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

Medicare Part C and Part D Data Validation (42 CFR 422.516(g) and 423.514(g)) (CMS-10305)

DV Procedure Manual_FINAL_03015019

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

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Medicare Part C and Part D Reporting Requirements Data Validation
Procedure Manual

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Prepared by:
Centers for Medicare & Medicaid Services
Center for Medicare
Medicare Drug Benefit and C&D Data Group
Last Updated: March 2019

Table of Contents
Contents
1.

INTRODUCTION ........................................................................................................................ 4

1.1. Data Validation Requirement ....................................................................................................................................... 4
1.2. Data Validation Scope ................................................................................................................................................. 4
1.3. Types of Organizations Required to Undergo Data Validation ....................................................................................... 4
1.4. Requirement to Use This Manual and Tools.................................................................................................................. 5
1.5. Organization of the Procedure Manual ......................................................................................................................... 5

PART C AND PART D REPORTING SECTIONS REQUIRING DATA VALIDATION 2020-2021 ................... 7

2.1. Part C and Part D Reporting Sections Requiring Data Validation in 2020 ........................................................................ 7
2.2. Part C and Part D Reporting Sections Requiring Data Validation in 2021 ........................................................................ 8
2.3. Reporting Requirements Excluded from the Validation Requirement at This Time ........................................................... 8

PLANNING FOR DATA VALIDATION ACTIVITIES ......................................................................... 9

3.1.1
Select appropriate contractor based on Standards for Selecting a Data Validation Contractor ....................................... 9
3.1.2 Standards for Selecting a Data Validation Contractor.......................................................................................... 9
3.1.3 Timing of Data Validation Contractor Selection................................................................................................... 9
3.1.4 Requesting a Contractor Change Mid-Review ..................................................................................................... 9
3.2 Notify CMS of DVC Selection / Request Access to Health Plan Management System (HPMS) Plan Reporting Data Validation
Module (PRDVM) ....................................................................................................................................................... 10
3.2.1 Documentation of Data Validation Contractor Selection Process ...................................................................... 10
3.2.2 Request Access to HPMS Plan Reporting Data Validation Module ..................................................................... 10
3.3 Complete the Web-based Data Validation Training ..................................................................................................... 12
3.4 Review all Data Validation Documents ....................................................................................................................... 12
3.4.1 Introduction to the Data Validation Standards .................................................................................................. 12
3.4.2 Data Validation Standards and Reporting Section Criteria ................................................................................. 12
3.4.3 Reporting Section Criteria................................................................................................................................ 15

PERFORMING DATA VALIDATIONACTIVITIES ......................................................................... 17

4.1 Complete Organizational Assessment Instrument (OAI) and Provide Appropriate ........................................................ 17
4.2 Analyze OAI Responses ............................................................................................................................................ 17
4.2.1. Perform OAI Gap Analysis ............................................................................................................................... 18
4.2.2. Review Source Code and Other Documentation ...................................................................................................... 18
4.2.3. Prepare Interview Discussion Guide................................................................................................................. 18
4.3 Prepare for Site Visit .................................................................................................................................................. 18
4.3.1 Select Dates and Appropriate Location(s) of Site Visit ...................................................................................... 18
4.3.2 Develop Agenda for Site Visit ........................................................................................................................... 18
4.3.3 Prepare for Data Extraction and Sampling ........................................................................................................ 19
4.4
Conduct Site Visit ............................................................................................................................................ 19
4.4.1 Conduct Entrance Conference ......................................................................................................................... 19
4.4.2 Conduct Interviews with Organization Staff ...................................................................................................... 19

4.4.3
4.4.4
4.4.5
4.5

Observe Reporting Processes ......................................................................................................................... 19
Extract Census or Sample Data ........................................................................................................................ 20
Conduct Exit Conference ................................................................................................................................. 21
Request Additional Documents (If Required) .................................................................................................... 21

ANALYZING RESULTS AND SUBMISSION OF FINDINGS ............................................................ 21

5.1 Determine Compliance with Data Validation Standards and Record Findings in Excel Version of the Findings Data Collection
Form (FDCF) to Upload into the HPMSPRDVM ................................................................................................................. 21
5.1.1. Reporting Findings for Standards Using Binary Scale ...................................................................................... 22
5.1.2. Reporting Findings for Standards Using Likert Scale ........................................................................................ 23
5.1.3. Review of the Findings Data Collection Form .................................................................................................... 24
5.1.4. Guidance for Interpreting Standards and Making a Findings Determination ....................................................... 34
5.2 Provide Draft Findings to Sponsoring Organization .................................................................................................... 41
5.3 Review Draft Findings with Sponsoring Organization and Obtain Additional Documentation Necessary to Resolve Issues ... 41
5.4. Submit Data Validation Review Findings via HPMS PRDVM ........................................................................................ 42
5.4.1. Data Validation Contractor’s Submission of Findings ....................................................................................... 42
5.4.2. Sponsoring Organization Disagreement with Findings ..................................................................................... 42

POST- DATA VALIDATION ACTIVITIES ..................................................................................... 42

6.1 Compile Archive of Data Validation Work Papers........................................................................................................ 42
6.2 Receive Pass or Not Pass Threshold Level and Assess Pass or Not Pass Determination based on Final Scores .................. 43
6.2.1 Pass/Not Pass Determination ........................................................................................................................... 43
6.2.2 CMS Notification to Sponsoring Organization of Pass/Not Pass Determinations ................................................ 43
6.3 Sponsoring Organization Appeal of Data Validation Determination (If Applicable) ......................................................... 43

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

Appendices
Appendix A: Standards for Selecting a Data Validation Contractor
Appendix B: Part C and Part D Reporting Section Data Validation Standards
Appendix C: Model Language for Letter to Confirm Selection of Data Validation Contractor
Appendix D: Example Application for Access to CMS Computer Systems
Appendix E: Organizational Assessment Instrument Appendix F: Interview Discussion Guide
Appendix G: Example Site Visit Agenda
Appendix H: Data Extraction and Sampling Instructions
Appendix I: Example Data File Inventory Log
Appendix J: Findings Data Collection Form
Appendix K: Data Validation Pass/Not Pass Determination Methodology

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

INTRODUCTION

1.1. Data Validation Requirement
The Centers for Medicare & Medicaid Services (CMS) requires that organizations (sponsoring organizations)
(SOs) contracted to offer Medicare Part C and/or Part D benefits be subject to an independent yearly review to
validate data reported to CMS per the Medicare Part C and Part D Reporting Requirement Technical
Specifications (Technical Specifications).1 The purpose of the independent data validation (DV) is to ensure that
Part C and Part D SOs are reporting health and drug plan data that are reliable, valid, complete, comparable, and
timely.
The validated data improves reporting and provides CMS with assurance that data are credible and
consistently collected and reported by Part C and Part D SOs. CMS uses these reported data to respond to
inquiries from Congress, oversight agencies, and the public about an SO’s performance using indicators such
as operations, costs, availability and use of services, provider network adequacy, and grievance rates. The
validated data also allow CMS to more effectively monitor and compare the performance of SOs over time.
These data may be used for Star Ratings, and other performance measures. Additionally, SOs can take
advantage of the DV process to more effectively assess their own performance and make improvements to
their internal data, systems, and reporting processes.
The primary purpose of this Procedure Manual (Manual) is to provide SOs and the data validation contractors
(DVCs) they select to perform the DV with information regarding the Part C and Part D Reporting
Requirements Data Validation program. The Manual provides background information and an overview of the
DV program, discusses the scope and timeframe required for the DV, and describes the tools and processes
used for conducting the DV.

1.2. Data Validation Scope
CMS requires that the annual, retrospective DV be conducted once per year. For the 2020 DV cycle, the DV
will take place during the April 1, 2020 – June 30, 2020 timeframe and will incorporate all data submitted to
CMS by March 31st based on the previous calendar years’ reporting requirements. Any data submitted or resubmitted by a SO after March 31 cannot be used for purposes of the DV. The reviewer must submit findings
from the annual DV review to CMS by June 30, 2020.
The DV reviews will continue to be conducted at the contract level. CMS believes the contract is the most
appropriate unit of analysis in conducting this DV, given that the Part C/D data are generally available at the
contract level and that the contract is the basis of any legal and accountability issues concerning the
rendering of services.

1.3. Types of Organizations Required to Undergo Data Validation
All Part C and Part D SOs that report Part C and/or Part D data to CMS per the Technical Specifications,
regardless of enrollment size, are required to undergo an annual DV review.
The only SOs exempt from participating in the data validation program are:
•
•

Program of All-Inclusive Care for the Elderly (PACE) SOs and Part C Health Care Prepayment
Plans.
An SO that terminates its contract(s) to offer Medicare Part C and/or Part D benefits, or that is
subject to a CMS termination of its contract(s), is not required to undergo a DV review for the final
contract year’s reported data. Similarly, for reporting sections that are reported at the plan benefit
package (PBP) level, PBPs that terminate are not required to undergo a DV review for the final
year’s reported data.

See 42 CFR §422.516(g) and §423.514(g)

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

Any SO that delegates the data collection, calculation, and/or reporting for any reporting section or data
element to a Pharmacy Benefit Manager (PBM) or other type of delegated entity must have the DVC it hires
include the data and reporting processes for which the PBM/delegated entity is responsible in its DV review
for each applicable contract. For example, all entities are required to provide applicable policies, procedures,
and source data to the DVC for validation if they submit data to an SO that is used for any reporting section.

1.4. Requirement to Use This Manual and Tools
CMS requires that SOs and their selected DV contractors use the processes and tools contained in this
Manual and its appendices to conduct the annual DV. This includes each of the following documents:
1. Standards for Selecting a Data Validation Contractor (Appendix A)
2. Data Validation Standards (Appendix B)
3. Model Language for Letter to Confirm Selection of Data Validation Contractor (Appendix C)
4. Example Application for Access to CMS Computer Systems (Appendix D)
5. Organizational Assessment Instrument (OAI) (Appendix E)
6. Interview Discussion Guide (IDG) (Appendix F)
7. Example Site Visit Agenda (Appendix G)
8. Data Extraction and Sampling Instructions (Appendix H)
9. Example Data File Inventory Log (Appendix I)
10. Findings Data Collection Form (FDCF) (Appendix J)
11. Pass/ Not Pass Determination Methodology (Appendix K)
The Data Validation Standards (Standards) and other documentation associated with the implementation of
the DV program assess an SO’s information systems capabilities and overall processes for collecting, storing,
compiling, and reporting the required Part C and Part D reporting sections. CMS expects to establish
consistency in the DV program by requiring that all entities use appropriate tools and follow the same process.
In order to ensure that the DV documentation can incorporate periodic clarifications to the Part C and Part D
Reporting Requirements Technical Specifications, CMS intends to update this Manual and the DV tools
contained in its appendices annually; CMS will post the most current version publicly at: Medicare Part C and
D Data Validation and within the Health Plan Management System (HPMS) Plan Reporting Data Validation
Module (PRDVM). Prior to beginning each annual DV, it is the responsibility of all SOs and DVCs to confirm
that they are using the most recent DV documentation available on the CMS DV website.
In the event of a conflict between the Technical Specifications and the Data Validation Standards reporting
section criteria, the Data Validation Standards supersede the Technical Specifications. DVCs must use the
Data Validation Standards reporting section criteria to determine DV findings. CMS will take a conflict
between the Technical Specifications and the Data Validation Standards into consideration when evaluating
the results of the DV review.

1.5. Organization of the Procedure Manual
Exhibit 1 below illustrates how the Manual is organized. The document’s content is structured according to the
four phases that comprise the DV process. The graphic presents the phases in the order in which the annual
DV cycle is conducted.

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

EXHIBIT 1. DATA VALIDATION PROGRAM PHASES
Planning for DV Activities => Performing DV Activities=> Analyzing Results and Submission of
Findings => Completing Post-DV Activities
Each phase of the DV review process contains several activities. Exhibit 2 displays the activities in the order
in which they are found in the document and the order in which they are conducted, beginning with the
selection of an appropriate DVC and ending with the appeal of DV determinations. The DV review process
largely entails a collaborative effort between the SO and its independent, external DVC in terms of information
sharing up to the point of the DVC’s final submission of DV review findings to CMS. Each of these steps is
described in more detail throughout the Manual.
EXHIBIT 2. DATA VALIDATION PROGRAM ACTIVITIES
DV Phase

Planning for
DV Activities

Performing
DV Activities

Analyzing
Results and
Submission
of Findings

Completing
PostActivities

Step

Responsible Party

DVC, SO

3
4

DVC, SO
DVC, SO

DVC, SO

DVC

DVC, SO

DVC

DVC, SO

DV Activities
Select appropriate DVC based on Standards for Selecting
a Data Validation Contractor
Notify CMS of DVC Selection / Request Access to Health
Plan Management System (HPMS) Plan Reporting Data
Validation Module (PRDVM)
Complete the web-based Data Validation Training
Review all DV documents
Complete Organizational Assessment Instrument (OAI)
and provide appropriate documentation to selected DVC
per the OAI’s documentation request
Analyze OAI Responses
Prepare for site visit (site visit agenda, resource needs,
and logistics)
Conduct on-site review (convene entrance conference,
conduct interviews with SO staff, observe SO’s reporting
processes, and obtain census and/or sample files)
Request additional documents following site visit (if
applicable)
Determine compliance with Data Validation Standards
and record findings in Excel-version of the Findings Data
Collection Form (FDCF)
Provide draft findings to SO
Review draft findings and obtain additional
documentation
necessary to resolve issues
Submit findings to CMS via HPMS PRDVM and receive
DV scores
Compile archive of DV work papers
Receive Pass or Not Pass threshold level and
assess Pass or Not Pass determination based on
final DV scores

Timeline
December*-March
January-April
February-March
January-March
March 2 - April 1
March 2 or later
Early April
Early April (allow
for up to 1 week)
Mid/Late April
June
June
June
No Later than June 30
July 31
Summer/Fall

Within 5 days of
receiving threshold
level from CMS.
* References to December refer to the calendar year before the DV review; all other references to months refer to the same
calendar year as the DV review.
16

Appeal DV determination(s) (if applicable)

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

PART C AND PART D REPORTING SECTIONS REQUIRING
DATA VALIDATION 2020-2021
This section provides an overview of the Part C and Part D reporting sections that will undergo validation
over the next two years. The DV reporting section criteria that are included in the DV Standards are mapped
specifically to these reporting sections.

2.1.

Part C and Part D Reporting Sections Requiring Data Validation in 2020
Seven Part C and Part D reporting sections are included in Exhibit 3. Please note that all 7 reporting sections
require a reporting deadline of 2/24/20 or before.
EXHIBIT 3. PART C AND PART D REPORTING SECTIONS REQUIRING DATA VALIDATION IN 2020
Reporting
Period(s)

Data Submission
Due Date(s) to CMS

DV Findings
Due to CMS*

Grievances

1/1 - 3/31
4/1 - 6/30
7/1 - 9/30
10/1 - 12/31

First Monday of
February in 2020

6/30

Organization Determinations/
Reconsiderations

1/1 - 3/31
4/1 - 6/30
7/1 - 9/30
10/1 - 12/31

Last Monday of
February in 2020

6/30

1/1 - 12/31

Last Monday of
February in 2020

6/30

Last Monday of
February in 2020

6/30

First Monday of
February in 2020

6/30

2020 Reporting Section

Part C

Special Needs Plans (SNPs) Care
Management

Part D
Medication Therapy Management
Programs

Grievances

Coverage Determinations and
Redeterminations

Improving Drug Utilization Controls

1/1 - 12/31
1/1 - 3/31
4/1 - 6/30
7/1 - 9/30
10/1 - 12/31
1/1 – 3/31
4/1 - 6/30
7/1 - 9/30
10/1 - 12/31
1/1 - 3/31
1/1 - 6/30
1/1 - 9/30
1/1 - 12/31

Last Monday of
February in 2020

6/30

Last Monday of
February in 2020

6/30

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

2.2.

Part C and Part D Reporting Sections Requiring Data Validation in 2021
The 2021 DV includes the 7 Part C and Part D reporting sections included in Exhibit 4. Please note that all 7
reporting sections require a reporting deadline of 2/22/21 or before.
EXHIBIT 4. PART C AND PART D REPORTING SECTIONS REQUIRING DATA VALIDATION IN 2021
2021 Reporting Section

Reporting
Period(s)

Data Submission
Due Date(s) to CMS

DV Findings
Due to CMS*

Part C

Grievances

1/1 - 3/31
4/1 - 6/30
7/1 - 9/30
10/1 - 12/31

First Monday of
February in 2021

6/30

Organization Determinations/
Reconsiderations

1/1 - 3/31
4/1 - 6/30
7/1 - 9/30
10/1 - 12/31

Last Monday of
February in 2021

6/30

Special Needs Plans (SNPs) Care
Management

1/1 - 12/31

Last Monday of
February in 2021

6/30

Last Monday of
February in 2021

6/30

First Monday of
February in 2021

6/30

Last Monday of
February in 2021

6/30

Part D
Medication Therapy Management
Programs
Grievances

Coverage Determinations and
Redeterminations

Improving Drug Utilization Controls

2.3.

1/1 - 12/31
1/1 - 3/31
4/1 - 6/30
7/1 - 9/30
10/1 - 12/31
1/1 - 3/31
4/1 - 6/30
7/1 - 9/30
10/1 - 12/31
1/1 - 3/31
1/1 - 6/30
1/1 - 9/30
1/1 - 12/31

Last Monday of
February in 2021

6/30

Reporting Requirements Excluded from the Validation Requirement at This Time
Nine Part C and Part D reporting sections will not undergo validation, as they have either been suspended
from reporting, or will be used for monitoring purposes only. Exhibit 5 lists the reporting sections required for
reporting but excluded from the DV review at this time.
EXHIBIT 5. PART C AND PART D REPORTING SECTIONS EXCLUDED FROM DATA VALIDATION

•
•
•
•

Part C Reporting Sections
Enrollment/ Disenrollment
Employer Group Plan Sponsors
Rewards and Incentives Programs
Payments to Providers

•
•

Part D Reporting Sections
Enrollment/ Disenrollment
Employer/ Union- Sponsored Group Health Plan Sponsors

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

PLANNING FOR DATA VALIDATION ACTIVITIES

3.1.1

Select appropriate contractor based on Standards for Selecting a Data Validation
Contractor
CMS requires that the DV be conducted by an independent, external entity, and believes that this will ensure
that the data used to develop plan performance measures are credible to other stakeholders, and that
information used to respond to Congressional and public inquiries are reliable for monitoring plans. The SO is
responsible for acquiring the independent Data Validation Contractor (DVC) and for all other costs associated
with completing the independent DV and reporting the results to CMS.

3.1.2

Standards for Selecting a Data Validation Contractor
CMS has provided a set of Standards for Selecting a DVC (Appendix A) as guidance for SOs to use in
acquiring a contractor. These standards describe the minimum qualifications, credentials, and resources that
the selected DVC must possess, as well as the conduct that the DVC must exhibit. SOs must acquire one
DVC to conduct the validation on reported data and if necessary, the DVC may subcontract in order to
ensure that it has the expertise required for each DV area and to meet the minimum standards. SOs may
use their own staff only to assist the DVC in obtaining the information, data, and documents needed to
complete the DV review.
SOs may also permit a different DVC to perform mock audits, pre-assessments, and any other types of
review throughout the year. However, in order to meet CMS’ standards for organizational independence, a
SO may not use the same DVC who conducted these activities to conduct the subsequent DV review of
those reported data. More detailed information pertaining to organizational independence is included in
Appendix A, Standards for Selecting a Data Validation Contractor. While the DVC conducting the formal DV
review may not participate in mock audits, pre-assessments, or other types of reviews, the DVC can begin
preparing for the DV review prior to April 1 so that the validation review can begin as soon as possible as of
April 1. These types of preparation activities may include:
•
•

Meeting with the SO to discuss the validation process, resource needs, timeline, etc.
Providing the SO with a list of documents, data, and materials that are needed to complete the
review.

Any specific questions about what types of activities are permitted prior to April 1 or regarding whether or not
a particular entity meets the organizational independence standard should be directed to
[email protected].
The Standards for Selecting a Data Validation Contractor also contain best practices that DVCs are expected
to adhere to throughout the course of the review. The DVC should remain an objective, independent third
party and avoid acting in a consulting capacity. The DVC should remain impartial in all of its activities and
focused on determining if SOs’ systems, programs, data, etc. are accurate, reliable, valid, and complete
based on instructions and standards outlined in Appendix A and CMS’ policies. The DVC should provide
general feedback and specific information on deficiencies to help SOs improve, and should maintain
confidentiality of SOs’ privileged information.

3.1.3

Timing of Data Validation Contractor Selection
An SO may select a DVC at any time, up to and during the April through June DV review period. SOs should
implement the contract to allow sufficient time for the DVC to perform all of the requirements of the review
during the required timeframe and submit findings to CMS via the PRDVM in HPMS by June 30.

3.1.4

Requesting a Contractor Change Mid-Review
An SO may not change its DVC during the formal review period (April-June) unless there are conditions that
are unrelated to DV findings such as negligence or malfeasance on the part of the DVC. If a change in
9

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

contractor is required, the new DVC is required to complete the DV review in its entirety (starting with the OAI
analysis through the submission of findings to CMS) within the required April - June DV review timeline.
CMS will consider DVC change requests submitted mid-review on a case-by-case basis only. Requests must
be in writing and be submitted to CMS via the [email protected] email box.

3.2

Notify CMS of DVC Selection / Request Access to Health Plan Management System
(HPMS) Plan Reporting Data Validation Module (PRDVM)

3.2.1

Documentation of Data Validation Contractor Selection Process
SOs must document their DVC selection process and be able to show, upon request by CMS, how their
chosen DVC meets the minimum qualifications, credentials, and resources set forth in the Standards for
Selecting a Data Validation Contractor. This includes maintaining a copy of the documentation that all
DVC staff assigned to the applicable DV review team completed the CMS Data Validation Training
program (see Section 3.3). CMS requires that the SO retain this documentation for the 10-year retention
period per federal regulations2.
If an SO chooses to select the same DVC it used for a previous year’s DV review, it must still document
the selection process as described above.

3.2.2

Request Access to HPMS Plan Reporting Data Validation Module
Once the SO has selected a DVC, the next step is for the DVC to request staff access to the PRDVM in
HPMS. This module allows users to upload and review DV findings and submit them to CMS. The
credentials assigned to a user will allow that individual to access only the PRDVM and those
SO(s)/contract(s) with which they are associated. The DVC staff will use these credentials to access the
appropriate screen(s) to upload DV findings within the PRDVM starting no earlier than April 1 of the
calendar year.

3.2.2.1 Process for Sponsoring Organization
Each SO is required to provide its DVC with an official letter from its SO in either hardcopy or an emailed
pdf format attachment. This letter must contain the following in order for individuals representing the DVC to
gain access to the PRDVM:
•
•
•
•
•
•

The SO’s acknowledgment that it has contracted with the selected DVC to complete the review,
The name of each individual who requires access (up to 5 individuals),
The type of functionality that each individual user requires,
Acknowledgement that the individuals have completed the web-based DV Training,
The contract number(s) the DVC will need access to, and
The SO’s Chief Executive Officer’s (CEO) signature.

Model language for this letter can be found in the Model Language for Letter to Confirm Selection of Data
Validation Contractor (Appendix C).
If an SO chooses to select the same DVC it used for a previous year’s DV review, it must still provide the
DVC with this signed letter for the current year’s DV activities.

See 42 CFR §422.504(d) and § 423.505(d)

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

3.2.2.2 Process for Data Validation Contractor
DVC staff must obtain individual access to the HPMS PRDVM. If the designated user(s) from the DVC
does not have active access to HPMS, each user should download the Application for Access to CMS
Computer Systems at : Access to CMS Data & Application and follow the instructions provided in Example
Application for Access to CMS Computer Systems (Appendix D) for requesting reviewer access to the
HPMS PRDVM. CMS will allow up to 5 individuals from each DVC to have access to this Module on behalf
of each SO. One application must be completed for each user. The DVC must send the completed
application(s), along with the letter from each SO (signed by the CEO) for which they are under
contract to complete the DV review. Sending letters along with the form will speed up your process
time. Should a form be received without a letter, we will process but the user will only get theHPMS
main home page until a DV letter is received. The letters may be sent as email attachments to
[email protected] or [email protected] but forms (as they contain
PII) must be sent via traceable carrier to:
Kristy Holtje
Re: Plan Reporting Data Validation Reviewer HPMS Access
7500 Security Blvd.
Location: C4-17-24 / Mailstop: C4-18-13
Baltimore, MD 21244-1850
If a DVC is serving multiple SOs, only one CMS user access form is required for each of that DV
contractor’s PRDVM users, however, a letter must be provided from each SO for which the individual DVC
will be serving as an agent in HPMS.
The process for gaining access to the PRDVM in HPMS can begin with the submission of only one
application and the letter from the SO. The DVC can submit new applications as they are obtained, along
with a copy of the SO letter, until they have reached the limit of 5 individuals.
For individuals that already have active CMS Enterprise User Administration (EUA) User IDs and HPMS
access, a new Application for Access to CMS Computer Systems is not necessary. Instead, their current
credentials must be modified to allow access to the PRDVM. For this access, individuals need to ensure
that the letter from each SO linking the DVC to the SO (signed by the CEO) includes the individual’s
current User ID and an explanation that the user already has HPMS Access. This letter must be sent to
CMS via email or traceable carrier to the address indicated above. If a user had PRDVM access as a DVC
previously, they do not need letters resent on their behalf. Letters are only required for changes to a DVC
user’s account.
The findings from the annual DV review must be submitted to CMS by June 30 of each calendar year. To
assure timely access to the HPMS PRDVM to meet this annual DV timeframe, CMS strongly recommends
requests for HPMS PRDVM access be submitted by early April. Any requests received after this date will
be processed on a rolling basis. It will take approximately four weeks for the designated individuals to
obtain the credentials (CMS EUA User IDs and passwords) to access the PRDVM.
For DVC staff that participated in a previous year’s DV and already have an active CMS Enterprise User
Administration (EUA) User ID and HPMS access, a new Application for Access to CMS Computer
Systems is not necessary. However, these individuals must still follow the process described above to
provide CMS with the letter from the SO linking the DVC to the SO in order to obtain access to the HPMS
PRDVM for the current year’s DV activities.

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

3.3

Complete the Web-based Data Validation Training
CMS has developed a web-based DV Training that provides an opportunity for SOs and DVCs to learn more
about the DV program and its specific requirements. The training is offered through the CMS Medicare
Learning Network (MLN) Learning Management System (LMS) and can be found at:
https://learner.mlnlms.com.
During the DV preparation phase, all SO staff involved in the DV should complete the CMS DV Training
individually to familiarize themselves with the DV process and requirements.
Additionally, all DV staff are required to take the CMS DV Training prior to working on the DV project.
Once the training is completed, a certificate of completion is generated. The DVC must provide this
documentation to any hiring SO for all DV staff before commencing work on the DV.
CMS plans to offer continuing education credits resulting from successful completion of the DV Training.
The continuing education certificate will be automatically generated upon successful completion of the
course along with the certificate of completion.
Any DVC staff that participated in a previous year’s DV must still take the current year’s CMS DV Training
prior to working on the DV project and provide documentation to the hiring SO the current year’s training
was completed before commencing work on the DV.

3.4

Review all Data Validation Documents
As noted in Section 1.4, there are 11 documents (including this Manual) that should be reviewed well in
advance of the DV period. This Manual describes these materials. This section will focus specifically on the
DV standards, which are further described in Data Validation Standards (Appendix B).

3.4.1

Introduction to the Data Validation Standards
The DV Standards include general standards and reporting section criteria that DV staff must use to
determine whether the data each SO reported to CMS per the Part C/Part D Reporting Requirements
Technical Specifications are accurate, valid, timely, and reliable.
The standards assess an SO’s information systems capabilities and its processes for collecting, storing,
compiling, and reporting Part C and/or Part D data. They also assess whether SOs follow the applicable
Technical Specifications to compile data, take into account appropriate data exclusions, and verify
calculations, computer code, and algorithms.
In preparation for the DV process, both the SO and the DVC must review and learn the standards. Refer
to Appendix B for the complete set of Part C and Part D Reporting Section Data Validation Standards
along with guidance related to interpreting the standards.

3.4.2

Data Validation Standards and Reporting Section Criteria

3.4.2.1 Data Validation Standards Instructions
The DV Standards include identical instructions relating to the types of information that must be reviewed
for each reporting section, a set of validation standards (also identical for each reporting section), and
reporting section criteria that are based on the applicable Technical Specifications.
The DVC must use these standards in conjunction with the Data Extraction and Sampling Instructions
(Appendix H) and the Excel version FDCF (Appendix J) to evaluate the SO’s processes for producing and
reporting the reporting sections. CMS strongly recommends that the DVC and the SO’s leadership team
and reporting section report owners/ data providers review the DV Standards documentation before and
during the review of each reporting section to ensure that they thoroughly understand the standards and
reporting section criteria. This will also help to ensure all applicable data fields are extracted for each
reporting section.
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The top portion of each set of standards (which is identical for each reporting section) details the
documents and reports that the DVC is required to use to determine compliance with the standards for
each specific reporting section. The documents and reports are listed within the gray box underneath the
name of the applicable reporting section and are displayed in Exhibit 6.
EXHIBIT 6. GENERAL INSTRUCTIONS FOR DATA VALIDATION STANDARDS

[NAME OF REPORTING SECTION]
To determine compliance with the standards for [name of reporting section], the reviewer will assess the following information:
• Written response to OAI Sections 3 and 4, and
documentation requested per OAI Sections 5 and 6
• Outlier/data integrity notification(s)- See OAI 4.3.3 for
instructions on how to retrieve notices
• Results of interviews with organization staff

• Data file created for submission to CMS and copy of
HPMS screen shots of data entered
• Other relevant information provided by organization

Also contained within this section, if applicable, are notes to the DVC regarding a specific reporting section and
any nuances or differences that may be encountered during the review of that reporting section.
The second section of each set of standards is identical for all Part C and Part D reporting sections.

3.4.2.2 Data Validation Standards 1 - 7
3.4.2.2.1 Standard 1
Standard 1 (see Exhibit 7) contains the general and specific criteria for validating source documentation that the
SO provides to the DVC.
EXHIBIT 7. STANDARD 1: REQUIRED DATA FIELDS ARE ACCURATELY CAPTURED AND PROPERLY DOCUMENTED

DATA VALIDATION STANDARD 1
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.
Criteria for Validating Source Documents:
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.
b. Source documentscreate all required data fields for reporting requirements.
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.).
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).
e. Data file locations are referenced correctly.
f. If used, macros are properly documented.
g. Source documents are clearly and adequately documented.
h. Titles and footnotes on reports and tables are accurate.
i. Version control of source documents is appropriately applied.

3.4.2.2.2 Standard 2
Standard 2 (see Exhibit 8) instructs the DVC to validate the completeness of the underlying data and the
accuracy of each reported reporting section. Standard 2 provides an overview of reporting section criteria,
which must be met for each of the Part C and Part D reporting section being reported and is further detailed in
section 4.2.3. For example, the reporting section criteria assess whether the appropriate date ranges for the
reporting period are captured by the data system, and whether the expected counts and calculations are
accurate and match the corresponding source code and analysis plan. The criteria are also used to verify that
the SO has properly interpreted and defined key terms used to determine which data are applicable. For
example, the SO must properly define the terms “Coverage Determinations and Redeterminations” in
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accordance with CMS regulations, guidance and the Technical Specifications in order to ensure the quality of
the reported data for that reporting section. Standard 2e is further broken down into additional criteria that map
to the relevant technical specification data elements.
EXHIBIT 8. STANDARD 2: DATA ELEMENTS ARE ACCURATELY IDENTIFIED, PROCESSED, AND CALCULATED

DATA VALIDATION STANDARD 2
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.
Criteria for Validating Reporting Section Criteria (Refer to reporting section criteria section below):
a. The appropriate date range(s) for the reporting period(s) is captured.
b. Data are assigned at the applicable level (e.g., plan benefit package or contract level).
c. Appropriate deadlines are met for reporting data.
d. Terms used are properly defined per CMS regulations, guidance and Reporting Requirements Technical
Specifications.
e. 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.
3.4.2.2.3 Standard 3
Standard 3 (see Exhibit 9) is used to determine whether an SO implements policies and procedures for each
reporting section’s data submission. Not only should the DVC validate that the reported data were correctly
derived from the underlying database, but they should also verify that the data are accurately uploaded and/or
entered into CMS systems. If a reporting section requires both a file upload and data entry, both have to occur
in order for a SO to meet Sub-Standard 3a.

EXHIBIT 9. STANDARD 3: DATA SUBMISSION

DATA VALIDATION STANDARD 3
3

Organization implements policies and procedures for data submission, including the following:
a. Data elements are accurately entered / uploaded into CMS systems and entries match corresponding source
documents.
b. All source, intermediate, and final stage data sets and other outputs relied upon to enter data into CMS systems
are archived.
3.4.2.2.4 Standards 4 and 5
For Standards 4 and 5 (see Exhibit 10), the DVC must verify that the SO has, and implements, policies and
procedures for regular database updates, and for data archiving and restoration. This ensures that data are
kept up to date, and that systems are in place for timely data submission or re-submission in the event of data
loss.
EXHIBIT 10. STANDARDS 4 AND 5: DATA SYSTEM UPDATES AND ARCHIVE/RESTORATION

DATA VALIDATION STANDARD 4 & 5
4

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

Organization implements policies and procedures for archiving and restoring data in each data system (e.g., disaster
recovery plan).
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3.4.2.2.5 Standards 6 and 7
Standards 6 and 7 (see Exhibit 11) are applicable only in certain situations. Standard 6 is applicable if an SO’s
data systems underwent any changes during the reporting period. If this occurred, the DVC must examine
documentation of the changes to ensure there were no issues that adversely impacted the reported data.
Standard 7 applies if any of the data collection or validation processes are outsourced to another entity. This
standard assesses whether the SO has policies and procedures in place that address routine monitoring of the
delegated entities work and whether those policies and procedures are implemented.
The DVC should mark “Not Applicable” in the Excel-version FDCF if Standard 6 or 7 is not applicable to the
reporting section or contract under review.
EXHIBIT 11. STANDARDS 6 AND 7: DATA SYSTEM CHANGES AND OVERSIGHT OF DELEGATED ENTITY REPORTING

DATA VALIDATION STANDARDS 6 AND 7
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.

If data collection and/or reporting for this reporting section are 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 reviewer.

3.4.3 Reporting Section Criteria
In addition to the general instructions and validation standards, there is a third section, which contains the
reporting section criteria. The reporting section criteria vary for each Part C and Part D reporting section.
Reporting section criteria are used in conjunction with Standard 2 to determine if data elements are accurately
identified, processed, and calculated. The first three reporting section criteria for each reporting section (see
Exhibit 12) are used to validate whether the SO is utilizing the appropriate reporting period, reporting level, and
reporting deadline(s) per CMS requirements.
EXHIBIT 12. EXAMPLE REPORTING SECTION CRITERIA FOR APPROPRIATE REPORTING PERIOD, REPORTING LEVEL, AND
REPORTING DEADLINE

REPORTING SECTION CRITERIA
1

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

Organization properly assigns data to the applicable CMS contract and plan.

Organization meets deadline for reporting annual data to CMS by 2/24/2020.
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 submission 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 for rest of the
reporting section criteria for this reporting section.
Several of the reporting section standards contain a reporting section criterion to validate whether the SO properly
defined key terms that it used to compile reported data per CMS regulations, guidance and the Technical
Specifications. Exhibit 13 shows an example of this criterion for the Part D Coverage Determinations and
Redeterminations reporting section.

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

EXHIBIT 13. REPORTING SECTION CRITERION FOR DEFINING KEY TERMS

REPORTING SECTION CRITERIA
4

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.
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.
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 re-openings.

The other reporting section criteria reference the applicable data element from the Technical Specifications when
possible and differ considerably depending on the reporting section and data element. Exhibit 14 shows an
example of selected reporting section criteria applicable to the Part C Grievances reporting section. The exact
criteria for each Part C and D reporting section are based on the Technical Specifications.

EXHIBIT 14. REPORTING SECTION CRITERIA FOR SELECTED PART C GRIEVANCES DATA ELEMENTS
6

REPORTING SECTION CRITERIA
Organization accurately calculates the total number of grievances, including the following criteria:
a. Includes all grievances that were completed (i.e., organization has notified member of its decision) during the
reporting period, regardless of when the grievance was received.
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.
c. If a grievance contains multiple issues filed under a single complainant, each issue is calculated as a separate
grievance.
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.
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.
f. Includes all methods of grievance receipt (e.g., telephone, letter, fax, and in-person).
g. Includes all grievances regardless of who filed the grievance (e.g., member or appointed representative)
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.
i. For MA-PD contracts: Includes only grievances that apply to the Part C benefit (If a clear distinction cannot be
made for an MA-PD, cases are reported as Part C grievances).
j. Excludes withdrawn grievances.
[Data Elements A-E]
Organization accurately calculates the number of grievances by category for which it provided timely notification of the
decision, including the following criteria:
a. Includes only grievances for which the member is notified of decision according to the following timelines:
i. For standard grievances: no later than 30 days after receipt of grievance.
ii. For standard grievances with an extension taken: no later than 44 days after receipt of grievance.
iii. For expedited grievances: no later than 24 hours after receipt of grievance.
[Data Elements B]

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

PERFORMING DATA VALIDATION ACTIVITIES

4.1

Complete Organizational Assessment Instrument (OAI) and Provide Appropriate
Documentation to Selected DVC per the OAI’s Documentation Request
The Organizational Assessment Instrument (OAI) (Appendix E) focuses on how the SO collects, stores, and
reports data. Completing the OAI is mandatory and CMS highly recommends that SOs complete this
document in advance of the DV, as the DV review relies significantly on the information captured in this tool.
The completed OAI may reduce required DVC resources, and make the DV review more efficient and
effective. SOs should provide the completed OAI to their selected DVC electronically. CMS estimates that the
OAI should take a minimum of two weeks to complete and should be submitted to the DVC no later than
early April. SOs may not send their completed OAI or source code, SOPs, etc. to their DVCs prior to the start
of the DV cycle on April 1.
Each SO must provide to its DVC the basic information regarding its Medicare contracts and which Part C
and/or Part D reporting sections each contract submits to CMS. SOs that hold more than one contract with
CMS only need to complete one version of the OAI that covers all of its contracts. If the information provided
in the OAI varies by contract, the document allows for the flexibility to identify the differences for the DVC in
applicable sections.
All documentation and responses to questions in the OAI should reflect the SO’s systems and processes that
were in place during the reporting period(s) undergoing the DV review. For example, if the data being
reviewed are for the 2019 reporting period, the SO should include only diagrams of the information systems
in place in 2019 or the programming code used in 2019 to calculate the reporting sections.
It is up to the SO and its DVC to work out mutually agreeable methods for sharing and protecting proprietary
data, such as that requested in the OAI, and protected health information. The Standards for Selecting a
Data Validation Contractor (Appendix A) includes minimum security requirements with which the DVC’s
facility, equipment, and processes must comply. The SO is responsible for ensuring that the DVC complies
with all Health Insurance Portability and Accountability Act (HIPAA) privacy and security requirements.
The SO must supply all the information required for the DV review; otherwise, it will be out of compliance with
CMS requirements and will be subject to compliance actions from CMS. If an SO contracts with delegated
entities (e.g., PBMs) that are not cooperative in supplying required information, the SO is still responsible for
the required information and it is up to the SO to determine how to proceed. Additionally, if an SO or its
delegated entity does not provide the information required to determine if a standard or sub-standard has
been met, the DVC is required to select “No” in the FDCF for that standard or sub-standard.

4.2

Analyze OAI Responses
CMS recommends DVCs perform a preliminary review of the documentation submitted in the OAI in advance
of each site visit so that any follow-up regarding the documentation can be done during the site visit. The
documentation submitted by the SO when completing the OAI should be adequate and enabling of an
effective review. The amount of detail provided in the documentation will determine the ease of the review
process, especially for the review of programming code/source code.
Additionally, the OAI provides supplemental questions to help the DVC better understand the processes used
by the SO to compile and submit its reporting sections. The SO’s responses to these questions will provide
insight as to who is responsible for the quality control and submission of the data, the processes for
incorporating CMS updates to the Technical Specifications into the SO’s systems, and descriptions of any
past issues that may have occurred during the reporting process.

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

4.2.1. Perform OAI Gap Analysis
Upon receiving the completed OAI, the DVC should review the document for completeness and accuracy.
Sections of the OAI that are missing or incomplete should be noted, and the DVC should follow-up with the
SO to complete. It is up to the DVC to determine whether any identified gaps in the OAI responses require
addressing prior to the site visit, or can be addressed during the site visit portion of the review.

4.2.2. Review Source Code and Other Documentation
Data dictionaries and source code are critical for allowing the DVCs to map ambiguous field names and
internal status codes to meaningful descriptions. Well organized and structured documentation of the
reporting and data extraction processes for the various reporting sections will assist the DVC in gaining a
more thorough understanding of the SO. The DVC should be familiar with data systems and processes
detailed by the SO in the OAI to ensure thorough preparation for the site visit.

4.2.3. Prepare Interview Discussion Guide
The Interview Discussion Guide (IDG) (Appendix F) is intended to facilitate the discussion between the DVC
and the SO’s report owners and subject matter experts. The IDG is a dynamic tool containing both general
and reporting section questions that can guide an effective discussion regarding an SO’s underlying data
systems and reporting processes. If, during review of the documentation provided in response to the OAI, the
DVC discovers evidence that may indicate errors in the SO’s data or reporting processes, the DVC should
modify the IDG used for that SO with new questions that may identify any vulnerabilities or opportunities for
repeated errors with data collection or reporting. Additionally, the IDG should serve as a “guide” for the DVC;
it is up to the DVC’s discretion to include additional questions and/or detail to the document to discuss during
site visit interviews and to ensure the additional detail is documented accordingly.

4.3

Prepare for Site Visit

4.3.1

Select Dates and Appropriate Location(s) of Site Visit
CMS requires SO and DVC to include a site visit as part of the DV review to conduct the following activities:
(1) conduct interviews with SO staff, (2) observe the SO’s reporting processes, and (3) obtain census and/or
sample files to support the validation of Part C and Part D reporting sections. SOs and DVCs are responsible
for determining mutually agreeable dates for performing the site visit. It is estimated that the site visit for a full
Part C and Part D data validation review should take up to one week to complete.
It is up to the discretion of the DVC to determine the most appropriate location(s) of the site visit (e.g., virtual,
SO’s facility, PBM’s facility, other delegated entity’s facility). CMS encourages SOs and DVCs to conduct a
physical site visit, but SOs and DVC may elect to conduct a virtual site visit, using a virtual meeting tool or
teleconference(s), if appropriate.

4.3.2

Develop Agenda for Site Visit
To further prepare for each SO’s site visit, the DVC and SO should work together to prepare a site visit
agenda. Appendix G contains a sample agenda that can be used for the site visit portion of the DV review.
This agenda is structured to include an entrance and exit conference, and interviews and demonstrations of
data systems for each reporting section included in the DV. It is also recommended that the DVC create a
sign-in sheet to be completed throughout the site visit in order to collect contact information for each SO’s
report owners and subject matter experts in case any follow-up is required.
It is important to note that the number of days required to complete the site visit may be contingent upon the
size of the SO, efficiency of the SO’s operations, level of reporting automation, and scope of the DV review.
The DVC must schedule sessions with the SO’s report owner(s) for each reporting section and allow
sufficient time for the SO to provide an overview of each of the relevant data systems used in gathering data

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

and producing reports, as well as to complete the data extraction/sampling process (see Section 4.4.4 for
more information). Multiple sessions could be conducted concurrently during the site visit at the discretion of
the DVC, or the agenda could be structured so that interviews and demonstrations of reporting processes are
scheduled by each report owner in order to reduce repetitive discussions and demonstrations, especially in
cases where one report owner oversees the processes for multiple reporting sections that use the same data
system(s). This will ensure optimal time and resource management during the site visit.

4.3.3

Prepare for Data Extraction and Sampling
In preparation for the data extraction and sampling during the site visit, the DVC should review information
provided in the completed OAI and, if necessary, hold conference calls with the SO to discuss the SO’s
processes. Calls held specifically with each reporting section’s report owner can also provide an opportunity
for the DVC to review the Data Extraction and Sampling Instructions (Appendix H) in more detail and for the
report owners to seek clarification as needed. These discussions can also inform the DVC about the SO’s
data systems and sources from which the sample data would be pulled.
There are two methodologies that can be used to extract data for each reporting section. The first is to extract
the full census of data for a reporting section, meaning that every data record that is relevant to a reporting
section is extracted. When possible, DVCs should attempt to extract the full census. Extracting the census
will enable the DVC to determine with the greatest precision whether reporting sections were submitted
accurately. If the size or complexity of a database presents an unusual time burden on the DVC and/or SO,
then the second method, extraction of a random sample, which is a subset of the full census, can be used.
DVCs must use their best judgment to decide if extracting a full census is feasible, or if selecting a random
sample will provide the data necessary for the DV review. Refer to Appendix H for further details regarding
these two methodologies. In addition, DVCs must determine if the SO’s staff requires supervision during the
actual data extraction process, or if the SO’s staff are able to extract data without supervision. See Section
4.4.4 for additional requirements if the DVC is unable to supervise the data extraction process.

4.4

Conduct Site Visit

4.4.1

Conduct Entrance Conference
The entrance conference provides an opportunity for the DVC and the SO’s management and individual report
owners to introduce themselves and discuss expectations for the site visit. At the entrance conference, the
DVC should describe the objectives for the review and discuss any administrative needs of the team.
Optionally, the SO may provide a high-level overview of its organization, focusing on its operations with
respect to meeting the CMS reporting requirements. CMS recommends that the entire review team also meet
briefly with the SO’s management and individual report owners at the beginning of each day of the site visit to
go over administrative needs and review the day’s agenda.

4.4.2

Conduct Interviews with Organization Staff
During the site visit, the DVC must conduct interviews with the subject matter experts and report owners for
each reporting section and reporting system. These interviews provide a first-hand opportunity for the DVC to
gain a thorough understanding of each SO’s data collection and reporting processes involved with meeting
CMS reporting requirements. The DVC should reference the IDG as needed to ensure that all key topics are
addressed during the interviews. Also, any outstanding questions and follow-up items identified during the
analysis of OAI responses should be addressed during the interviews.

4.4.3

Observe Reporting Processes
The site visit allows the opportunity for the SO to provide a significant amount of useful information to the
DVC. Designated SO staff (i.e., report owners) must provide visual demonstrations of the data systems and
reporting processes including data extraction from originating data sources, data analysis, quality assurance

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

processes, and processes for entering or uploading final data into CMS systems. The following is a sample
list of the parts of the process that should be demonstrated:
•
•
•
•
•
•
•
•
•
•

Location of report owner and data providers
Location and function of all data warehouses
Types of data used (format, amount of tables)
Links and joins to other areas/ departments/ data
Types of programming used to create the reports
Review processes and oversight
Timeframes for the process (amount of time it takes to run specific parts of the report)
Approximations of report volume
Updates to the process and system changes
Storage locations, security and access constraints

The visual demonstrations provide a clear illustration of the reporting processes, provide the DVC with insight
into the SO’s ability to ensure accurate, valid and timely data, and allow an opportunity to get immediate
responses to any questions or concerns about the reported data.

4.4.4

Extract Census or Sample Data
The next step is for the DVC to work with the report owners to draw a census or a random sample from each
reporting section’s final stage data set, following the Data Extraction and Sampling Instructions (Appendix H).
The document describes guidelines and methodologies for extracting SOs’ data. Two methodologies of
extraction are available to DVCs. The first method is referred to as the census. Extracting all records used in
the calculation of data elements for a specific reporting section would constitute extracting a census of data.
When possible, DVCs should attempt to extract the full census. Extracting the census will enable the DVC to
determine with the greatest precision whether reporting sections were submitted accurately. The second
method used for data extraction is a random sample. The random sample is a subset of the census data. If
extraction of the census proves to be too burdensome due to the size or complexity of the data for a specific
reporting section, a sample of records should be extracted instead.
The random sampling process involves using built-in random number generators in the applications used to
display the data or perform the query (Microsoft Excel or SQL). Once a random number is assigned to each
unique record ID, the data owner can sort the data by the random number field and choose the statistically
appropriate number of records as the sample. A discussion of minimum sample sizes can be found in Data
Extraction and Sampling Instructions. The unique IDs from the random sample in the final stage data set are
then applied against the source data set to pull the corresponding source data records. The processes used
to draw the random data samples vary considerably, depending on the report owner and reporting section.
For example, some report owners may be able to easily draw the sample data for their reporting section
without having to manually clean or manipulate the data, while other report owners may have to perform
more extensive query programming and manual data cleaning in order to draw the sample data. During each
of the sessions to demonstrate reporting processes, the SO’s report owners should brief the review team on
the processes used to assemble the sample data files, including the source, intermediate, and final stage
data sets. When uploading the DV findings to CMS in the PRDVM, the DVC must report which data
extraction method was used (full census or random sample) to validate data for each standard. For both
methods, DVCs must examine source data as a means of verifying that the organization’s underlying data
are correct: for example, reviewing customer service call logs or member letters to verify that grievances
were properly categorized as grievances and to verify the grievance categories applied were correct. Source
data examples for each reporting section are provided in the Data Extraction and Sampling Instructions.
DVCs are expected to include the number and percentage of errors or variance from HPMS-filed data found
when examining the source data. For purposes of recording results in the FDCF, an error is any discrepancy
that either impacted the number of events reported or has the potential to impact the number of events
reported in future reporting periods. These errors must be reported in the “Review Results” area of the FDCF
and include the sample size selected for the source data.

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

It is mandatory that DVCs follow the Data Extraction and Sampling Instructions. If the SO’s staff is extracting
the data, it is highly recommended that the DVC supervise the data extraction process to ensure these
instructions are followed correctly. If the DVC is unable to supervise the data extraction process, the DVC
must obtain documentation from the SO describing how the extraction process was performed. For example,
if a random sample is extracted, the DVC should request and validate the programming code used to extract
the sample data. If a full census is extracted, the DVC should validate that the record counts match between
the census extraction and the source and final stage data files.
CMS recommends that the DVC record details about each reporting section’s data set into a Data File
Inventory Log (Appendix I). Appendix I contains an example log that the DVC can use. It includes details
such as the reporting section name, report owner, data file name, type of data file (e.g., source, intermediate,
or final stage data file), number of rows or records, and a description of the file. By completing this log, the
DVC will be able to easily reference the data files during its post-site visit assessment of data.
The SO should write all data files to tab-delimited or comma-delimited text files with variable names in the
first row, and transfer these files to the DVC’s secure storage device for each reporting section’s data. The
SO must also provide the DVC a file layout or data dictionary for the data files in either Word documents or
Excel spreadsheets on the same secure storage device. The SO and DVC must ensure that they have
established mutually agreeable methods for sharing protected health information and that the DVC complies
with all HIPAA privacy and security requirements.

4.4.5

Conduct Exit Conference
CMS recommends that the entire DV review team meet briefly with the SO’s management and individual
report owners at the end of each day of the site visit to go over any action items or outstanding
documentation needs. The site visit should conclude with an exit conference, where the DVC should provide
the SO with a summary of next steps and note any follow-up that may need to occur.

4.5

Request Additional Documents (If Required)
CMS recognizes that it may not be possible to obtain all of the required data and documentation during the
scheduled site visit and follow-up conversations and requests may be required. The DVC should make every
attempt to gather all required data and documentation during the site visit. In the event that not all information
is available, or follow-up is required after the conclusion of the scheduled site visit, the DVC should have
additional conversations with the SO and/or make requests for documentation. DVCs and SOs should
understand that the DV is an iterative and collaborative effort, and SOs should be prepared to provide
additional data and documentation after the site visit has been held.

ANALYZING RESULTS AND SUBMISSION OF FINDINGS

5.1

Determine Compliance with Data Validation Standards and Record Findings in Excel
Version of the Findings Data Collection Form (FDCF) to Upload into the HPMSPRDVM
Following the site visit, the DVC must assess the documentation and census/sample data received from the
SO, as well as the information gained during the interviews and demonstrations of the SO’s reporting
processes and information systems.
The DVC must complete the Excel version of the FDCF as it determines the findings for each contract
included in the scope of the review. DVCs must now use the Excel version of the FDCF to record findings
and then translate the findings into the PRDVM in a data file upload. The FDCF mirror the content of the DV
Standards document, but allow the DVC to record notes, data sources referenced, and findings for the
different standards and criteria specified for a given reporting section. The DVC will record reporting sectionlevel, and in some cases data element-level, findings for each reporting section. Most DV standards

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

(Standards 1, 4, 5, 6, and 7) are assessed at the reporting section-level, as they assess SO processes that
are not likely to vary at the data element-level. Once the DVC uploads the FDCF into PRDVM, the DVC may
print the findings he/she uploaded into the PRDVM and share them with the SO at any point during the
review by accessing the HPMS report entitled “Review Data Validation Findings Report.”
When using the FDCF, DVCs should only complete areas displayed in white for data sources, review results,
and findings. Areas displayed in gray are not applicable and should not be completed. In the "Data Sources
and Review Results:" column, the DVC should enter the data sources used and review results for each
standard or sub-standard. Next to this column, in the "Findings" column, the DVC must select the appropriate
choice based on whether or not the plan met the requirement for the standard or sub-standard.

5.1.1. Reporting Findings for Standards Using Binary Scale
For all standards except 1.c, 1.d, 1.e, 1.g, 1.h, and 2.e, the findings are reported using binary scale. The DVC
must select "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, the DVC must select "N." In instances where
a standard or sub-standard is not applicable, the DVC must select “N/A” and must enter the reason for the
“N/A” in the “Review Results” field.
CMS expects that there will be situations when the DVC finds that an SO is only in partial compliance
with specific DV standards. CMS does not believe that only a 100 percent score demonstrates
compliance, and has established a threshold whereby a minimum of 90% of records are accurate (e.g.,
sample or census records, source documents, policies and procedures, data entry records) in order to
record a “Yes” finding for any standard. Applying this threshold to standards that require the review of
policies and procedures should be done when it is possible to readily quantify the adherence to or
implementation of said policies and procedures (see Exhibit 16). Exhibit 16 provides examples of how to
calculate this minimum threshold specifically for Standard 3.a, for which the DV involves samples or the
complete census of records and/or data values. Note that the 90% accuracy threshold does not apply to
the individual grievance categories in the Part C and Part D Grievances reporting sections; 100% correct
records are required for each data element measured by Standard 3a in these reporting sections.
EXHIBIT 16. EXAMPLES OF CALCULATIONS TO DETERMINE MINIMUM THRESHOLD OF CORRECT SAMPLE/CENSUS
RECORDS FOR “YES” FINDING
Sample/
Census Size
150

Calculation for
Minimum Threshold
0.90 x 150 = 135

At least 135 of the records are correct for the standard to be recorded as “Yes”.

205

0.90 x 205 = 184.5

At least 185 of the records are correct for the standard to be recorded as “Yes”
(round 184.5 to 185).

Minimum Threshold of Correct Records for “Yes” Finding

EXHIBIT 16. EXAMPLE OF HOW TO DETERMINE MINIMUM THRESHOLD OF IMPLEMENTED POLICIES OR
PROCEDURES FOR “YES” FINDING
Standard
4

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

Minimum Threshold for a “Yes” Finding
SO has a policy in place for updating its enrollment system on a monthly
basis to ensure accurate information and protect the data integrity.
Eleven out of the twelve months in the contract year, the SO implemented
the enrollment system update policy as it is written (11/12 = 91.6%)

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

5.1.2. Reporting Findings for Standards Using Likert Scale
For standards 1.c, 1.d, 1.e, 1.g, 1.h, and 2.e, the scoring uses a five-point Likert-type scale. DVCs are
required to review the percentage of records that meet the standards, and enter a score based on the Likerttype scale. The scale corresponds to the percentage of errors that are found in plan data as shown below:
1.
2.
3.
4.
5.

Contract data has more than 20 percent error in records – Contract will receive a score of 1 for the
given standard/ sub-standard.
Contract data has between 15.1 percent and 20 percent error in records – Contract will receive a
score of 2 for the given standard/ sub-standard.
Contract data has between 10.1 percent and 15 percent error in records – Contract will receive a
score of 3 for the given standard/ sub-standard.
Contract data has between 5.1 percent and 10 percent error in records – Contract will receive a
score of 4 for the given standard/ sub-standard.
Contract data has less than or equal to a 5% error in records – Contract will receive a score of 5 for
the given standard/ sub-standard.

Exhibit 17 provides the different scenarios that a DVC might face and corresponding scores to be assigned to
the contract for the given standard.
EXHIBIT 17. EXAMPLE OF HOW TO DETERMINE MINIMUM THRESHOLD OF IMPLEMENTED POLICIES OR PROCEDURES FOR
“YES” FINDING
Standard

Percentage of Errors That are Found by the
DVC in Plan Data

1a, 1.b, 1.i, 2.a, 2.b, 2.c, 2.d,
3.a, 3.b, 4, 5, 6, 7

Fewer than 10 percent error in contract data for
the given reporting section/ data element(s)

1a, 1.b, 1.i, 2.a, 2.b, 2.c, 2.d,
3.a, 3.b, 4, 5, 6, 8

More than 10 percent error in contract data for the
given reporting section/ data element(s)

1a, 1.b, 1.i, 2.a, 2.b, 2.c, 2.d,
3.a, 3.b, 4, 5, 6, 9

Standard not applicable

Leave blank

1.c, 1.d, 1.e, 1.g, 1.h, 2.e

If any of the listed standards is not
applicable
More than 20 percent error in contract
data for the given reporting section/ data
element(s)
Between 15.1 percent and 20 percent error in
contract data for the given reporting section/
data element(s)

Leave blank

1.c, 1.d, 1.e, 1.g, 1.h, 2.e

Between 10.1 percent and 15 percent error in
contract data for the given reporting section/
data element(s)

1.c, 1.d, 1.e, 1.g, 1.h, 2.e

Between 5.1 percent and 10 percent error in
contract data for the given reporting section/ data
element(s)

1.c, 1.d, 1.e, 1.g, 1.h, 2.e

5 percent error or less in contract data for
the given reporting section/ data
element(s)

1.c, 1.d, 1.e, 1.g, 1.h, 2.e

DV Response (DV
Findings Reported
on Column 'H' on
FDCF)
Yes

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

5.1.3. Review of the Findings Data Collection Form
Exhibit 18 illustrates an example of the FDCF for Standard 1. The DVC will assess this standard at the
reporting section-level and must determine a finding for each of the nine sub-standards contained in
Standard 1.
EXHIBIT 18. EXAMPLE ROWS FROM FDCF FOR STANDARD 1

Standard/
Substandard
ID
1

Reporting
Section
Criteria ID

Standard/Sub-standard Description

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

Data Sources:

1.b

Source documents create all required data fields
for reporting requirements.

Review Results:

1.c

Review Results:

1.e

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.).
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).
Data file locations are referenced correctly.

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:

1.a

1.d

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

Review Results:

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

Standard 2 requires the DVC to assess reporting section-level findings for Sub-Standards 2.a through 2.c, which are
based on reporting section criteria 1 through 3 and, if applicable, Sub-Standard 2.d, which is based on reporting section
criterion 4. Exhibit 19 illustrates an example of the FDCF for Standard 2, Sub-Standards 2.a through 2.d. for the Part D
Grievances reporting section.
EXHIBIT 19. EXAMPLE OF THE FDCF FOR STANDARD 2, SUB-STANDARDS 2.A THROUGH 2.D. FOR THE PART D
GRIEVANCES REPORTING SECTION

Standard/
Substandard
ID

Reporting
Section
Criteria ID

2.a

2.b

RSC-1

RSC-2

Standard/Sub-standard Description

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

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

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
2/3/2020. [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.

2.d

RSC-4

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 Parts C & D Enrollee Grievances,
Organization/Coverage Determinations and Appeals Manual. This
includes applying all relevant guidance properly when performing
its calculations.

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

The DVC must also determine data element-level findings for Sub-Standard 2.e, which examines each data
element for compliance with the applicable reporting section criteria that varies across the data elements reported
by the SO. Exhibit 20 illustrates an example of the FDCF for Standard 2, Sub-Standard 2.e, RSC-6 for the Part D
Grievance reporting section.
EXHIBIT 20. EXAMPLE ROWS FROM FDCF FOR STANDARD 2, SUB-STANDARD 2.E RSC-6 FOR PART D GRIEVANCES
REPORTING SECTION*
Data Sources
and Review
Results: Enter
review results
and/or data
sources
Data
Sources:

Standard/
Substandard
ID

Reporting
Section
Criteria ID

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.
RSC-6: Organization accurately calculates the
total number of grievances, including
the following criteria:

2.e

RSC-6.a

Data Element A
RSC-6.a: Includes all
grievances that were
completed (i.e. organization
has notified member of its
decision) during the reporting
period, regardless of when the
grievance was received.

Review
Results:

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

Standard/Sub-standard Description

Data Element E

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

Review
Results:

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

2.e

RSC-6.b

2.e

Data Element A

Review
Results:

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.c

Data Element A

Review
Results:

2.e

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:

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

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

2.e

RSC-6.c

2.e

RSC-6.d

2.e

Data Element E

Review
Results:

Data Element A

Review
Results:

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.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:

2.e

RSC-6.e

Data Element E

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-E]

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

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

2.e

RSC-6.f

2.e

Data Element A

Review
Results:

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.g

Data Element A

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:

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

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

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

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:

2.e

RSC-6.h

Data Element E

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-E]

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:

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

Data
Sources:

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

2.e

RSC-6.j

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-E]

Data
Sources:

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:

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

Standard 3 contains two Sub-Standards. Sub-Standard 3.a requires the DVC to assess data element-level findings and
Sub-Standard 3.b requires reporting section-level findings. Sub-Standard 3.a is assessed at the data element-level for
reporting sections that CMS requires to be manually entered into the HPMS Plan Reporting Module because it confirms
that there were no manual data entry errors for each data element, and for reporting sections that are reported as file
uploads, it confirms at the sub-standard level that the SO used the correct file layout. Exhibit 21 illustrates an example of
the FDCF for Standard 3 for the Part D Grievances reporting section.
EXHIBIT 21. EXAMPLE ROWS FROM FDCF FOR STANDARD 3 FOR PART D GRIEVANCES REPORTING SECTION

Standard/
Substandard ID

3.a

Reporting
Section
Criteria ID

Standard/Sub-standard Description

Organization implements policies and
procedures for data submission,
including
the following:
Data Element A
Data elements
are accurately
entered/uploade
d into CMS
systems and
entries match
corresponding
source
documents.

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

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:

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

Review Results:

3.a

3.b

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

Review Results:

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

Standards 4 through 7 assesses policies and procedures for periodic data system updates; an SO will most likely
have these policies and procedures in place for an entire reporting section, as opposed to having them in place for
only certain data elements. Exhibit 22 displays example rows from the FDCF for Standards 4 through 7.
EXHIBIT 22. EXAMPLE ROWS FROM FDCF FOR STANDARDS 4 THROUGH 7

Standard/
Substandard ID

Reporting
Section
Criteria ID

Standard/Sub-standard Description

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

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

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

Review Results:

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:

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:

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

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

5.1.4. Guidance for Interpreting Standards and Making a Findings Determination
In order to ensure consistency with the review process, CMS has provided below a description of the
data sources and criteria that DVCs must use to determine findings for each of the DV standards.
Standard 1
This validation standard is assessed at the reporting section-level and is used to determine that all source documents
accurately capture required data fields and are properly documented. The guidance for evaluating Standard 1 is
described below.
EXHIBIT 23. GUIDANCE FOR STANDARD 1
Data Validation Standard 1:
Assessed at the reporting section-level and is used to determine that all source documents
accurately capture required data fields and are properly documented
Criteria
Guidance
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.
Criteria for Validating Source Documents (Sub-Standards):
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.
b) Source documents create all required data fields for
reporting requirements.
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.).
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).
e) Data file locations are referenced correctly
f) If used, macros are properly documented.
g) Source documents are clearly and adequately
documented.
h) Titles and footnotes on reports and tablesare
accurate.
i) Version control of source documents is appropriately
applied.

Determine if the SO’s source documents (e.g., programming
code, spreadsheet formulas, analysis plans, saved data queries,
file layouts, process flows) accurately capture the data fields
required for each reporting section under review and are
documented with the necessary detail and information to create
data file sets and other outputs.
Ensure that all source documentation is legible, descriptive, and
understandable, including each of the following:
• Standard Operating Procedures (SOPs) include detailed
workflows and processesrelated to managing, producing,
and tracking source documents.
• Titles and footnotes used in programs and reported
output are legible and correspond to HPMS reports and
tables.
• SOPs, file-naming conventions, dates of source
documentsand output reports reflect application of
version control.
• Data file locations are referenced correctly within source
code (i.e., these files can be located using the references
that exist within the source code).
• Dated HPMS entries match the source document(s)
used to create the data entered into HPMS.
Ensure that the data validation reviewer is using the
documentation that is current and relevant to the time period of
the reporting requirements.

Please note that Standards 1 and 2 should be addressed concurrently given that an evaluation of source documents
directly impacts the quality of the actual data and vice versa (that elements for each reporting section are accurately
identified, processed, and calculated). For example, the DVC should ensure that all source documentation (file
layouts, data dictionaries, programming code, work instructions, SOPs, etc.) is available and allows for the complete
validation for each reporting section’s validation.

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

Standard 2
This validation standard assesses whether the data elements for each reporting section are accurately
identified, processed, and calculated. Each DVC should ensure that it has staff fluent in the programming
language (SQL, SAS, Microsoft VBA) used by the SO. The guidance for evaluating Standard 2 is described
below.
Since the DV reviews must be conducted at the contract level, for the reporting sections that require reporting at the
plan benefit package (PBP)-level, if the DVC finds that the SO incorrectly identified, processed, or calculated the data
reported for any of the PBPs included under a contract, then the DVC must assign a “No” finding in the FDCF for the
entire contract for the applicable sub-standard or data element (for Sub-Standard 2.e).
While careful inspection of the source code should detect most errors in the reported data, a careful review of the
census or sample data gathered from the SO will minimize the chance that a programming error was undetected by
the DVC. Many of the same items that will be checked in reviewing the source code can also be checked by
analyzing the extracted data sets.
EXHIBIT 24. GUIDANCE FOR STANDARD 2
Data Validation Standard 2:
Assesses whether the data elements for each reporting section are accurately identified, processed, and calculated. Each data
validation reviewer should ensure that it has staff fluent in the programming language (SQL, SAS, Microsoft VBA) used by the SO.
Criteria

Guidance

(Sub-Standard 2a – 2d)
Assess the programming code to determine if the data was extracted from the
system properly and if the calculations used in reporting data to CMS are accurate
according to the reporting section criteria applicable to each reporting section
under review.

Criteria for Validating Reporting Section
Criteria (Refer to reporting sectioncriteria
section below):
a) The appropriate date range(s) for the
reporting period(s) is captured.
b) Data are assigned at the applicable level
(e.g., plan benefit package or contract
level).
c) Appropriate deadlines are met for
reporting data (e.g., quarterly).
d) Terms used are properly defined per
CMS regulations, guidance and
Reporting Requirements Technical
Specifications.
e) 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.

A thorough review of source code must examine every line of code to ensure the
following for each reporting section under review:
• Data is extracted from the appropriate source system: Verify that all data
sets found in the programming code can be traced back to the appropriate
source data sets.
• Data sets are filtered correctly: Verify that data inclusion and exclusion
criteria were applied according to the reporting section criteria.
o For example, proper inclusion of records would ensure that source
code indicates that only those records falling within the reporting
period date range are included in the reported data. An example of
correct exclusion would document source code that indicates
beneficiaries are not eligible for a particular benefit (e.g., Medication
Therapy Management Program).
• Individual data sets are joined or merged correctly (this is especially
important when moving data from source data sets to intermediate data
sets): Verify that the correct key data field was used to generate the new
data set and that the correct type of join (or data merge) was used to avoid
creating duplicate records or improperly combining records from various
data sets.
• Data set progression is accurate: Verify that required data fields in both
the source and final stage files allow for file comparison and
understanding of data production from source system through the final
stage file.
o If full census data is not extracted, verify thatthe sample size is
sufficient and representative of the population of interest.
o While the Data Extraction and Sampling Instructions provide
minimum sample sizes, reviewers often will need larger data sets to
check for errors that occur infrequently. Statisticians should rely on
standard statistical practices when determining the proper sample
size so that any estimates generated are statistically significant.
• All data elements are accurate: Verify that each data element is
consistent with the reporting section criteria.
35

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

Data Validation Standard 2:
Assesses whether the data elements for each reporting section are accurately identified, processed, and calculated. Each data
validation reviewer should ensure that it has staff fluent in the programming language (SQL, SAS, Microsoft VBA) used by the SO.
Criteria

Guidance
(Sub-Standard 2c)
Assess the Submission Activity Report from the HPMS Plan Reporting Module to
determine if appropriate deadlines were met for reporting data by performing the
following:
• Request a copy of the contract’s Submission Activity Report from the SO: This report
displays information about the original submission and all subsequent
resubmissions for a particular contract or contracts. The report also displays
Reporting Period, Contract Number, Plan ID, Submission Version, Due Date and
Date Submitted for each section.
• Determine if the SO has, for any reason, re-submitted its data to CMS for a reporting
section:
o The data validation reviewer should verify that the SO’s original submission(s)
met the CMSdeadline.
o If the deadline was met, the reviewer must assess a “Yes” finding for this
reporting section criterion. However, if an SO re-submits data for any reason and
if the re-submission was completed by March 313 of the calendar year of the
data validation review (i.e., immediately prior to the data validation review
timeframe), the data validation reviewer should use the SO’s corrected data
submission for performing the validation, not the original data. The March 31st
deadline will give the reviewer enough time to include the corrected data in the
scope of its review of data and determination of findings.
o If the SO received CMS permission to submit data after the reporting
deadline (i.e., its first submission), the reviewer must request that the SO
show proof that it requested and was granted an extension by CMS. If this
proof is valid, then the reviewer should consider the deadline as being met,
and assess a “Yes” finding for this reporting section criterion.
o For either of the above scenarios, the reviewer must clearly document
the circumstances in the “Data Sources and Review Results” section
of the FDCF.

These instructions should not discourage SOs from re-submitting corrected data to CMS if necessary; however, resubmissions after March 31st will not be included in the scope of the DV review and will not change a reviewer’s “No”
finding or a CMS determination of Not Pass.

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

Guidance
(Sub-Standard 2e)
Assess the census/sample data provided by the SO to determine each of the
following for each reporting section under review:
• Data records are selected properly:
o Perform frequency calculations to list all unique occurrences of data fields
pertinent to the calculation of the reporting section to verify they contain
values within an acceptable range for the data field.
o Calculating frequency of occurrence for certain data fields might also alert the
reviewer to obvious mistakes in the dataextraction.
o Verify that data has been selected at the proper level (e.g., either the
contract or the plan benefit package level).
o Check date ranges, demographic information, and eligibility
information to examine proper data filtering.
• Individual data sets are joined or merged correctly:
o Sample a few records, when individual data sets are available
(most likely for intermediate data sets), from the individual data
sets to confirm that they were joined properly.
o Check for duplicate records and determine if record counts for the
component data sets agree with those found in the merged data set.
• All data elements are calculated accurately:
o Recalculate the data fields that the SO used to calculate the data
elements and refer to the reporting section criteria for each reporting
section.
o Calculate sums of the individual records within each reporting
section to ensure that they equal those reported to CMS.
Verify that the calculation of each of the data elements is consistent with the
reporting section criteria*.

* CMS has added a reporting section criteria (RSC #5) which will be used by the DVCs to confirm that the
data does not have any logical errors. RSC #5 includes data integrity checks, that the DVC must verify at the
data element level. These data integrity checks include confirming that a data element does not include
outlier records [for example, under Part C Organization Determination and Reconsideration (ODR), RSC 5.g
checks if the date of disposition for each reopening (Subsection #5, Data Element N) is within the reporting
quarter]. The checks also include confirming that a data element has a valid value [for example, under Part
C ODR, RSC 5.j verifies the validity of the data submitted for reopening disposition (Subsection #5, Data
Element O) as being either Fully Favorable, Partially Favorable, Adverse, or Pending].

Exhibit 24 provides several examples of how to review source code and evaluate the integrity of the data.
However, the DVC may use other methods of DV to ensure a comprehensive and complete review of the
source code and census/sample data. The DVC must clearly document all errors found in programming
code, referring to the program examined, the precise location in the program, the nature of the error, and
the impact of the error in the “Data Sources and Review Results” section of the FDCF. Likewise, any
evidence from the review of census/sample data that leads to a negative finding must be clearly
documented in the applicable section of the FDCF.

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

Standard 3
This validation standard assesses whether the SO implements policies and procedures for entering and/or
uploading each data submission to CMS systems. The guidance for evaluating Standard 3 is described in
Exhibit 25.
EXHIBIT 25. GUIDANCE FOR STANDARD 3
Data Validation Standard 3:
Assesses whether the SO implements policies and procedures for entering or uploading each data submission to CMS
systems.
CRITERIA
Guidance
(Sub-Standard 3a)
Organization implements policies and procedures for data
submission, including the following:
Determine who is responsible for entering/uploading data into
CMS systems for each reporting section under review and if
a) Data elements are accurately entered / uploaded into
the SO has written work instructions or policies and
CMS systems and entries match correspondingsource
procedures for the entry or submission of the Part C and Part
documents.
D Reporting Requirements.
b) All source, intermediate, final stage data sets and other
outputs relied upon to enter data into CMS systems are
archived.
Evaluate Sub-Standard 3a by performing the following actions:
• Compare the data file created for submission to CMS with a
copy of the HPMS screen shots of data entered to confirm
there were no manual data entry errors.
• For file uploads, confirm that the data file adheres to the
record layout specified in the applicable Technical
Specifications document.
• For the reporting sections that require reporting at the plan
benefit package (PBP)-level, if the reviewer finds that the
SO did not accurately enter and/or upload data reported for
any of the PBPs included under a contract, then the
reviewer must assign a “No” finding in the FDCF for the
entire contract for the applicable data element(s) for SubStandard 3a.
• If a reporting section requires both a file upload and data
entry, both have to occur in order for a SO to meet SubStandard 3a.
(Sub-Standard 3b)
Determine if the SO has a policy or procedure for archiving all
source, intermediate, and final stage data sets relied upon to
enter data into CMS systems, and confirm that the SO
implemented this policy for the reporting section under review.

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

Standard 4
This validation standard is assessed at the reporting section-level and is used to assess whether the SO has
and implements policies and procedures for regular database updates. The data sources and criteria for
evaluating Standard 4 are described in Exhibit 26.
EXHIBIT 26. GUIDANCE FOR STANDARD 4
Data Validation Standard 4:
Assessed at the reporting section-level and is used to assess whether the SO has and implements policies and procedures for
regular database updates.
Criteria
Guidance
Organization implements policies and procedures for
periodic data system updates (e.g., changes in enrollment,
provider/pharmacy status, claims adjustments).

Determine if the SO has policies and procedures in place for
performing periodic updates for each data system used for the
reporting section under review that ensures reported data are
accurate and timely.
Determine if the SO implements and adheres to the policies
and procedures referenced above (i.e., was any data for the
reporting section under review negatively impacted by a failure
to implement or follow these policies and procedures?).

Standard 5
This validation standard is assessed at the reporting section-level and is used to assess whether the SO
has and implements policies and procedures for data archiving and restoration. The data sources and
criteria for evaluating Standard 5 are described in Exhibit 27.
EXHIBIT 27. GUIDANCE FOR STANDARD 5
Data Validation Standard 5:
Assessed at the reporting section-level and is used to assess whether the SO has and implements policies and procedures for
data archiving and restoration
Criteria
Source
Organization implements policies and procedures for
archiving and restoring data in each data system (e.g.,
disaster recovery plan).

Determine if the SO has policies and procedures in place for
archiving and restoring data in each data system used for the
reporting section under review that ensures timely data
submission or re-submission in the event of data loss.
Determine if the SO implements and adheres to the policies
and procedures referenced above (i.e., was any data for the
reporting section under review negatively impacted by a failure
to implement or follow these policies and procedures?).

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

Standard 6
This validation standard is assessed at the reporting section-level and is used to assess whether the validity
of the SO’s data was adversely impacted by any changes to data systems during the reporting period. The
data sources and criteria for evaluating Standard 6 are described in Exhibit 28.
Standard 6 applies if an SO’s data systems underwent any changes during the reporting period. The DVC
should mark “Not Applicable” in the FDCF if Standard 6 is not applicable to the contract under review.
EXHIBIT 28. GUIDANCE FOR STANDARD 6
Data Validation Standard 6:
Assessed at the reporting section-level and is used to assess whether the validity of the SO’s data was adversely impacted by
any changes to data systems during the reporting period.
Criteria
Guidance
If organization’s data systems underwent any changes
Review documentation on data system changes and
during the reporting period (e.g., as a result of a merger,
determine if changes to an SO’s data system adversely
acquisition, or upgrade): Organization provided
impacted data reported.by conducting the following activities:
documentation on the data system changes and, upon
• Determine if there were any changes to data sources used
review, there were no issues that adversely impacted data
for data collection and storage, data processing, analysis,
reported.
and reporting for the reporting section under review.
• Determine if data system changes were the root cause of
any outlier notices received from CMS for the reporting
section under review.
• Determine if the SO implemented any process or quality
improvement activities during the reporting period
specifically related to the data system change for the
reporting section under review.
Determine if the validity of the SO’s data was adversely
impacted by any changes to data systems during the reporting
period.

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

Standard 7
This validation standard is assessed at the reporting section-level and is used to assess whether the SO
routinely monitors the quality of a delegated entity’s work and processes related to the reporting
requirements. The data sources and criteria for evaluating Standard 7 are described in Exhibit 29.
Standard 7 applies if any of the data collection or validation processes are outsourced to another entity. The
DVC should mark “Not Applicable” in the FDCF if Standard 7 is not applicable to the reporting section or
contract under review.
EXHIBIT 29. GUIDANCE FOR STANDARD 7
Data Validation Standard 7:
Assessed at the reporting section-level and is used to assess whether the SO routinely monitors the quality of a delegated
entity’s work and processes related to the reporting requirements.
Criteria
Guidance
If data collection and/or reporting for this reporting section
are 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 reviewer.

Assess the following if data collection and/or reporting for a
reporting section is delegated to another entity:
• Determine if the SO has policies and procedures in place
for overseeing the delegated entity’s reporting process /
results for the reporting section under review.
• Determine if the SO implements and adheres to the policies
and procedures referenced above (i.e., was any data for the
reporting section under review negatively impacted by a
failure to implement or follow these policies and
procedures?).
Plans are not expected to replicate the delegated entities
process and recalculate all of their numbers but are expected
to have policies and procedures in place for routine
monitoring. It is expected that these policies and procedures
are implemented as frequently as needed to verify the
delegated entities’ reporting.
SOs are responsible for a delegated entities calculations and
numbers and therefore if they are incorrect, the responsibility
ultimately falls on the SO.

5.2

Provide Draft Findings to Sponsoring Organization
Once the findings have been documented in the FDCF, the DVC must share the draft findings with the SO.
When the DVC uploads the Microsoft Word version of the FDCF into the PRDVM during its review, they
may print the findings uploaded into the PRDVM and share them with the SO at any point during the
review by accessing the PRDVM report entitled “Review Data Validation Findings Report.”

5.3

Review Draft Findings with Sponsoring Organization and Obtain Additional
Documentation Necessary to Resolve Issues
The SO and DVC should build time into the April-June DV schedule to allow sufficient review of the
findings. Any issues identified during this review must be resolved prior to the data validation contractor’s
June 30 deadline for submitting findings to CMS.
Following any review of the draft findings with the SO, the DVC must update the FDCF with any necessary
revisions. This final version will be used to report the results of the data validation review to CMS.

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

5.4.

Submit Data Validation Review Findings via HPMS PRDVM

5.4.1.

Data Validation Contractor’s Submission of Findings
Following the conclusion of the DV review and the finalization of findings, the DVC must report the findings
by uploading the FDCF to CMS via the PRDVM in HPMS by June 30. Instructions for using this module are
contained in the PRDVM Quick Reference Guide, which is available in the PRDVM. The FDCF includes
review results and/or data sources that were reviewed for each standard or sub-standard, as well as the
Yes, No, or Not Applicable finding, or a 1-5 Likert scale. Associated with each standard or substandard.
DVCs should also indicate which extraction method (full census or sample) was used for each standard.

5.4.2.

Sponsoring Organization Disagreement with Findings
If the SO disagrees with any of the findings submitted by the DVC, it may submit information indicating this
disagreement to CMS within 30 calendar days of the date that final findings are submitted via the PRDVM.
Submissions should be sent to CMS via the [email protected] email box and
should contain all of the following information in order to be considered for review:
•
•

•

Email subject line must state: “Data Validation: Reported Findings Discrepancy”
Content of email must include the information below, in list format and in the following order:
o Name of SO
o CMS contract number(s)
o SO’s contact name, title, phone number and email address
o Name of DVC organization
For each area of discrepancy, list the following information:
o Part C or Part D, name of reporting section
o Standard/ sub-standard ID, reporting section criteria ID
o Description of DVC’s finding
o Reason for disagreement with finding
o Steps that were taken to resolve the disagreement with the DVC prior to the submission of the
finding
o Outcome of discussions, areas of impasse, and any additional information

CMS will review any findings disagreements on a case by case basis.

POST- DATA VALIDATION ACTIVITIES

6.1

Compile Archive of Data Validation Work Papers
The DVC must prepare a complete archive of work papers associated with the annual DV and provide it to
the SO. At a minimum, this archive must contain the documentation described in Exhibit 30. The DVC should
also retain a complete copy of this archive in accordance with its contract with the SO.
When the SO receives the archive from the DVC, the SO must add the documentation of its DVC selection
process to the archive, including how its chosen DVC meets the minimum qualifications, credentials, and
resources set forth in the Standards for Selecting a Data Validation Contractor. The SO must retain this
complete archive for the 10-year retention period required per federal regulations and be prepared to provide
the archive to CMS upon request.

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

EXHIBIT 30. MINIMUM DOCUMENTATION REQUIRED FOR DATA VALIDATION ARCHIVE
DATA VALIDATION ARCHIVE
•
•
•
•
•
•

Documentation of Data Validation Contractor
Selection Process
Documentation of completion of CMS Data
Validation Training for all staff assigned to the data
validation team
Completed OAI, including all documentation
provided in response to OAI Section 5
Final Site Visit Agenda
Completed Sign-in Sheets from site visit (if used)
Final IDG used during site visit

•
•
•
•
•
•

Copies of any formal presentations during site visit
Notes on staff interviews and demonstrations during
site visit
Census/sample data
Additional documentation provided by SO
during/after site visit
Draft findings in FDCF Notes on issues resulting in
changes to draft findings
Final FDCF

6.2

Receive Pass or Not Pass Threshold Level and Assess Pass or Not Pass
Determination based on Final Scores

6.2.1

Pass/Not Pass Determination
For each of the standards, sub-standards, and data elements, the reviewer must assess a “Yes/No”
finding or a score using a 1-5 Likert scale. Each finding is associated with CMS-assigned percentage
points and can vary depending on the sub-standard or data element being scored. A “No” or 1 finding,
however, will always result in a score of zero percentage points. The Data Validation Pass/Not Pass
Determination Methodology (Appendix K) identifies the individual score CMS has assigned to each
standard and sub-standard for all reporting sections.
After all findings are submitted to CMS, CMS will calculate a percentage score for all Part C reporting
sections as a group, all Part D reporting sections as a group, and a combined Part C and Part D
determination for those contracts reporting both Part C and Part D data. CMS then establishes passing
thresholds for Part C, Part D, and an overall combined Part C/Part D score based on the distribution of
scores.

6.2.2

CMS Notification to Sponsoring Organization of Pass/Not Pass Determinations
CMS will release a memo through HPMS PRDVM regarding the thresholds established. SOs then determine
if they passed or did not pass by comparing their score received via HPMS against the threshold announced
in the memo. If an SO does not pass, they will receive follow-up communication from CMS.

6.3

Sponsoring Organization Appeal of Data Validation Determination (If Applicable)
An SO has the right to appeal any Not Pass determination(s) it receives for the Part C and/or Part D reporting
sections or for the overall combined Part C and Part D determination. Please note that the pass/not pass
thresholds are not applied to individual reporting sections.
If the SO wishes to appeal a Not Pass determination, it must submit an appeal to CMS within 5 business
days of receiving information from CMS about the threshold level. Submissions must be sent to CMS via the
[email protected] email box and must contain all of the following information in
order to be considered.
•
•

Email subject line must state: “Data Validation: Appeal of Not Pass Determination”
Content of email must include the information below, in list format and in the
following order:

Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual

•

Name of SO

o
o
o

CMS contract number(s)
SO’s contact name, title, phone number and email address
Name of DVC organization

For each Not Pass determination included in the appeal, list the following information:
o Indicate whether the appeal pertains to the overall Not Pass for Part C and/or Part D
reporting sections
CMS
contract number(s) that received the subject Not Pass determination
o
o Justification for appeal
o Include as attachment any documentation supporting the justification for appeal. The
documentation must have been in existence at the time of the DV. For example, if after the
DV, the SO resubmits corrected data, revises a policy and procedure, or corrects a
programming code that caused it to improperly calculate reported data; the SO cannot
submit documentation of these corrections to appeal a Not Pass determination.

Once the appeal is received, CMS will carefully consider the justification and any supporting documentation to
determine if the Not Pass determination should be changed to a Pass determination. CMS has not established a
timeframe for the consideration of SO appeals.

File Type	application/pdf
File Title	Medicare Part C and Part D Reporting Requirements Data Validation Procedure Manual
Subject	Medicare Drug Benefit and C&D Data Group
Author	CMS
File Modified	2019-03-15
File Created	2019-03-14