Form CMS-10691 Data Request and Attestation

Request for Standardized Extracts of Medicare Claims Data for Our Enrollees:
Select Contract Number(s):
o
o

All Contracts
Select One or More Contracts
SXXXX
SXXXX
SXXXX
SXXXX

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Certify Request for Standardized Extracts of Medicare Claims Data for Our Enrollees:
SXXXX, SXXXX

Click to Certify

o

Certification

We would like to request standardized extracts of Medicare claims data for our
enrollees.
In making this request, we attest that we understand the following purposes and
limitation on the use of the claims data as described in 42 CFR 423.153(g).
1.

Purposes. A PDP sponsor must comply with all laws that may be applicable to
data received under this provision, including state and federal privacy and
security laws, and, furthermore subject to the limitations in 42 CFR
423.153(g)(4) may only use or disclose the data provided by CMS for the
following purposes:
(i) To optimize therapeutic outcomes through improved medication
use, as such phrase is used in paragraph 42 CFR 423.153 (d)(1)(i).
(ii) To improve care coordination so as to prevent adverse health
outcomes, such as preventable emergency department visits and
hospital readmissions.
(iii) For activities falling under paragraph (1) of the definition of
‘‘health care operations’’ under 45 CFR 164.501.
(iv) For activities falling under paragraph (2) of the definition of
‘‘health care operations’’ under 45 CFR
164.501.
(v) For ‘‘fraud and abuse detection or compliance activities’’ under 45
CFR 164.506(c)(4)(ii).
(vi) For disclosures that qualify as ‘‘required by law’’ disclosures at 45
CFR 164.103.

2.

Limitations. A PDP sponsor must comply with the following requirements
regarding the data provided by CMS in 42 CFR 423.153(g):
(i) The PDP sponsor will not use the data to inform coverage
determinations under Part D;
(ii) The PDP sponsor will not use the data to conduct retroactive
reviews of medically accepted indications determinations;
(iii) The PDP sponsor will not use the data to facilitate enrollment
changes to a different prescription drug plan or an MA–PD plan
offered by the same parent organization;
(iv) The PDP sponsor will not use the data to inform marketing of
benefits.
(v) The PDP sponsor will contractually bind its contractors that have
access to the Medicare claims data, and any other potential
downstream data recipients, to the terms and conditions imposed on
the PDP Sponsor under this paragraph (g).

We attest that we will comply with the requirements provided in in 42 CFR 423.153(g).
PRA Disclosure Statement

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no
persons are required to respond to a collection of information unless it displays a valid
OMB control number. The valid OMB control number for this information collection is
0938-TBD. The time required to complete this information collection is estimated to
average 1 - 5 minutes per response, including the time to review instructions, search
existing data resources, gather the data needed, and complete and review the
information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security
Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.

Submit

Request for Standardized Extracts of Medicare Claims Data for Our Enrollees:
Confirmation
Certification Requested for:
SXXXX
SXXXX

Certification Request Date:
12/13/2019 10:03 AM
12/13/2019 10:04 AM

Certification Requested By:
John Doe
John Doe

Request to Stop Standardized Extracts of Medicare Claims Data for Our Enrollees:
Select Contract Number(s):
o
o

All Contracts
Select One or More Contracts
SXXXX
SXXXX
SXXXX
SXXXX

Next

Request to Stop Standardized Extracts of Medicare Claims Data for Our Enrollees:
Confirmation
Requested for:
SXXXX
SXXXX

Request Date:
12/13/2019 10:03 AM
12/13/2019 10:04 AM

Requested By:
John Doe
John Doe