Download:
pdf |
pdfBurden Change
Reason for
Change
Type of Change*
30 day package
60 day package
PreIn the "Program Area Impacted" column, removed reference to MTM
AuditIssueSummary.pdf
Rev
MTM not included in this collection request.
No Change
Attachment_IAdded the following question: Please describe how you oversee the call routing process to ensure incoming requests are properly
B_CPE_Compliance
classified and processed in accordance with 42 CFR Parts 422 and 423 Subpart M requirements.
_Officer_Questionnaire_
CO-Q.pdf
Add
With the removal of CDAG and ODAG call log universes, proper routing No Change
and follow up of calls will now be assessed through the CPE program.
This question facilitates discussion between the compliance officer and
CMS audit team.
Attachment_IB_CPE_Compliance
_Officer_Questionnaire_
CO-Q.pdf
Attachment_IC_CPE_Organizational_
Structure_Governance
_PPT_ Template.pdf
With removal of Attachment 1-A, CPE Self Assessment Questionnaire, we re-named/lettered the remaining CPE collection
instruments. "Attachment_I-B_CPE_Compliance _Officer_Questionnaire_CO-Q" was renamed, "Attachment_I-A_CPE_Compliance
_Officer_Questionnaire_CO-Q"
Rev
To allow for updated, sequential naming conventions.
No Change
Page #6: Updated to reflect most current year examples (2018/2019)
Rev
Provide most up to date example
No Change
Attachment_IPage #16: Removed bullet: Describe the approach and mechanisms used to monitor FDRs performance against contractual and
C_CPE_Organizational_ regulatory requirements.
Structure_Governance
_PPT_ Template.pdf
Del
Removed duplication of information collected via the FDR oversight
questionnaire
No Change
Attachment_IPage #16: Removed bullet: Describe how and when the sponsor checks its employees, board members and first-tier entities against
C_CPE_Organizational_ the OIG and GSA exclusions databases.
Structure_Governance
_PPT_ Template.pdf
Del
Information no longer needed.
No Change
Attachment_IWith removal of Attachment 1-A CPE Self Assessment Questionnaire, we re-named/lettered the remaining CPE collection
C_CPE_Organizational_ instruments. "Attachment_I-C_CPE_Organizational_Structure_Governance _PPT_ Template" was renamed, "Attachment_IStructure_Governance B_CPE_Organizational_Structure_Governance _PPT_ Template"
_PPT_ Template.pdf
Rev
To allow for updated, sequential naming conventions.
No Change
Attachment_ID_CPE_FDR_Oversight
_Questionnaire_FDRQ.pdf
Attachment_ID_CPE_FDR_Oversight
_Questionnaire_FDRQ.pdf
Attachment_IE_CPE_SIU_FWA_Que
stionnaire_FWA-Q.pdf
Corrected typo in question #5
Rev
Technical correction
No Change
With removal of Attachment 1-A CPE Self Assessment Questionnaire, we re-named/lettered the remaining CPE collection
instruments. "Attachment_I-D_CPE_FDR_Oversight_Questionnaire_FDR-Q" was renamed, "Attachment_IC_CPE_FDR_Oversight_Questionnaire_FDR-Q"
Rev
To allow for updated, sequential naming conventions.
No Change
With removal of Attachment 1-A CPE Self Assessment Questionnaire, we re-named/lettered the remaining CPE collection
instruments. "Attachment_I-E_CPE_SIU_FWA_Questionnaire_FWA-Q" was renamed, "Attachment_ID_CPE_SIU_FWA_Questionnaire_FWA-Q"
Rev
To allow for updated, sequential naming conventions.
No Change
Attachment_I_CPE_Aud
itProcess_DataRequest.
pdf
Attachment_I_CPE_Aud
itProcess_DataRequest.
pdf
Within the tracer evaluation section, added guidance regarding the process of evaluating Employee and Compliance Team and First
Tier Entity (ECT& FTE) samples.
Add
Addresses frequently asked questions from the industry.
No Change
Under Supporting Documentation within the Tracer Case Summary and Documentation Reviews section, removed the following
bullet: Evidence of sponsor’s monthly screening to identify employees and FDRs excluded by the Office of Inspector General (OIG)
and General Services Administration (GSA).
Del
Information collection no longer needed.
No Change
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
Attachment_I_CPE_Aud
itProcess_DataRequest.
pdf
Attachment_I_CPE_Aud
itProcess_DataRequest.
pdf
Attachment_I_CPE_Aud
itProcess_DataRequest.
pdf
Attachment_I_CPE_Aud
itProcess_DataRequest.
pdf
Attachment_I_CPE_Aud
itProcess_DataRequest.
pdf
Attachment_I_CPE_Aud
itProcess_DataRequest.
pdf
Within the Detection Controls and Activities section, removed the following compliance standard: Did the sponsor review the OIG and Del
GSA exclusion systems, as required, to ensure that none of their employees or FDRs were excluded or became excluded from
participation in federal programs.
Updated date examples throughout document (i.e., 2019).
Rev
Information collection no longer needed.
No Change
To reflect the most current year.
No Change
Within Table 1, removed column: FTE Contract Effective Date and updated column letters through the remainder of the table.
Rev
Information collection no longer needed.
No Change
Clarified in the field descriptions of all program audit data requests that where "NA" applies, it should be listed as NA and not N/A.
Add
Technical correction.
No Change
Within Table 2, Column: Employee Type, updated the field description to add the following clarification: If an employee fills multiple
roles (e.g., full-time employee and governing body member), identify all roles in this field separated by a forward slash (e.g., fulltime/BOD).
In Tables 1, 3 and 4: Column: Compliance or FWA, added the following language to the description field: In situations where the
activity can be both compliance and FWA related, sponsoring organizations should list “FWA” in the record layout and, during the
universe validation process, the sponsoring organization can explain to the audit team which issues are related to both compliance
and FWA.
Attachment_II_FA_Audit Updated date examples in the column descriptions, throughout document, to reflect the most current year (i.e., 2019 for prior year;
Process_DataRequest.p 2020 for current)
df
Add
Allows sponsoring organization to provide greater detail in reporting
employee roles.
No Change
Add
Further clarifies submission guidance.
No Change
Rev
To provide clearer example.
No Change
Attachment_II_FA_Audit
Process_DataRequest.p
df
Attachment_II_FA_Audit
Process_DataRequest.p
df
Rev
To improve consistency in audit collection instruments
No Change
Add
Further clarifies submission guidance.
No Change
Red
Facilitates more logical flow of information.
No Change
Rev
To provide clearer example.
No Change
Rev
To create greater consistency across FA and CDAG universes.
No Change
Red
Facilitates more logical flow of information.
No Change
Rev
To better align with the Compliance Standard applicable to Table 4.
No Change
Rev
Correction of typo.
No Change
Del
HPMS cannot accept files in the csv format.
No Change
Standardized the NDC field name and description across FA and CDAG universe tables.
Added the following instructions to Table 5: Include eligible members (including members enrolled in employer plans and MedicareMedicaid Plans (MMPs)) for which the Sponsoring organization does not utilize prior claims history. In some cases, the Sponsoring
organization may have the full claims history for the member from the most recent PBP, and thus, the Sponsoring organization may
be able to determine new versus ongoing therapy. In this example, the member should not be included in the New Member Universe
since they are determined to be a continuing member.
Attachment_III_CDAG_ Renumbered the CDAG Tables sequentially. Previous CDAG Tables 11, 12, 13, 14 and 15 have been updated to Table numbers 9,
AuditProcess_DataRequ 10, 11, 12 and 13 respectively. This edit is reflected throughout the document.
est.pdf
Attachment_III_CDAG_ Updated examples throughout the document to reflect the more current applicable time period (i.e., 2020).
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_ Standardized the NDC field name and description across FA and CDAG universe tables.
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_ Relettered Column IDs throughout the tables to account for removal of columns specified below.
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_ Within the Universe Preparation & Submission section, in the timeliness table, updated the "compliance standard to apply" column for
AuditProcess_DataRequ table 1 to remove the word "adjudication."
est.pdf
Attachment_III_CDAG_ In the Audit Elements section updated the total number of samples to reflect 65.
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_ In Appendix A, removed reference to csv files.
AuditProcess_DataRequ
est.pdf
Removed references to withdrawn cases throughout protocol.
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Del
Withdrawn cases are to be excluded from universes.
No Change
Add
Regulatory requirements do not address processing requirements for
withdrawn cases in CDAG.
No Change
Removed the following exclusion criteria: Requests that require an AOR (or other conforming instrument) but the AOR has not been Del
received as of the date of the universe submission.
Provides greater clarity/reduces confusion.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Promotes greater clarity and consistency in the way plans identify their
members in the universes.
No Change
Within Field Name NDC, updated the description field. Removed "withdrawn" from the Column: Request Disposition description field. Rev/De To align with the addition of withdrawn cases from the table's exclusion
l
criteria.
No Change
Removed "withdrawn" from description field in Column: Was request denied for lack of medical necessity.
Del
To align with the addition of withdrawn cases from the table's exclusion
criteria.
No Change
Removed column: If denied for lack of medical necessity, was the review completed by a physician or other appropriate health care
professional?
Del
Information collection no longer needed or captured elsewhere.
No Change
Removed "or documented good faith attempt" from the Column: Date oral notification provided to enrollee description field.
Del
Simplified collection request by referring readers to this policy clarifying No Change
by visiting section 10.5.4 of the Parts C & D Enrollee Grievances,
Organization/Coverage Determinations, and Appeals Guidance (issued
February 2019) for more information on good faith efforts.
Attachment_III_CDAG_ Removed "or documented good faith attempt" from the Column: Time oral notification provided to enrollee.
AuditProcess_DataRequ
est.pdf
Del
Simplified collection request by referring readers to this policy clarifying No Change
by visiting section 10.5.4 of the Parts C & D Enrollee Grievances,
Organization/Coverage Determinations, and Appeals Guidance (issued
February 2019) for more information on good faith efforts.
Attachment_III_CDAG_ Removed "The term “provided” means when the letter left the sponsor’s establishment by US Mail, fax, or electronic communication.
AuditProcess_DataRequ Do not enter the date a letter is generated or printed within the sponsor’s organization" from the Column: Date written notification
est.pdf
provided to enrollee description field.
Del
Attachment_III_CDAG_ Removed "The term “provided” means when the letter left the sponsor’s establishment by US Mail, fax, or electronic communication.
AuditProcess_DataRequ Do not enter the date a letter is generated or printed within the sponsor’s organization" from the Column: Time written notification
est.pdf
provided to enrollee description field.
Del
Attachment_III_CDAG_ Removed "For untimely decisions" from the Column: Date forwarded to IRE description field.
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_ Removed "For untimely decisions" from the Column: Time forwarded to IRE description field.
AuditProcess_DataRequ
est.pdf
Del
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Simplified collection request.
No Change
Del
Simplified collection request.
Table 1
In the instructions, updated the exclusion criteria by adding withdrawn requests.
Rev
No Change
Removed Column: Date enrollee notified request has been forwarded to IRE.
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Del
To better align with updated regulations.
No Change
In the instructions, updated the exclusion criteria by adding withdrawn requests.
Add
Regulatory requirements do not address processing requirements for
withdrawn cases in CDAG.
No Change
Removed the following exclusion criteria: Requests that require an AOR (or other conforming instrument) but the AOR has not been
received as of the date of the universe submission.
Del
Provides greater clarity/reduces confusion.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members in the universes.
No Change
Within Field Name NDC, updated the description field.
Rev
To improve consistency in audit collection instruments.
No Change
Added " and safety edit exception" to the description field of Column: Exception Type.
Add
Added to account for opioid requests.
No Change
Removed "For at-risk appeals; valid value is QL" from the Column: Formulary UM Exception Type description field.
Del
The at-risk appeals language had been added to this universe in error.
No Change
Removed "withdrawn" from the Column: Request Disposition description field.
Del
To align with the addition of withdrawn cases from the table's exclusion
criteria.
No Change
Removed "withdrawn" from description field in Column: Was request denied for lack of medical necessity.
Del
To align with the addition of withdrawn cases from the table's exclusion
criteria.
No Change
Removed column: If denied for lack of medical necessity, was the review completed by a physician or other appropriate health care
professional?
Del
Information collection no longer needed or captured elsewhere.
No Change
Removed "or documented good faith attempt" from the Column: Date oral notification provided to enrollee description field.
Del
Simplified collection request by referring readers to this policy clarifying No Change
by visiting section 10.5.4 of the Parts C & D Enrollee Grievances,
Organization/Coverage Determinations, and Appeals Guidance (issued
February 2019) for more information on good faith efforts.
Attachment_III_CDAG_ Removed "or documented good faith attempt" from the Column: Time oral notification provided to enrollee.
AuditProcess_DataRequ
est.pdf
Del
Simplified collection request by referring readers to this policy clarifying No Change
by visiting section 10.5.4 of the Parts C & D Enrollee Grievances,
Organization/Coverage Determinations, and Appeals Guidance (issued
February 2019) for more information on good faith efforts.
Attachment_III_CDAG_ Removed "The term “provided” means when the letter left the sponsor’s establishment by US Mail, fax, or electronic communication.
AuditProcess_DataRequ Do not enter the date a letter is generated or printed within the sponsor’s organization" from the Column: Date written notification
est.pdf
provided to enrollee description field.
Del
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Table 2
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
Attachment_III_CDAG_ Removed "The term “provided” means when the letter left the sponsor’s establishment by US Mail, fax, or electronic communication.
AuditProcess_DataRequ Do not enter the date a letter is generated or printed within the sponsor’s organization" from the Column: Time written notification
est.pdf
provided to enrollee description field.
Del
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Removed "For untimely decisions" from the Column: Date forwarded to IRE description field.
Del
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Simplified collection request.
No Change
Removed "For untimely decisions" from the Column: Time forwarded to IRE description field.
Del
Simplified collection request.
No Change
Removed Column: Date enrollee notified request has been forwarded to IRE.
Del
To better align with updated regulations.
No Change
In the instructions, updated the exclusion criteria by adding withdrawn requests.
Add
Regulatory requirements do not address processing requirements for
withdrawn cases in CDAG.
No Change
Removed the following exclusion criteria: Requests that require an AOR (or other conforming instrument) but the AOR has not been
received as of the date of the universe submission.
Del
Provides greater clarity/reduces confusion.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members in the universes.
No Change
Within Field Name NDC, updated the description field.
Rev
To improve consistency in audit collection instruments.
No Change
Removed "withdrawn" from the Column: Request Disposition description field.
Del
To align with the addition of withdrawn cases from the table's exclusion
criteria.
No Change
Removed "The term “provided” means when the letter left the sponsor’s establishment by US Mail, fax, or electronic communication.
Do not enter the date a letter is generated or printed within the sponsor’s organization" from the Column: Date written notification
provided to enrollee description field.
Del
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Provides greater clarity.
No Change
Table 3
Attachment_III_CDAG_ Clarified the description in Column: Date reimbursement provided to read: Date check or reimbursement provided to the enrollee (i.e., Add
AuditProcess_DataRequ mailed to the enrollee). Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter NRD if the request was approved but no
est.pdf
reimbursement was due to the enrollee. Enter NP if the payment has not been issued at the time of the universe submission. Enter
NA if the request was not approved.
Attachment_III_CDAG_ Removed "For untimely decisions" from the Column: Date forwarded to IRE description field.
Del
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_ Removed Column: Date enrollee notified request has been forwarded to IRE.
Del
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_ Table 4
AuditProcess_DataRequ
est.pdf
Simplified collection request.
No Change
To better align with updated regulations.
No Change
In the instructions, updated the exclusion criteria by adding withdrawn requests.
Add
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Regulatory requirements do not address processing requirements for
withdrawn cases in CDAG.
No Change
Removed the following exclusion criteria: Requests that require an AOR (or other conforming instrument) but the AOR has not been Del
received as of the date of the universe submission.
Provides greater clarity/reduces confusion.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members in the universes.
No Change
Within Field Name NDC, updated the description field.
Rev
To improve consistency in audit collection instruments.
No Change
Removed "withdrawn" from the Column: Request Disposition description field.
Del
To align with the addition of withdrawn cases from the table's exclusion
criteria.
No Change
Removed "withdrawn" from description field in Column: Was request denied for lack of medical necessity.
Del
To align with the addition of withdrawn cases from the table's exclusion
criteria.
No Change
Removed column: If denied for lack of medical necessity, was the review completed by a physician or other appropriate health care
professional?
Del
Information collection no longer needed or captured elsewhere.
No Change
Removed "or documented good faith attempt" from the Column: Date oral notification provided to enrollee description field.
Del
Simplified collection request by referring readers to this policy clarifying No Change
by visiting section 10.5.4 of the Parts C & D Enrollee Grievances,
Organization/Coverage Determinations, and Appeals Guidance (issued
February 2019) for more information on good faith efforts.
Attachment_III_CDAG_ Removed "The term “provided” means when the letter left the sponsor’s establishment by US Mail, fax, or electronic communication.
AuditProcess_DataRequ Do not enter the date a letter is generated or printed within the sponsor’s organization" from the Column: Date written notification
est.pdf
provided to enrollee description field.
Del
Attachment_III_CDAG_ Removed "The term “provided” means when the letter left the sponsor’s establishment by US Mail, fax, or electronic communication.
AuditProcess_DataRequ Do not enter the date a letter is generated or printed within the sponsor’s organization" from the Column: Time written notification
est.pdf
provided to enrollee description field.
Del
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Removed "For untimely decisions" from the Column: Date forwarded to IRE description field.
Del
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Simplified collection request.
No Change
Removed "For untimely decisions" from the Column: Time forwarded to IRE description field.
Del
Simplified collection request.
No Change
Removed Column: Date enrollee notified request has been forwarded to IRE.
Del
To better align with updated regulations.
No Change
Add
Regulatory requirements do not address processing requirements for
withdrawn cases in CDAG.
No Change
Table 5
In the instructions, updated the exclusion criteria by adding withdrawn requests.
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Removed the following exclusion criteria: Requests that require an AOR (or other conforming instrument) but the AOR has not been
received as of the date of the universe submission.
Del
Provides greater clarity/reduces confusion.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members in the universes.
No Change
Within Field Name NDC, updated the description field.
Rev
To improve consistency in audit collection instruments.
No Change
Added " and safety edit exception" to the description field of Column: Exception Type.
Add
Added to account for opioid requests.
No Change
Removed "For at-risk appeals; valid value is QL" from the Column: Formulary UM Exception Type description field.
Del
The at-risk appeals language had been added to this universe in error.
No Change
Removed "withdrawn" from the Column: Request Disposition description field.
Del
To align with the addition of withdrawn cases from the table's exclusion
criteria.
No Change
Removed "withdrawn" from description field in Column: Was request denied for lack of medical necessity.
Del
To align with the addition of withdrawn cases from the table's exclusion
criteria.
No Change
Removed column: If denied for lack of medical necessity, was the review completed by a physician or other appropriate health care
professional?
Del
Information collection no longer needed or captured elsewhere.
No Change
Removed "or documented good faith attempt" from the Column: Date oral notification provided to enrollee description field.
Del
Simplified collection request by referring readers to this policy clarifying No Change
by visiting section 10.5.4 of the Parts C & D Enrollee Grievances,
Organization/Coverage Determinations, and Appeals Guidance (issued
February 2019) for more information on good faith efforts.
Attachment_III_CDAG_ Removed "The term “provided” means when the letter left the sponsor’s establishment by US Mail, fax, or electronic communication.
AuditProcess_DataRequ Do not enter the date a letter is generated or printed within the sponsor’s organization" from the Column: Date written notification
est.pdf
provided to enrollee description field.
Del
Attachment_III_CDAG_ Removed "The term “provided” means when the letter left the sponsor’s establishment by US Mail, fax, or electronic communication.
AuditProcess_DataRequ Do not enter the date a letter is generated or printed within the sponsor’s organization" from the Column: Time written notification
est.pdf
provided to enrollee description field.
Del
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Removed "For untimely decisions" from the Column: Date forwarded to IRE description field.
Del
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Simplified collection request.
No Change
Removed "For untimely decisions" from the Column: Time forwarded to IRE description field.
Del
Simplified collection request.
No Change
Removed Column: Date enrollee notified request has been forwarded to IRE.
Del
To better align with updated regulations.
No Change
Table 6
Add
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
In the instructions, updated the exclusion criteria by adding withdrawn requests.
To better align with regulations.
No Change
Removed the following exclusion criteria: Requests that require an AOR (or other conforming instrument) but the AOR has not been Del
received as of the date of the universe submission.
Provides greater clarity/reduces confusion.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members in the universes.
No Change
Within Field Name NDC, updated the description field.
Rev
To improve consistency in audit collection instruments.
No Change
Removed "withdrawn" from the Column: Request Disposition description field.
Del
To align with the addition of withdrawn cases from the table's exclusion
criteria.
No Change
Removed "The term “provided” means when the letter left the sponsor’s establishment by US Mail, fax, or electronic communication.
Do not enter the date a letter is generated or printed within the sponsor’s organization" from the Column: Date written notification
provided to enrollee description field.
Del
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Removed "For untimely decisions" from the Column: Date forwarded to IRE description field.
Del
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Simplified collection request.
No Change
Removed "For untimely decisions" from the Column: Time forwarded to IRE description field.
Del
Simplified collection request.
No Change
Removed Column: Date enrollee notified request has been forwarded to IRE.
Del
To better align with updated regulations.
No Change
In the instructions, updated the exclusion criteria by adding withdrawn requests.
Add
Regulatory requirements do not address processing requirements for
withdrawn cases in CDAG.
No Change
Removed the following exclusion criteria: Requests that require an AOR (or other conforming instrument) but the AOR has not been
received as of the date of the universe submission.
Del
Provides greater clarity/reduces confusion.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members in the universes.
No Change
Within Field Name NDC, updated the description field.
Rev
To improve consistency in audit collection instruments.
No Change
Added clarification to Column: Was the request denied for lack of medical necessity? Clarifying that the request pertains to a
Add/De
coverage determination. Also removed: "Answer NA if the request was not denied (i.e., approved, auto- forwarded, dismissed...)” from l
the description field of this column.
Removed column: If denied for lack of medical necessity, was the review completed by a physician?
Del
Information collection no longer needed or captured elsewhere.
No Change
No Change
Table 7
Removed "withdrawn" from the Column: Request Disposition description field.
Del
Added clarification to Column: Was the request denied for lack of medical necessity? Clarifying that the request pertains to a
coverage determination. Also removed: "Answer NA if the request was not denied (i.e., approved, auto- forwarded, dismissed,
withdrawn)” from the description field of this column.
Removed column: If denied for lack of medical necessity, was the review completed by a physician?
Rev/De Provides greater clarity.
l
No Change
Del
Information collection no longer needed or captured elsewhere.
No Change
Removed "The term “provided” means when the letter left the sponsor’s establishment by US Mail, fax, or electronic communication.
Do not enter the date a letter is generated or printed within the sponsor’s organization" from the Column: Date written notification
provided to enrollee description field.
Del
Add
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Provides greater clarity.
No Change
Del
Simplified collection request.
No Change
Del
To better align with updated regulations.
No Change
Add
Regulatory requirements do not address processing requirements for
withdrawn cases in CDAG.
No Change
Del
Provides greater clarity/reduces confusion.
No Change
Rev
Promotes greater clarity and consistency in the way plans identify their
members in the universes.
No Change
Rev
To improve consistency in audit collection instruments.
No Change
Del
To align with the addition of withdrawn cases from the table's exclusion
criteria.
No Change
Attachment_III_CDAG_ Clarified the description in Column: Date reimbursement provided to read: Date check or reimbursement provided to the enrollee (i.e.,
AuditProcess_DataRequ mailed to the enrollee). Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter NRD if the request was approved but no
est.pdf
reimbursement was due to the enrollee. Enter NP if the payment has not been issued at the time of the universe submission. Enter
NA if the request was not approved.
Attachment_III_CDAG_ Removed "For untimely decisions" from the Column: Date forwarded to IRE description field.
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_ Removed Column: Date enrollee notified request has been forwarded to IRE.
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_ Table 8
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_ In the instructions, updated the exclusion criteria by adding withdrawn requests.
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_ Removed the following exclusion criteria: Requests that require an AOR (or other conforming instrument) but the AOR has not been
AuditProcess_DataRequ received as of the date of the universe submission.
est.pdf
Attachment_III_CDAG_ Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
AuditProcess_DataRequ Made aligning edit to the Field Length of this column changing it from 20 to 11.
est.pdf
Attachment_III_CDAG_ Within Field Name NDC, updated the description field.
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_ Removed "withdrawn" from the Column: Request Disposition description field.
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_ Added clarification to Column: Was the request denied for lack of medical necessity? Clarifying that the request pertains to a
AuditProcess_DataRequ coverage determination. Also removed: "Answer NA if the request was not denied (i.e., approved, auto- forwarded, dismissed,
est.pdf
withdrawn)” from the description field of this column.
Attachment_III_CDAG_ Removed column: If denied for lack of medical necessity, was the review completed by a physician?
AuditProcess_DataRequ
est.pdf
To align with the addition of withdrawn cases from the table's exclusion
criteria.
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
No Change
Add/De Provides greater clarity.
l
No Change
Del
No Change
Information collection no longer needed or captured elsewhere.
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
Attachment_III_CDAG_ Removed "or documented good faith attempt" from the Column: Date oral notification provided to enrollee description field.
AuditProcess_DataRequ
est.pdf
Del
Simplified collection request by referring readers to this policy clarifying No Change
by visiting section 10.5.4 of the Parts C & D Enrollee Grievances,
Organization/Coverage Determinations, and Appeals Guidance (issued
February 2019) for more information on good faith efforts.
Attachment_III_CDAG_ Removed "The term “provided” means when the letter left the sponsor’s establishment by US Mail, fax, or electronic communication.
AuditProcess_DataRequ Do not enter the date a letter is generated or printed within the sponsor’s organization" from the Column: Date written notification
est.pdf
provided to enrollee description field.
Del
Attachment_III_CDAG_ Removed "The term “provided” means when the letter left the sponsor’s establishment by US Mail, fax, or electronic communication.
AuditProcess_DataRequ Do not enter the date a letter is generated or printed within the sponsor’s organization" from the Column: Time written notification
est.pdf
provided to enrollee description field.
Del
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Removed "For untimely decisions" from the Column: Date forwarded to IRE description field.
Del
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Simplified collection request.
No Change
Removed "For untimely decisions" from the Column: Time forwarded to IRE description field.
Del
Simplified collection request.
No Change
Removed Column: Date enrollee notified request has been forwarded to IRE.
Del
To better align with updated regulations.
No Change
In the instructions, updated the exclusion criteria by adding withdrawn requests.
Add
Regulatory requirements do not address processing requirements for
withdrawn cases in CDAG.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members in the universes.
No Change
Table 9
No Change
Table 10
In the instructions, updated the exclusion criteria by adding withdrawn requests.
Add
Regulatory requirements do not address processing requirements for
withdrawn cases in CDAG.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members in the universes.
No Change
Provides greater clarity.
No Change
Regulatory requirements do not address processing requirements for
withdrawn cases in CDAG.
No Change
Added the following clarification to the description field in Column: Date reimbursement provided: Date check or reimbursement
Add
provided to the enrollee (i.e., mailed to the enrollee). Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter NRD if the request was
approved but no reimbursement was due to the enrollee. Enter NP if the payment has not been issued at the time of the universe
submission. Enter NA if the request was not approved.
Attachment_III_CDAG_ Table 11
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_ In the instructions, updated the exclusion criteria by adding withdrawn requests.
Add
AuditProcess_DataRequ
est.pdf
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Table 13
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Attachment_III_CDAG_
AuditProcess_DataRequ
est.pdf
Rev
Promotes greater clarity and consistency in the way plans identify their
members in the universes.
No Change
In the instructions, updated the exclusion criteria by adding withdrawn requests.
Add
Regulatory requirements do not address processing requirements for
withdrawn cases in CDAG.
No Change
Removed the following exclusion criteria: Requests that require an AOR (or other conforming instrument) but the AOR has not been
received as of the date of the universe submission.
Del
Provides greater clarity/reduces confusion.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members in the universes.
No Change
Removed "The term “provided” means when the letter left the sponsor’s establishment by US Mail, fax, or electronic communication.
Do not enter the date a letter is generated or printed within the sponsor’s organization" from the Column: Date written notification
provided to enrollee description field.
Del
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
In the instructions, updated the exclusion criteria by adding withdrawn requests.
Add
Regulatory requirements do not address processing requirements for
withdrawn cases in CDAG.
No Change
Removed the following exclusion criteria: Requests that require an AOR (or other conforming instrument) but the AOR has not been
received as of the date of the universe submission.
Del
Provides greater clarity/reduces confusion.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members in the universes.
No Change
Removed "The term “provided” means when the letter left the sponsor’s establishment by US Mail, fax, or electronic communication.
Do not enter the date a letter is generated or printed within the sponsor’s organization" from the Column: Date written notification
provided to enrollee description field.
Del
Attachment_III_CDAG_ Removed "The term “provided” means when the letter left the sponsor’s establishment by US Mail, fax, or electronic communication.
AuditProcess_DataRequ Do not enter the date a letter is generated or printed within the sponsor’s organization" from the Column: Time written notification
est.pdf
provided to enrollee description field.
Del
Attachment_IV_ODAG_ Updated examples throughout the document to reflect the more current applicable time period (i.e., 2020).
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_ Relettered Column IDs throughout the tables to account for removal of columns specified below.
AuditProcess_DataRequ
est.pdf
Rev
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
To provide clearer example.
No Change
Red
Facilitates more logical flow of information.
Table 12
No Change
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
Attachment_IV_ODAG_ Within the Timeliness - Organization Determinations, Appeals and Grievances (TODAG) section:
AuditProcess_DataRequ • simplified the list of screen shots and supporting documentation required for organization determinations and reconsideration under
est.pdf
2.1.
• corrected the number of universes to reflect 12 and number of samples to reflect 60 under 3.1.
Del/Re Simplified collection request.
v
No Change
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Within the Appropriateness of Clinical Decision-Making & Compliance with Organization Determinations and Appeals Processing
Requirements section, Corrected the typo number of sample case results under #4 to 35.
Rev
Based on a trend in sponsoring organizations' questions, we updated
this information for accuracy.
No Change
Within the Grievances and Misclassification of Requests section, removed language under 2.1 that referred to the acknowledgement
of the receipt of grievances.
Del
Simplified collection request.
No Change
In the instructions, added requests that do not require prior authorization to the exclusion criteria.
Add
Simplified collection request.
No Change
Removed the following exclusion criteria: Requests that require an AOR (or other conforming instrument) but the AOR has not been
received as of the date of the universe submission; and extensions of previously approved services.
Del
Provides greater clarity/reduces confusion.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members' in the universes.
No Change
Removed Column: Level of service
Del
Simplified collection request.
No Change
Removed Column: Request for expedited timeframe
Del
Simplified collection request.
No Change
Removed Column: If denied for lack of medical necessity, was the review completed by a physician or other appropriate health care
professional?
Del
Information collection no longer needed or captured elsewhere.
No Change
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Table 2
Table 1
Within Column: Date written notification provided to enrollee, removed the language: The term “provided” means when the letter left
Del
the sponsor’s establishment by US Mail, fax, or electronic communication. Do not enter the date a letter is generated or printed within
the sponsor’s organization.
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
In the instructions, added requests that do not require prior authorization to the exclusion criteria.
Add
Simplified collection request.
No Change
Removed the following exclusion criteria: Requests that require an AOR (or other conforming instrument) but the AOR has not been
received as of the date of the universe submission; and extensions of previously approved services.
Del
Provides greater clarity/reduces confusion.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members' in the universes.
No Change
Removed Column: Level of service
Del
Simplified collection request.
No Change
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Removed Column: Subsequent expedited request
Del
Simplified collection request.
No Change
Removed Column: If denied for lack of medical necessity, was the review completed by a physician or other appropriate health care
professional?
Del
Information collection no longer needed or captured elsewhere.
No Change
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Table 3
Within Column: Date written notification provided to enrollee, removed the language: The term “provided” means when the letter left
Del
the sponsor’s establishment by US Mail, fax, or electronic communication. Do not enter the date a letter is generated or printed within
the sponsor’s organization.
Added withdrawn requests to the exclusion criteria.
Add
Regulatory requirements do not address processing requirements for
withdrawn cases.
No Change
Removed from the exclusion criteria: Requests for extensions of previously approved services, concurrent review for inpatient hospital Del
and SNF services, post-service reviews, and notifications of admissions.
Clarified collection request.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members' in the universes.
No Change
Removed Column: Level of service
Del
Simplified collection request.
No Change
Removed Column: If denied for lack of medical necessity, was the review completed by a physician or other appropriate health care
professional?
Del
Information collection no longer needed or captured elsewhere.
No Change
In Column: Date written notification provided to enrollee, removed: The term “provided” means when the EOB, IDN or letter left the
Del
sponsor’s establishment by US Mail, fax, or electronic communication. Do not enter the date a letter is generated or printed within the
sponsor’s organization.
Attachment_IV_ODAG_ In Column: Date written notification provided to provider, removed: The term “provided” means when the letter left the sponsor’s
Del
AuditProcess_DataRequ establishment by US Mail, fax, or electronic communication. Do not enter the date a letter is generated or printed within the sponsor’s
est.pdf
organization.
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Table 4
In the instructions, removed the following exclusion criteria: Requests that require an AOR (or other conforming instrument) but the
AOR has not been received as of the date of the universe submission; and extensions of previously approved services.
Del
Provides greater clarity/reduces confusion.
No Change
Removed extensions of previously approved services from the exclusion criteria.
Del
Clarified collection request.
No Change
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Added withdrawn requests to the exclusion criteria.
Add
Regulatory requirements do not address processing requirements for
withdrawn cases.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members' in the universes.
No Change
Removed Column: Level of service
Del
Information collection no longer needed.
No Change
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Removed Column: If request denied or untimely, date enrollee notified request has been forwarded to IRE.
Within Column: Date written notification provided to enrollee, removed the language: The term “provided” means when the letter left
Del
the sponsor’s establishment by US Mail, fax, or electronic communication. Do not enter the date a letter is generated or printed within
the sponsor’s organization.
Del
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
To align with updated regulations.
No Change
In the instructions, removed the following exclusion criteria: Requests that require an AOR (or other conforming instrument) but the
AOR has not been received as of the date of the universe submission; and extensions of previously approved services.
Del
Provides greater clarity/reduces confusion.
No Change
Removed extensions of previously approved services from the exclusion criteria.
Del
Clarified collection request.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members' in the universes.
No Change
Removed Column: Level of service
Del
Information collection no longer needed.
No Change
Updated Column: Was the request denied for lack of medical necessity to read: Was the organization determination denied for lack Rev
of medical necessity. Made corresponding change to the description field, specifying reference to the initial request and removing the
option: Answer NA if the request was approved.
Removed Column: If denied for lack of medical necessity, was the review completed by a physician or other appropriate health care
Del
professional?
Clarified collection request.
No Change
Information collection no longer needed or captured elsewhere.
No Change
Removed Column: If the request was denied for lack of medical necessity, was the reconsideration completed by a physician other
than the person involved in making the initial OD?
Del
Simplified collection request.
No Change
Removed Column: Date oral notification provided to enrollee
Del
Simplified collection request and aligned tables to mirror regulation
requirements.
No Change
Within Column: Date written notification provided to enrollee/provider, removed the language: The term “provided” means when the
letter left the sponsor’s establishment by US Mail, fax, or electronic communication. Do not enter the date a letter is generated or
printed within the sponsor’s organization
Del
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
To better align with updated regulations.
No Change
Table 5
Attachment_IV_ODAG_ Within Column: Date written notification provided to enrollee/provider, updated the description field by adding the phrase: if the
AuditProcess_DataRequ decision was favorable.
est.pdf
Rev
Removed Column: If request denied or untimely, date enrollee notified request has been forwarded to IRE.
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Within Column: Time written notification provided to enrollee, updated the description field by adding the phrase: if the decision was
favorable. Also clarified: answer NA if denied or no written notification was provided.
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Del
To align with updated regulations.
No Change
In the instructions, removed the following exclusion criteria: Requests that require an AOR (or other conforming instrument) but the
AOR has not been received as of the date of the universe submission; and extensions of previously approved services.
Del
Provides greater clarity/reduces confusion.
No Change
Removed extensions of previously approved services from the exclusion criteria.
Del
Clarified collection request.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members' in the universes.
No Change
Removed Column: Level of service
Del
Information collection no longer needed.
No Change
Updated Column: Was the request denied for lack of medical necessity to read: Was the organization determination denied for lack Rev
of medical necessity. Made corresponding change to the description field, specifying reference to the initial request and removing the
option: Answer NA if the request was approved.
Removed Column: If denied for lack of medical necessity, was the review completed by a physician or other appropriate health care
Del
professional?
Clarified collection request.
No Change
Information collection no longer needed or captured elsewhere.
No Change
Removed Column: If the request was denied for lack of medical necessity, was the reconsideration completed by a physician other
than the person involved in making the initial OD?
Del
Simplified collection request.
No Change
Within Column: Date oral notification provided to enrollee, updated the description field by adding the phrase: if the decision was
favorable.
Rev
Updated table instructions to mirror regulation requirements.
No Change
Within Column: Time oral notification provided to enrollee, updated the description field by adding the phrase: if the decision was
favorable.
Rev
Updated table instructions to mirror regulation requirements.
No Change
Table 6
Within Column: Date written notification provided to enrollee, updated the description field by adding the phrase: if the decision was
favorable.
Add/De Simplified collection request to mirror regulation requirements.
No Change
l/Rev
Simplified collection request by referring readers to section 10.5.3 of the
Parts C & D Enrollee Grievances, Organization/Coverage
Also removed the language: The term “provided” means when the letter left the sponsor’s establishment by US Mail, fax, or electronic
Determinations, and Appeals Guidance issued in February, 2019, for
communication. Do not enter the date a letter is generated or printed within the sponsor’s organization. Also clarified: answer NA if
information on when a notification is considered delivered by a
denied or no written notification was provided.
sponsoring organization.
Add/Re To better align with regulatory requirements.
v
No Change
Within Column: Date forwarded to IRE if denied or untimely, added the following clarification in the description field: Answer NA if the Add
request was favorable or was not forwarded to the IRE.
To better align with regulatory requirements.
No Change
Removed column: If request denied or untimely, date enrollee notified request has been forwarded to IRE.
To align with updated regulations.
No Change
Del
Table 7
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Within Column: Date written notification provided to provider, revised the last sentence of the description field to read: Answer NA if
no written notification was provided.
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Removed extensions of previously approved services from the exclusion criteria.
Del
Clarified collection request.
No Change
Added withdrawn requests to the exclusion criteria.
Add
Regulatory requirements do not address processing requirements for
withdrawn cases.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members' in the universes.
No Change
Removed Column: Level of service
Del
Information collection no longer needed.
No Change
Updated Column: Date the reconsideration request was paid or denied to read “Date the reconsideration request was paid.”
Made corresponding edit to the description field, removing the phrase: "or the date the denied claim was upheld, which may be the
IRE auto-forward date". The updated clarification now reads: Date the reconsideration request was paid. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Sponsors should answer NA for untimely cases that are still open.
Rev
Clarified the information needed.
No Change
Updated Column: Was the request denied for lack of medical necessity to read: Was the organization determination denied for lack Rev
of medical necessity. Made corresponding change to the description field, specifying reference to the initial request and removing the
option: Answer NA if the request was approved.
Removed Column: If denied for lack of medical necessity, was the review completed by a physician or other appropriate health care
Del
professional?
Clarified collection request.
No Change
Information collection no longer needed or captured elsewhere.
No Change
Within Column: Date written notification provided to provider, removed the language: The term “provided” means when the letter left Del
the sponsor’s establishment by US Mail, fax, or electronic communication. Do not enter the date a letter is generated or printed within
the sponsor’s organization.
Rev
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Simplified description.
No Change
Removed extensions of previously approved services from the exclusion criteria.
Del
Clarified collection request.
No Change
Added withdrawn requests to the exclusion criteria.
Add
Regulatory requirements do not address processing requirements for
withdrawn cases.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members' in the universes.
No Change
Removed Column: Level of service
Del
Information collection no longer needed.
No Change
Table 8
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Table 9
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Table 10
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
Attachment_IV_ODAG_ Within Column: Date written notification provided to IRE, removed the language: The term “provided” means when the letter left the
Del
AuditProcess_DataRequ sponsor’s establishment by US Mail, fax, or electronic communication. Do not enter the date a letter is generated or printed within the
est.pdf
sponsor’s organization.
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Removed extensions of previously approved services from the exclusion criteria.
Del
Clarified collection request.
No Change
Added withdrawn requests to the exclusion criteria.
Add
Regulatory requirements do not address processing requirements for
withdrawn cases.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members' in the universes.
No Change
Removed Column: Level of service
Del
Information collection no longer needed.
No Change
Within Column: Date written notification provided to IRE, removed the language: The term “provided” means when the letter left the
Del
sponsor’s establishment by US Mail, fax, or electronic communication. Do not enter the date a letter is generated or printed within the
sponsor’s organization.
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Removed extensions of previously approved services from the exclusion criteria.
Del
Clarified collection request.
No Change
Added withdrawn requests to the exclusion criteria.
Add
Regulatory requirements do not address processing requirements for
withdrawn cases.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members' in the universes.
No Change
Removed Column: Level of service
Del
Information collection no longer needed.
No Change
Within Column: Request for expedited timeframe, increased the field length from 1 to 2.
Rev
Correction of error in character count.
No Change
Within Column: Date written notification provided to enrollee, removed the language: The term “provided” means when the letter left
Del
the sponsor’s establishment by US Mail, fax, or electronic communication. Do not enter the date a letter is generated or printed within
the sponsor’s organization.
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Table 11
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
Attachment_IV_ODAG_ Within Column: Date written notification provided to IRE, removed the language: The term “provided” means when the letter left the
Del
AuditProcess_DataRequ sponsor’s establishment by US Mail, fax, or electronic communication. Do not enter the date a letter is generated or printed within the
est.pdf
sponsor’s organization.
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Added withdrawn requests to the exclusion criteria.
Add
Regulatory requirements do not address processing requirements for
withdrawn cases.
No Change
Removed the following from the exclusion criteria:
• requests that require an AOR (or other conforming instrument) but the AOR has not been received as of the date of the universe
submission.
• requests for extensions of previously approved services, concurrent review for inpatient hospital and SNF services, post-service
reviews, and notifications of admissions.
Del
Provides greater clarity/reduces confusion.
No Change
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members' in the universes.
No Change
Within Column: Date written notification of resolution provided to enrollee, removed the language: The term “provided” means when
the letter left the sponsor’s establishment by US Mail, fax, or electronic communication. Do not enter the date a letter is generated or
printed within the sponsor’s organization.
Del
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_
AuditProcess_DataRequ
est.pdf
Table 12
Add
Regulatory requirements do not address processing requirements for
withdrawn cases.
No Change
Removed the following from the exclusion criteria: requests that require an AOR (or other conforming instrument) but the AOR has not Del
been received as of the date of the universe submission.
Provides greater clarity/reduces confusion.
No Change
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Promotes greater clarity and consistency in the way plans identify their
members' in the universes.
No Change
Within Column: Date written notification of resolution provided to enrollee, removed the following language: The term “provided”
means when the letter left the sponsor’s establishment by US Mail, fax, or electronic communication. Do not enter the date a letter is
generated or printed within the sponsor’s organization.
Del
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
Rev
Promotes greater clarity and consistency in the way plans identify their
members' in the universes.
Added withdrawn requests to the exclusion criteria.
Attachment_IV_ODAG_ Table 13
AuditProcess_DataRequ
est.pdf
Attachment_IV_ODAG_ Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
AuditProcess_DataRequ Made aligning edit to the Field Length of this column changing it from 20 to 11.
est.pdf
No Change
Del
Attachment_V_SNPUpdated the Review Period within the Audit Purpose and General Guidelines section of the SNP-MOC protocol to read, "(for example, Rev
MOC_AuditProcess_Dat for an engagement letter sent on March 9, 2020, the universe review period would be February 1, 2019 through March 9, 2020).”
aRequest.pdf
Attachment_V_SNPMOC_AuditProcess_Dat
aRequest.pdf
Attachment_V_SNPMOC_AuditProcess_Dat
aRequest.pdf
Attachment_V_SNPMOC_AuditProcess_Dat
aRequest.pdf
Attachment_V_SNPMOC_AuditProcess_Dat
aRequest.pdf
Attachment_V_SNPMOC_AuditProcess_Dat
aRequest.pdf
Attachment_V_SNPMOC_AuditProcess_Dat
aRequest.pdf
Attachment_V_SNPMOC_AuditProcess_Dat
aRequest.pdf
Attachment_V_SNPMOC_AuditProcess_Dat
aRequest.pdf
NA
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
Attachment_IV_ODAG_ Within Column: Date written notification provided to enrollee/provider, removed the following language: The term “provided” means
AuditProcess_DataRequ when the letter left the sponsor’s establishment by US Mail, fax, or electronic communication. Do not enter the date a letter is
est.pdf
generated or printed within the sponsor’s organization.
Simplified collection request by referring readers to section 10.5.3 of the No Change
Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance issued in February, 2019, for
information on when a notification is considered delivered by a
sponsoring organization.
To provide clearer example.
No Change
Within the Universe Preparation and Submission section, updated the reference to the Special Needs Plan Enrollees (SNPE) Record Rev
Layout (Table 1) to read SNPE instead of PE.
Corrects typo
No Change
Within the Universe Preparation and Submission section and Appendix A, clarified the following: Sponsoring organizations should
submit each universe in the Microsoft Excel (.xlsx) file format with a header row (or Text (.txt) file format without a header row)
following the record layouts shown in Appendix A, Tables 1 and 2."
In section Care Coordination, within the apply compliance standard section, added the following: CMS will defer to regulatory
requirements in absence of an applicable clause in the MOC.
Rev
Clarifies acceptable submission formats.
No Change
Add
Clarifies CMS audit guidelines
No Change
Provide greater consistency with other compliance standards, clarifies
CMS' intent to assess the requirement for both the ICP and the HRA.
No Change
Information collection no longer needed
No Change
Removed "and CMS requirements" from the end of compliance standard 2.5.1 and reworded the compliance standard to read: 2.5.1. Rev
Did the personnel who reviewed, analyzed, developed and implemented the HRA and ICP possess appropriate professional
knowledge and credentials, as defined in the MOC?
Removed compliance standard 2.5.2 and renumbered two remaining compliance standards accordingly.
Del
Revised Administrative Processes & Training/Credentialing compliance standard to read: Have all members of the sponsoring
organization’s staff (employed, contracted, or non-contracted) that serve on the ICT received training on the SNP plan model of care
to coordinate and/or deliver all services and benefits?
Updated Field Name: Cardholder ID to Enrollee ID and updated the corresponding description field.
Made aligning edit to the Field Length of this column changing it from 20 to 11.
Rev
Clarifies compliance standard
No Change
Rev
Promotes greater clarity and consistency in the way plans identify their
members' in the universes.
No Change
Updated example years in descriptions.
Rev
Provides more up to date examples.
No Change
NEW-- Included SNPCC Supplemental Questionnaire in this collection request.
Add
FA_ImpactAnalysis_.pdf Updated date format from MM/DD/YY to CCYY/MM/DD throughout
Rev
Allow sponsoring organizations the flexibility to provide the content of
No Change
this questionnaire in written format instead of previously collected verbal
input.
To better align with the format in the protocol universe tables.
No Change
FA_ImpactAnalysis_.pdf Added new column "Medicare Beneficiary Identifier"
Add
To better align with the format in the protocol universe tables.
No Change
CDAG_CDM_Impact.pdf Updated date format from MM/DD/YY to CCYY/MM/DD throughout
Rev
To better align with the format in the protocol universe tables.
No Change
CDAG_CDM_Impact.pdf Updated "Cardholder ID" to "Enrollee ID"
Rev
To align with updates to the protocol universe tables.
No Change
CDAG_GRV_Impact.pdf Updated date format from MM/DD/YY to CCYY/MM/DD throughout
Rev
To better align with the format in the protocol universe tables.
No Change
CDAG_GRV_Impact.pdf Updated "Cardholder ID" to "Enrollee ID"
Rev
To align with updates to the protocol universe tables.
No Change
ODAG_CDM_Impact.pdf Updated date format from MM/DD/YY to CCYY/MM/DD throughout
Rev
To better align with the format in the protocol universe tables.
No Change
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
ODAG_CDM_Impact.pdf Updated "Cardholder ID" to "Enrollee ID"
Rev
To align with updates to the protocol universe tables.
No Change
ODAG_CDM_Impact.pdf Removed column: Level of service (e.g., inpatient/outpatient/ER/urgent care)
Del
To align with removal of the same column from the protocol.
No Change
ODAG_CDM_Impact.pdf Removed column: If request denied or untimely, date enrollee notified request has been forwarded to IRE.
Del
To align with updated regulations.
No Change
ODAG_DIS_Impact.pdf
Updated date format from MM/DD/YY to CCYY/MM/DD throughout
Rev
To better align with the format in the protocol universe tables.
No Change
ODAG_DIS_Impact.pdf
Updated "Cardholder ID" to "Enrollee ID"
Rev
To align with updates to the protocol universe tables.
No Change
ODAG_GRV_Impact.pdf Updated date format from MM/DD/YY to CCYY/MM/DD throughout
Rev
To better align with the format in the protocol universe tables.
No Change
ODAG_GRV_Impact.pdf Updated "Cardholder ID" to "Enrollee ID"
Rev
To align with updates to the protocol universe tables.
No Change
ODAG_PMNT_Impact.p
df
ODAG_PMNT_Impact.p
df
ODAG_PMNT_Impact.p
df
SNPMOC_ICP_ICT_Impact.
pdf
SNPMOC_ICP_ICT_Impact.
pdf
SNP-MOC_Impact.pdf
Updated date format from MM/DD/YY to CCYY/MM/DD throughout
Rev
To better align with the format in the protocol universe tables.
No Change
Updated "Cardholder ID" to "Enrollee ID"
Rev
To align with updates to the protocol universe tables.
No Change
In column: Issue Description -- List type of service (e.g., SNF/HH/PT/OT) and level of service (e.g., inpatient/outpatient/ER/urgent
care): Removed "and level of service (e.g., inpatient/outpatient/ER/urgent care)"
Updated date format from MM/DD/YY to CCYY/MM/DD throughout
Del
To align with removal of the Level of Service column from the protocol.
No Change
Rev
To better align with the format in the protocol universe tables.
No Change
Updated "Cardholder ID" to "Enrollee ID"
Rev
To align with updates to the protocol universe tables.
No Change
Updated date format from MM/DD/YY to CCYY/MM/DD throughout
Rev
To better align with the format in the protocol universe tables.
No Change
SNP-MOC_Impact.pdf
Updated "Cardholder ID" to "Enrollee ID"
Rev
To align with updates to the protocol universe tables.
No Change
Rev
To better align with the format in the protocol universe tables.
No Change
Rev
To align with updates to the protocol universe tables.
No Change
Rev
Details regarding OMB-10938-NEW are available with that separate
collection request.
No Change
Supporting Statement A Updated the background section to provide a high level summary of changes since the August 16, 2019 collection request. Details of Rev
those changes are summarized more fully throughout this crosswalk.
Orients readers to key changes in this collection request.
No Change
Supporting Statement A Updated Section 8: Federal Register: Included the Federal Register citation for the 60-day notice and summary of the number of
public comments.
Add
Self explanatory.
No Change
Supporting Statement A Updated Section 12: Burden Estimates (Hours & Wages): Clarified that no changes were made to the burden of this collection
request.
Add
Self explanatory.
No Change
SNPUpdated date format from MM/DD/YY to CCYY/MM/DD throughout
MOC_Training_Impact.p
df
SNPUpdated "Cardholder ID" to "Enrollee ID"
MOC_Training_Impact.p
df
Supporting Statement A Updated the notes section to simplify the history of recent, related program audit collection requests. Focus on the August 16, 2019
collection request as compared to this request.
Burden Change
Reason for
Change
Type of Change*
30 day package
60 day package
Supporting Statement A Updated Section 12: Burden Estimates (Hours & Wages)- Within the Attachments (Routine Audits) Section:
Removed the following instruments:
• Attachment_I-A_CPE_Self-Assessment_Questionnaire_SA-Q;
• Attachment_III-A_CDAG_SupplementalQuestions;
• Attachment_IV-A_ODAG_SupplementalQuestionnaire;
• Attachment_VI_MTM_AuditProcess_DataRequest;
• MTM_ImpactAnalysis
• Audit Survey
Del
As explained in the 60-day collection request, we had proposed to
No Change
remove these instruments. Therefore, they are no longer listed in the
summary table of instruments that are a part of this package.
Note: The Audit Survey has been removed from this summary table to
better align with the 60-day collection request package where it had not
been included given that it is an optional collection.
Supporting Statement A Updated Section 12: Burden Estimates (Hours & Wages)- Within the Attachments (Routine Audits) Section:
Added the following instruments:
• ODAG Payment Impact Analysis
• SNP MOC Training Impact Analysis
• SNP Care Coordination Questionnaire
Add
The two impact analyses were correctly identified in the section 17 of
No Change
the 60-day collection request but had been inadvertently omitted from
the table in section 12.
Because some sponsoring organizations preferred to provide, in written
format, the SNP information previously collected orally, we have
included this questionnaire in our collection request.
Supporting Statement A Updated Section 14: Cost to Federal Government: Clarified that no changes were made to the cost estimates.
Add
Self explanatory.
No Change
Supporting Statement A Updated Section 15: Changes to Burden: Clarified that no changes were made to the overall burden.
Add
Self explanatory.
No Change
Supporting Statement A Updated Section 17: Expiration Date: Added the SNP-MOC Questionnaire to the list of instruments that will include the expiration
date of this collection request. Removed the summary of the 5 documents that have been removed from the collection request.
Rev
Better reflects the content of this proposed collection request.
No Change
*Type of Change: Rev = Revision, Del = Deletion, Add = Addition, and Red = Redesignation
| File Type | application/pdf |
| File Title | 10191 PRA Crosswalk 60day to 30 day |
| Subject | 10191, Crosswalk, Program Audits |
| Author | CMS |
| File Modified | 2019-12-09 |
| File Created | 2019-12-09 |