report
grievances based on
category, what are "core
categories" referenced in
the Reporting
Requirements?

Commenters’
Recommendations

CMS Response

Revised
/Not
Revised

UCare requests that
CMS allow plans an
opportunity to review
and comment on the
document before it is
finalized.

The technical specifications will
be posted concurrently with the
Part C RR pending OMB
approval.

No

Thank you for your comment.
This sentence has been
removed.

Yes

Organization

Reporting Section

Description of Issue(s) or
Question

UCARE
1k2-93cg-anrq

Mid-Year Network
Changes

Regulatory
Relief Coalition
1k2-93cg-bor6

ODR

Regulatory
Relief Coalition
1k2-93cg-bor6

ODR

UCare supports the
suspension of the Mid-Year
Network Changes reporting
section.
We support the inclusion of
the proposed new data
elements to provide CMS
with additional information
regarding the circumstances
under which ODRs are
made. In addition, we
believe that it is critical to
add a number of additional
new data fields to collect
information relating to
MAOs’ use of Organization
Determinations that are
made pursuant to Prior
Authorization (PA) processes
and procedures.
The commenter requests
the ODR section of the form
entitled “Medicare Part C
Reporting Requirements be
modified to:
• Make it clear that each
request for PA is a
request for an
organization
determination;

Commenters’
Recommendations

CMS Response
Thank you for your comment.

We believe that it is
critical to add a
number of additional
new data fields to
collect information
relating to MAOs’ use
of Organization
Determinations that
are made pursuant to
Prior Authorization
(PA) processes and
procedures.

Revised
/Not
Revised
No

Thank you for your
recommendation. We may
consider exploring this
recommendation at a later date.

No

Thank you for your
recommendation. The current
guidelines states that a request
for prior authorization is
considered an organization
determination request. At this
time, CMS is not requesting the
specific procedure or service
involved. We currently require
plans to submit the rest of your
recommendations.

No

Organization

Reporting Section

Description of Issue(s) or
Question
Require all MAOs to
report the following
information for each
procedure subject to PA:
• The specific service or
procedure involved;
• The number of requests
for PA received for the
procedure;
• The number of requests
for PA for the service or
procedure that were
approved in full,
approved in part, denied
in full and denied in
part.
• The number of denials
appealed;
• The number of denials
reversed on appeal and
the number of denials
affirmed on appeal;
The commenter believes
that requiring MAOs to
report this PA data in a
uniform and consistent
manner is a necessary first
step to ensuring appropriate
access for Medicare
beneficiaries who choose to
enroll in a MA plan and will

Commenters’
Recommendations

CMS Response

Revised
/Not
Revised

Require all PA data
elements be reported
separately from other
organization
determination data
and facilitates data
aggregation.

Thank you for your
recommendation. We will
consider this recommendation
in the future.

No

•

Regulatory
Relief Coalition
1k2-93cg-bor6

ODR

Organization

Reporting Section

Blue Cross/Blue
Shield of IL,MT,
NM,OK,TX
1k2-93cg-ptwj

General

Medical Mutual
of Ohio

ODR

1k2-93cg-x773

Medical Mutual
of Ohio

1k2-93cg-x773

ODR

Description of Issue(s) or
Question

Commenters’
Recommendations

CMS Response

Revised
/Not
Revised

CMS appreciates the positive
response.

No

Can CMS label these
as they do in other
universes - A through
Z, and if needed AA,
AB, AC, etc.?

Please see revised document for
clarification.

Yes

Can consideration be
given to changing the
criteria for Table 4 to
include all claims paid
to an enrollee
regardless of whether

We have updated data elements
to provide clarification.

Yes

facilitate the oversight
requested by patient and
provider groups.
The commenter was
supportive of all the part C
proposed changes; 1) the
suspension of Mid-Year
Network Changes and
Private Fee For Service
Provider Dispute Resolution
Process; 2) the separation of
the Part C Reporting
Requirements from the Part
C Technical Specifications; 3)
the streamlining of the
reporting requirements for
Medicare Medicaid
Managed Care Plans.
The commenter is
concerned the reformatting
of the ORD Plan Reporting
Module from its current
numbering system to an
alpha listing of elements
would cause confusion.
Table 4 is used to report
organization determinations
classified as Direct Member
Reimbursements (DMR). By
definition a DMR claim is
one in which the enrollee

Organization

Reporting Section

Description of Issue(s) or
Question

Commenters’
Recommendations

has paid a healthcare
reimbursement is
related expense for which
being sought?
they are seeking
reimbursement under the
provisions of the health care
coverage. The lack of a
standard reliable way to
identify a DMR claim
using information available
on a HCFA 1500 claim form
requires a manual review of
all claims from the universe
of claims that are potential
DMR claims, i.e. nonelectronic and paid to the
enrollee It would make the
reporting effort more
straightforward and
eliminate the manual
intervention required today.
The revised approach would
still capture all the DMR
Claims as they are defined
today. The only difference
would be it would capture
any additional claim paid to
an enrollee which was not
submitted for the purpose of
seeking reimbursement.

CMS Response

Revised
/Not
Revised

Organization

Reporting Section

Description of Issue(s) or
Question

Commenters’
Recommendations

CMS Response

Medical Mutual
of Ohio

O/D R

The 2019 reporting
requirements request totals
for claims and services
submitted by enrollee vs
provider. There is no data
element on the HCFA 1500
claim form which allows for
the classification of the
submitter as the enrollee or
provider. We do not
currently track the claim
submitter by classification of
any kind. A manual process
would also be subject to
error.

We respectfully
request CMS
reconsider the
requirement to
classify claims and
services by submitter.

This data is currently collected
during audits as well as the
timeliness monitoring project.
This data is important because
there are different appeal rights
and different appeal paths. It
will also show better alignment
with the Independent Review
Entity (IRE) data.

Regulations.
Page 2 of the Part C 2019
Crosswalk indicates that
MMP plans will no longer be
required to report data
specific to ODR and
Grievances under Part C
reporting.

Will Pre-service
Determinations be
required as a new
requirement within
2019 MMP Core
Reporting?

1k2-93cg-x773

Anonymous-

1k2-93ci-kxfj

O/D R & Grievances
(MMPs)

As currently designed
the process to meet
this requirement
would be manual and
therefore place an
undue burden on our
plan.

Under Core Measure 4.2, MMPs
are to report all non-Part D (i.e.,
Part C, Medicaid, and
supplemental benefit)
grievances and appeals. They
should not include pre-service
coverage decisions in the
measure.
MMPs seeking technical
guidance for reporting Core
Measure 4.2, may contact
[email protected].
gov.

Revised
/Not
Revised
No

No

Organization

Reporting Section

Description of Issue(s) or
Question

Commenters’
Recommendations

CMS Response

Tufts Health
1k2-93ci-x37b

ODR

CMS is asked to add
subsection
numbers to
differentiate the
lettered elements.

Please see revised document for
clarification.

Tufts Health
1k2-93ci-x37b

ODR

Tufts Health
1k2-93ci-x37b

ODR

There are currently multiple
elements assigned to each
letter (A, B, C, etc.).
For example, "Total Number
of Organization
Determinations Made in the
Reporting Period Above"
would be
1A and "Number of
Organization Determinations
– Fully Favorable (Services) –
Contract Provider" would be
2A and "Total number of
Reconsiderations Made in
Reporting Time Period
Above" would be 3A.
6‐8
We ask CMS to clarify
whether Part B claims
should be included in this
report. If yes, does that
include Part B drugs that are
rendered at the point of sale
without prior authorization
required?
Element G: Number of
Organization Determinations
submitted by provider
(claims) 6
We ask CMS to clarify
whether the pharmacy

Revised
/Not
Revised
Yes

Thank you for your comment.
We are reviewing this issue and
will provide guidance in the Part
C Tech Specifications.

No

Thank you for your comment.
We are reviewing this issue and
will provide guidance in the Part
C Tech Specifications

No

Organization

Tufts Health
1k2-93ci-x37b

Reporting Section

ODR

Description of Issue(s) or
Question
should be considered the
provider (submitter) for Part
B claims rendered at the
point of sale without prior
authorization.
- For Part B drugs rendered
at a pharmacy, we ask CMS
to clarify whether plans
should report contract
versus non‐contract
provider according to
whether the rendering
pharmacy is contracted with
the plan/PBM.
For pre-service organization
determinations, there are
circumstances where a
contract provider requests
services on behalf of a
member to be rendered by a
non‐contracting provider.

Commenters’
Recommendations

CMS Response

Revised
/Not
Revised

We ask CMS to clarify
whether
plans should report
these requests
according to the
requesting provider
(contracted) or
according to the
servicing provider
(non‐contracted)?

We have updated the data
elements to address this
question.

Yes

Organization

Reporting Section

Description of Issue(s) or
Question

Commenters’
Recommendations

CMS Response

Tufts Health
Plan
1k2-93ci-x37b

ODR

A request might be received
from a contracting provider
on 1/28. The request is
approved on 2/2, but the
provider's contract was
terminated on 1/30; on 2/2
the submitting provider is no
longer in our
network. Would this be
reported as a contract or
non‐contract organization
determination?

We ask CMS to clarify
whether plans should
report the provider's
status (non/contract)
as of the date the
request was received
or as of the date the
request is
authorized/denied?

The plan must determine under
which data element this request
should be reported because it is
based on how the plans process
such a request.

United Health
Care

ODR

United seeks clarification
regarding the number of
reconsiderations submitted
by provider (claim)
because contracted provider
submissions should be
included in the
Member/Member
Representative
submitted totals (element
E), whereas non-contracted
providers can appeal on
their own behalf for
claim denials.

We request CMS
modify Element G
from “Number of
Reconsiderations
submitted by Provider
(Claims)” to “Number
of Reconsiderations
submitted by NonContracted Provider
(emphasis added)
(Claims).”

CMS agrees with this
recommendation. We have
revised the data element to

Yes

With respect to Special
Needs Plans (SNPs) Care
Management

United requests that
CMS add detail to the
technical

Thank you for your
recommendations. We will take
them into consideration in

No

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United Health
Care
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SNP

Revised
/Not
Revised
No

capture
enrollee/representative
claims submitted data instead
of contract and non-contract
provider data.

Organization

United Health
Care
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Reporting Section

SNP

Description of Issue(s) or
Question

Commenters’
Recommendations

CMS Response

the technical specifications
are written at a high level,
and Medicare Advantage
(MA) Plans would benefit
from additional CMS
clarification in the technical

specifications to
reflect CMS responses
to all MA
Plan submitted
questions and develop
FAQs similar to
Division of
Medicare Advantage
Operations (DMAO)
Mailbox FAQs to aid in
consistent
interpretation of the
technical
specifications
Therefore, United
recommends that
CMS remove
beneficiaries who
refuse to complete an
HRA, or decline
outreach, from the
denominator.

developing future Qs and As for
Part C Reporting.

“The Health Risk Assessment
(HRA) Measure - C08”
compares the number of
initial and annual HRAs
performed to the total
number of eligible enrollees.
The measure includes
beneficiaries who refuse or
decline outreach in the total
number of eligible enrollees.
By including “refusals,” MA
Plans are penalized for
respecting beneficiaries’
desire not to be contacted.
This negatively impacts the
overall beneficiary
experience. Therefore,

Any changes to a Star Ratings
measure needs to be proposed
through the Call Letter and
regulatory process.

Revised
/Not
Revised

No

Organization

Health Partners

Reporting Section

ODR

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Health Partners

ODR

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MMM
Healthcare (PR)

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ODR

Description of Issue(s) or
Question

Commenters’
Recommendations

CMS Response

United recommends that
CMS remove beneficiaries
who refuse to complete an
HRA, or decline outreach,
from the denominator.
The commenter is referring
to the revised reporting
format for Part C ODR
Reporting.
The change will result in the
updating the labeling of
elements in each subsection
to the same lettering format
that is consistent with Part D
Reporting.

Revised
/Not
Revised

They request CMS
consider including
differentiation in the
alpha format to
separate each
subsection as they all
start with the letter
"a" and are not
differentiated with
any numerical values.

Please see revised document for
clarification.

Yes

Consider changing
Reporting Section II Part C Organization
Determinations to a
file upload from a
data entry submission.

Thank you for your comment.
This will go into development
for CY 2019 Plan Reporting
Module.

No

A contract provider is a provider
with which an MA organization
contracts or makes
arrangements to furnish
covered health care services to
Medicare enrollees under an

No

Recommends that CMS
consider changing Reporting
Section II - Part C
Organization
Determinations to a file
upload from a data entry
submission to be consistent
with Part D Reporting.
The commenter is
requesting clarification
regarding the definition of
contracted provider.
Regarding the new elements
for Organization
Determinations (A-L) and for

Organization

Reporting Section

Description of Issue(s) or
Question
Reconsiderations (A-L) - the
contractor is requesting
clarification regarding the
definition of contracted
provider. For claims, does
the term contracted
provider means the billing
provider or the provider that
rendered the service?
For authorization requests,
Does it referred to the
requesting provider or the
provider that will render the
service? In addition, we
understand that additional
clarification must be
included to address the
scenario when a
Contracted provider is
cancelled, and was active
with the Plan only for a
short term (e.g. 2 months)
during the reporting period.

Commenters’
Recommendations

CMS Response
MA coordinated care plan or
network PFFS plan.
For claims it is based on who
submits the claim; who is
requesting reimbursement.
For authorization, it refers to
who is requesting the service.

Revised
/Not
Revised