Appendix B Crosswalk

2019 (old version),2020 (new version),Type of Change,Reason for Change,Burden Change
Part C: Grievances,,,,
RSC 5.d. Number of expedited grievances in which timely notification was given (Data Element D) does not exceed total grievances (Data Element A),RSC 5.d. Number of expedited grievances in which timely notification was given (Data Element D) does not exceed total expedited grievances (Data Element C).,Update,Consistent with current technical guidance. ,None
"RSC 5.f. Originally only referenced A, B, C, E.
",RSC - 5.f. should reference A � E.,Update,Consistent with current technical guidance. ,None
Part C: Organization Determinations/Reconsiderations,,,,
Original Appendix B for 2d: RSC 4a and RSC 4b were broken out:,Combine RSC 4a and RSC 4b into one line item.,Update,Consistent with current technical guidance. ,None
Part C: SNP,,,,
"RSC 7. In �note to reviewer�, ICD-9",RSC 7. Changed to ICD-10,Update,Consistent with current technical guidance. ,None
"RSC 10. The information will not be captured by designated CPT or ICD-9 Procedure codes
",RSC 10. The information will not be captured by designated CPT or ICD-10 Procedure codes,Update,Consistent with current technical guidance. ,None
Part D: Coverage Determinations/Redeterminations,,,,
"Currently, Appendix B has 2d - RSC 4 and within the 2.d RSC - 4 there are a. � c in the description. In order to updated this language (not reference Chapter 18) and synch with Part C, we are going to change the description text.
",Going forward the new 2d - RSC 4 for Coverage Determinations will be one line item,Update,Consistent with current technical guidance. ,None
"RSC 6.h. Includes both standard and expedited coverage determinations

",RSC 6.h. Includes both standard and expedited coverage determinations (includin exceptions),Update,Consistent with current technical guidance. ,None
Part D: DUR,,,,
"RSC 4 a. Applying all relevant guidance to properly establish and implement a care coordination formulary-level cumulative opioid morphine milligram equivalent (MME) threshold point of sale (POS) edit, and if applicable, a hard formulary-level cumulative opioid threshold POS edit, and an opioid naïve days supply POS edit. ","RSC 4 a. Applying all relevant guidance to properly establish and implement a care coordination formulary-level cumulative opioid morphine milligram equivalent (MME) threshold point of sale (POS) edit, an opioid naïve days supply POS edit, and if applicable, a hard formulary-level cumulative opioid MME threshold POS edit.",Update,Consistent with current technical guidance. ,None
"RSC 4 b. Organization provides documentation that its care coordination safety POS edit, and if applicable, hard MME safety POS edit, and its opioid naïve days supply safety POS edit were properly tested and validated prior to its implementation date.","RSC 4 b. Organization provides documentation that its care coordination safety POS edit, an opioid naïve days supply POS edit, and if applicable, a hard formulary-level cumulative opioid MME threshold POS edit were properly tested and validated prior to its implementation date.",Update,Consistent with current technical guidance. ,None
RSC 4 c.i Properly reports the care coordination safety edit formulary-level cumulative opioid MME threshold reported matches the CY 2019 care coordination safety edit formulary-level cumulative opioid MME threshold submission to CMS via HPMS.,"RSC 4 c.i Properly reports the care coordination safety edit formulary-level cumulative opioid MME threshold, provider count, and pharmacy count criteria reported matches the CY 2019 care coordination safety edit formulary-level cumulative opioid MME threshold submission to CMS via HPMS.",Update,Consistent with current technical guidance. ,None
"RSC 4.c.ii Properly reports the care coordination safety edit provider count criteria matches the CY 2019 care coordination safety edit provider count submission to CMS via HPMS.
",N/A,Deleted,To be consistent with Part D reporting requirements.,None
"RSC 4.c. iii Properly reports the care coordination safety edit pharmacy count criteria matches the CY 2019 care coordination safety edit pharmacy count submission to CMS via HPMS.
",N/A,Deleted,To be consistent with Part D reporting requirements.,None
RSC 4.d.i Properly reports the hard MME safety edit formulary-level cumulative opioid MME threshold reported matches the CY 2019 hard MME safety edit formulary-level cumulative opioid MME threshold submission to CMS via HPMS.,"RSC 4.d. i. Properly reports the hard MME safety edit formulary-level cumulative opioid MME threshold, provider count, and pharmacy count criteria reported matches the CY 2019 hard MME safety edit formulary-level cumulative opioid MME threshold submission to CMS via HPMS.",Update,Consistent with current technical guidance. ,None
RSC 4.d.ii Properly reports the hard MME safety edit provider count criteria matches the CY 2019 hard MME safety edit provider count submission to CMS via HPMS.,N/A,Deleted,To be consistent with Part D reporting requirements.,None
RSC 4.d.iii Properly reports the hard MME safety edit pharmacy count criteria matches the CY 2019 hard MME safety edit pharmacy count submission to CMS via HPMS.,N/A,Deleted,To be consistent with Part D reporting requirements.,None
RSC 5 a.ii. The number of care coordination safety edit claim rejections overridden by the pharmacist at the pharmacy (Data Element D) does not exceed the number of claims rejected due to the care coordination safety edit (Data Element C).,RSC 5 b.ii. The number of care coordination safety edit claim rejections overridden by the pharmacist at the pharmacy (Data Element D) is a value less than or equal to the number of claims rejected due to the care coordination safety edit (Data Element C).,Update,Consistent with current technical guidance. ,None
RSC 5. a. iii. The number of unique beneficiaries with at least one care coordination safety edit claim rejection overridden by the pharmacist at the pharmacy (Data Element F) does not exceed the number of unique beneficiaries with at least one claim rejected due to the care coordination safety edit (Data Element E).,RSC 5. b. iii. The number of unique beneficiaries with at least one care coordination safety edit claim rejection overridden by the pharmacist at the pharmacy (Data Element F) is a value less than or equal to the number of unique beneficiaries with at least one claim rejected due to the care coordination safety edit (Data Element E).,Update,Consistent with current technical guidance. ,None
RSC 5. b. ii. The number of unique beneficiaries with at least one hard MME safety edit claim rejection that also had a coverage determination or appeal request from hard MME safety edit rejections (Data Element O) does not exceed the number of unique beneficiaries with at least one claim rejected due to the hard MME safety edit (Data Element M).,RSC 5. b.ii. The number of unique beneficiaries with at least one hard MME safety edit claim rejection that also had a coverage determination or appeal request from hard MME safety edit rejections (Data Element O) is a value less than of equal to the number of unique beneficiaries with at least one claim rejected due to the hard MME safety edit (Data Element M).,Update,Consistent with current technical guidance. ,None
RSC 5. b. iii. The number of unique beneficiaries with at least one hard MME safety edit claim rejection with a coverage determination or appeal request from hard MME safety edit rejections that had a favorable (either full or partial) coverage determination or appeal (Data Element P) does not exceed the number of unique beneficiaries with at least one claim rejected due to the hard MME safety edit (Data Element M).,RSC 5. b. iii. The number of unique beneficiaries with at least one hard MME safety edit claim rejection with a coverage determination or appeal request from hard MME safety edit rejections that had a favorable (either full or partial) coverage determination or appeal (Data Element P) is a value less than or equal to the number of unique beneficiaries with at least one claim rejected due to the hard MME safety edit (Data Element M).,Update,Consistent with current technical guidance. ,None
RSC 5. d.iii. The number of unique beneficiaries with at least one opioid naïve days supply safety edit claim rejection that also had a coverage determination or appeal request for an opioid drug subject to the edit (Data Element V) does not exceed the number of unique beneficiaries with at least one claim rejected due the opioid naïve days supply safety edit (Data Element T).,i.iii. The number of unique beneficiaries with at least one opioid naïve days supply safety edit claim rejection that also had a coverage determination or appeal request for an opioid drug subject to the edit (Data Element V) is a value less than or equal to the number of unique beneficiaries with at least one claim rejected due the opioid naïve days supply safety edit (Data Element T).,Update,Consistent with current technical guidance. ,None
"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.","RSC 6. c. iii. Rejected opioid claims are counted at the unique plan, beneficiary, prescriber, pharmacy, drug (strength and dosage form), and quantity date of service (DOS).",Update,Consistent with current technical guidance. ,None
RSC 8.a.iii Includes all coverage determinations or appeals (fully favorable and partially favorable).,RSC 8.a.iii Includes all coverage determinations or appeals requests. ,Update,Consistent with current technical guidance. ,None
RSC 8.b.iii Includes all coverage determinations or appeals (fully favorable and partially favorable).,RSC 8.b.iii Includes all coverage determinations or appeals requests. ,Update,Consistent with current technical guidance. ,None
RSC 9.a. i. The beneficiary�s opioid claim is also included in data element O.,RSC 9. a.i. The beneficiary�s opioid claim is also included in data element M.,Update,Consistent with current technical guidance. ,None
RSC 9.b.i. The beneficiary�s opioid claim is also included in data element V.,RSC 9.b.i. The beneficiary�s opioid claim is also included in data element T.,Update,Consistent with current technical guidance. ,None
RSC 10.a.i The beneficiary�s opioid claim is also included in data element O.,RSC 10.a.i The beneficiary�s opioid claim is also included in data element M.,Update,Consistent with current technical guidance. ,None
RSC 10.b.i The beneficiary�s opioid claim is also included in data element V.,RSC 10.b.i The beneficiary�s opioid claim is also included in data element T.,Updated,Consistent with current technical guidance. ,None
Part D: MTM,,,,
"2.e � RSC � 5.y.  deleted the extra �Data Element�:  If a CMR was received Data Element (Data Element P = Yes), there is a reported provider who performed the CMR (Data Element T ? missing).","2.e � RSC � 5.y.  deleted the extra �Data Element�:  If a CMR was received (Data Element P = Yes), there is a reported provider who performed the CMR (Data Element T ? missing).",Update,Consistent with current technical guidance. ,None