| 2019 (old version) | 2020 (new version) | Type of Change | Reason for Change | Burden Change |
| Part D: MTM | ||||
| RSC 5.s. If a CMR was not received (Data Element P = No), there are no reported delivery date(s) (Data Element R = missing) | RSC 5.s. If a CMR was not received (Data Element P = No), there are no reported delivery date(s) (Data Element R = missing) unless the CMR summary was returned via mail, then the reported delivery date should be the date that the written summary was sent (Data Element R ≠ missing). | Update | Consistent with current technical guidance. | None |
| RSC 6. Organization accurately identifies data on MTM program participation and uploads it into Gentran, including the following criteria: |
RSC 6. Organization accurately identifies data on MTM program participation and uploads it into HPMS, including the following criteria: |
Update | Consistent with current submisison process. | None |
| RSC 6.i. Includes members who moved between contracts in each corresponding file uploaded to Gentran. Dates of enrollment, disenrollment elements, and other elements (e.g., TMR/CMR data) are specific to the activity that occurred for the member within each contract (Data Elements B, C, D, E, F, G, H, I, J). | RSC 6.i. Includes members who moved between contracts in each corresponding file uploaded to HPMS. Dates of enrollment, disenrollment elements, and other elements (e.g., TMR/CMR data) are specific to the activity that occurred for the member within each contract (Data Elements B, C, D, E, F, G, H, I, J). | Update | Consistent with current submisison process. | None |
| RSC 7. Organization accurately identifies MTM eligible members who are cognitively impaired at the time of CMR offer or delivery of CMR and uploads it into Gentran, including the following criteria: |
RSC 7. Organization accurately identifies MTM eligible members who are cognitively impaired at the time of CMR offer or delivery of CMR and uploads it into HPMS, including the following criteria: | Update | Consistent with current submisison process. | None |
| RSC 8. Organization accurately identifies data on members who opted-out of enrollment in the MTM program and uploads it into Gentran, including the following criteria: |
RSC 8. Organization accurately identifies data on members who opted-out of enrollment in the MTM program and uploads it into HPMS, including the following criteria: | Update | Consistent with current submisison process. | None |
| RSC 9. Organization accurately identifies data on CMR offers and uploads it into Gentran, including the following criteria: | RSC 9. Organization accurately identifies data on CMR offers and uploads it into HPMS, including the following criteria: | Update | Consistent with current submisison process. | None |
| RSC 10. Organization accurately identifies data on CMR dates and uploads it into Gentran, including the following criteria: |
RSC 10. Organization accurately identifies data on CMR dates and uploads it into HPMS, including the following criteria: | Update | Consistent with current submisison process. | None |
| RSC 11. Organization accurately identifies data on MTM drug therapy problem recommendations and uploads it into Gentran, including the following criteria: |
RSC 11. Organization accurately identifies data on MTM drug therapy problem recommendations and uploads it into HPMS, including the following criteria: |
Update | Consistent with current submisison process. | None |
| Part D: CD/RD | ||||
| RSC 5.b. Number of exception decisions made in the reporting period (Data Elements 1.G−1.R) does not exceed the total number of processed coverage determination decisions that include exceptions (Data Element 1.A). | RSC 5.b. Number of exception decisions made in the reporting period (Data Elements (1.H + 1.I + 1.J) + (1.L + 1.M + 1.N) + (1.P + 1.Q + 1.R)) does not exceed the total number of processed coverage determination decisions that include exceptions (Data Element 1.A). | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC. 5f. Verify that the date of disposition for each reopening (Data Element 3.B.11) is after the date of original disposition (Data Element 3.B.5). | RSC. 5f. Verify that the date of disposition for each reopening (Data Element 3.B.11) is equal to or later than the date of original disposition (Data Element 3.B.5). |
Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 5.g. Verify that the date of each reopening disposition (Data Element 3.B.11) is after the date that the case was reopened (Data Element 3.B.9). | RSC 5.g. Verify that the date of each reopening disposition (Data Element 3.B.11) is equal to or later than the date the case was reopened (Data Element 3.B.9). | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 6i. Includes requests for coverage determinations (including exceptions) that are withdrawn or dismissed. | RSC 6.i. Excludes requests for coverage determinations (including exceptions) that are withdrawn or dismissed. | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 7f. Includes requests for exceptions that are withdrawn or dismissed. Verify that all standard exceptions that are withdrawn or dismissed are included. Verify that all expedited exceptions that are withdrawn or dismissed are included. | RSC 7f. Excludes requests for exceptions that are withdrawn or dismissed. | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 8a. Properly categorizes the number of coverage determinations (including exceptions) by final decision: fully favorable, partially favorable, or adverse. Verify that all cases included in the count for the total number of processed coverage determinations made in the reporting period are identified as one of the accepted disposition types. | RSC 8a. Properly categorizes the number of coverage determinations (excluding exceptions) by final decision: fully favorable, partially favorable, or adverse. Verify that all cases included in the count for the total number of processed coverage determinations made in the reporting period are identified as one of the accepted disposition types. | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 10.k. Includes dismissals and withdrawals. | RSC 10k. Excludes dismissals and withdrawals. | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| Part D: DUR | ||||
| RSC 6.a.iii. Rejected opioid claims are counted at the unique contract, beneficiary, prescriber, pharmacy, drug (daily dose and quantity), and date of service (DOS). | RSC 6.a.iii. Rejected opioid claims are counted at the unique plan, beneficiary, prescriber, pharmacy, drug (strength and dosage form), quantity, and date of service (DOS) and formulary-level opioid MME POS edit. | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 6.a.iv. Properly counts the number of unique beneficiaries by contract that triggered the care coordination safety edit and if applicable, a provider and pharmacy criterion. | RSC 6.a.iv. Properly counts the number of unique beneficiaries by plan that triggered the care coordination safety edit and if applicable, a provider and pharmacy criterion. | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 6.b.iii. Rejected opioid claims are counted at the unique contract, beneficiary, prescriber, pharmacy, drug (daily dose for and quantity), and date of service (DOS). | RSC 6.b.iii. Rejected opioid claims are counted at the unique plan, beneficiary, prescriber, pharmacy, drug (strength and dosage form), quantity, and date of service (DOS) and formulary-level opioid MME POS edit. | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 6.b.iv. Properly counts the number of unique beneficiaries by contract that triggered the established hard MME safety edit threshold and if applicable, a provider and pharmacy criterion. | RSC 6.b.iv. Properly counts the number of unique beneficiaries by contract plan that triggered the established hard MME safety edit threshold and if applicable, a provider and pharmacy criterion. |
Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 6.c.iii. Rejected opioid claims are counted at the unique contract, beneficiary, prescriber, pharmacy, drug (daily dose and quantity), and date of service (DOS). | RSC 6.c.iii. Rejected opioid claims are counted at the unique plan, beneficiary, prescriber, pharmacy, drug (strength and dosage form), quantity, date of service (DOS) and formulary-level opioid MME POS edit. | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 6.c.iv. Properly counts the number of unique beneficiaries by contract that triggered the opioid naïve days supply safety edit. | RSC 6 c.iv. Properly counts the number of unique beneficiaries by plan that triggered the opioid naïve days supply safety edit. |
Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| 2019 (old version) | 2020 (new version) | Type of Change | Reason for Change | Burden Change |
| Part D: MTM | ||||
| RSC 5.s. If a CMR was not received (Data Element P = No), there are no reported delivery date(s) (Data Element R = missing) | RSC 5.s. If a CMR was not received (Data Element P = No), there are no reported delivery date(s) (Data Element R = missing) unless the CMR summary was returned via mail, then the reported delivery date should be the date that the written summary was sent (Data Element R ≠ missing). | Update | Consistent with current technical guidance. | None |
| RSC 6. Organization accurately identifies data on MTM program participation and uploads it into Gentran, including the following criteria: |
RSC 6. Organization accurately identifies data on MTM program participation and uploads it into HPMS, including the following criteria: |
Update | Consistent with current submisison process. | None |
| RSC 6.i. Includes members who moved between contracts in each corresponding file uploaded to Gentran. Dates of enrollment, disenrollment elements, and other elements (e.g., TMR/CMR data) are specific to the activity that occurred for the member within each contract (Data Elements B, C, D, E, F, G, H, I, J). | RSC 6.i. Includes members who moved between contracts in each corresponding file uploaded to HPMS. Dates of enrollment, disenrollment elements, and other elements (e.g., TMR/CMR data) are specific to the activity that occurred for the member within each contract (Data Elements B, C, D, E, F, G, H, I, J). | Update | Consistent with current submisison process. | None |
| RSC 7. Organization accurately identifies MTM eligible members who are cognitively impaired at the time of CMR offer or delivery of CMR and uploads it into Gentran, including the following criteria: |
RSC 7. Organization accurately identifies MTM eligible members who are cognitively impaired at the time of CMR offer or delivery of CMR and uploads it into HPMS, including the following criteria: | Update | Consistent with current submisison process. | None |
| RSC 8. Organization accurately identifies data on members who opted-out of enrollment in the MTM program and uploads it into Gentran, including the following criteria: |
RSC 8. Organization accurately identifies data on members who opted-out of enrollment in the MTM program and uploads it into HPMS, including the following criteria: | Update | Consistent with current submisison process. | None |
| RSC 9. Organization accurately identifies data on CMR offers and uploads it into Gentran, including the following criteria: | RSC 9. Organization accurately identifies data on CMR offers and uploads it into HPMS, including the following criteria: | Update | Consistent with current submisison process. | None |
| RSC 10. Organization accurately identifies data on CMR dates and uploads it into Gentran, including the following criteria: |
RSC 10. Organization accurately identifies data on CMR dates and uploads it into HPMS, including the following criteria: | Update | Consistent with current submisison process. | None |
| RSC 11. Organization accurately identifies data on MTM drug therapy problem recommendations and uploads it into Gentran, including the following criteria: |
RSC 11. Organization accurately identifies data on MTM drug therapy problem recommendations and uploads it into HPMS, including the following criteria: |
Update | Consistent with current submisison process. | None |
| Part D CD/RD: | ||||
| RSC 5.b. Number of exception decisions made in the reporting period (Data Elements 1.G−1.R) does not exceed the total number of processed coverage determination decisions that include exceptions (Data Element 1.A). | RSC 5.b. Number of exception decisions made in the reporting period (Data Elements (1.H + 1.I + 1.J) + (1.L + 1.M + 1.N) + (1.P + 1.Q + 1.R)) does not exceed the total number of processed coverage determination decisions that include exceptions (Data Element 1.A). | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC. 5f. Verify that the date of disposition for each reopening (Data Element 3.B.11) is after the date of original disposition (Data Element 3.B.5). | RSC. 5f. Verify that the date of disposition for each reopening (Data Element 3.B.11) is equal to or later than the date of original disposition (Data Element 3.B.5). |
Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 5.g. Verify that the date of each reopening disposition (Data Element 3.B.11) is after the date that the case was reopened (Data Element 3.B.9). | RSC 5.g. Verify that the date of each reopening disposition (Data Element 3.B.11) is equal to or later than the date the case was reopened (Data Element 3.B.9). | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 6i. Includes requests for coverage determinations (including exceptions) that are withdrawn or dismissed. | RSC 6.i. Excludes requests for coverage determinations (including exceptions) that are withdrawn or dismissed. | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 7f. Includes requests for exceptions that are withdrawn or dismissed. Verify that all standard exceptions that are withdrawn or dismissed are included. Verify that all expedited exceptions that are withdrawn or dismissed are included. | RSC 7f. Excludes requests for exceptions that are withdrawn or dismissed. | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 8a. Properly categorizes the number of coverage determinations (including exceptions) by final decision: fully favorable, partially favorable, or adverse. Verify that all cases included in the count for the total number of processed coverage determinations made in the reporting period are identified as one of the accepted disposition types. | RSC 8a. Properly categorizes the number of coverage determinations (excluding exceptions) by final decision: fully favorable, partially favorable, or adverse. Verify that all cases included in the count for the total number of processed coverage determinations made in the reporting period are identified as one of the accepted disposition types. | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 10.k. Includes dismissals and withdrawals. | RSC 10k. Excludes dismissals and withdrawals. | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| Part D: DUR | ||||
| RSC 6.a.iii. Rejected opioid claims are counted at the unique contract, beneficiary, prescriber, pharmacy, drug (daily dose and quantity), and date of service (DOS). | RSC 6.a.iii. Rejected opioid claims are counted at the unique plan, beneficiary, prescriber, pharmacy, drug (strength and dosage form), quantity, and date of service (DOS) and formulary-level opioid MME POS edit. | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 6.a.iv. Properly counts the number of unique beneficiaries by contract that triggered the care coordination safety edit and if applicable, a provider and pharmacy criterion. | RSC 6.a.iv. Properly counts the number of unique beneficiaries by plan that triggered the care coordination safety edit and if applicable, a provider and pharmacy criterion. | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 6.b.iii. Rejected opioid claims are counted at the unique contract, beneficiary, prescriber, pharmacy, drug (daily dose for and quantity), and date of service (DOS). | RSC 6.b.iii. Rejected opioid claims are counted at the unique plan, beneficiary, prescriber, pharmacy, drug (strength and dosage form), quantity, and date of service (DOS) and formulary-level opioid MME POS edit. | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 6.b.iv. Properly counts the number of unique beneficiaries by contract that triggered the established hard MME safety edit threshold and if applicable, a provider and pharmacy criterion. | RSC 6.b.iv. Properly counts the number of unique beneficiaries by contract plan that triggered the established hard MME safety edit threshold and if applicable, a provider and pharmacy criterion. |
Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 6.c.iii. Rejected opioid claims are counted at the unique contract, beneficiary, prescriber, pharmacy, drug (daily dose and quantity), and date of service (DOS). | RSC 6.c.iii. Rejected opioid claims are counted at the unique plan, beneficiary, prescriber, pharmacy, drug (strength and dosage form), quantity, date of service (DOS) and formulary-level opioid MME POS edit. | Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| RSC 6.c.iv. Properly counts the number of unique beneficiaries by contract that triggered the opioid naïve days supply safety edit. | RSC 6 c.iv. Properly counts the number of unique beneficiaries by plan that triggered the opioid naïve days supply safety edit. |
Update | Changes consistent with approved 2019 Part D TS & RR. | None |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |