CMS-10191 CDAG Audit Process and Data Request

Medicare Parts C and D Program Audit Protocols and Data Requests (CMS-10191)

Attachment_III_CDAG_AuditProcess_DataRequest

Medicare Parts C and D Program Audit Protocols and Data Requests

OMB: 0938-1000

Document [pdf]

Download: pdf | pdf

OMB Control Number 0938-1000 (Expires: TBD)

Part D Coverage Determinations,
Appeals and Grievances (CDAG)
Program Area
AUDIT PROCESS AND DATA REQUEST

PRA Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1000 (Expires: TBD). The time required to
complete this information collection is estimated to average 701 hours per response, including the time to review instructions, search existing data
resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time
estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C426-05, Baltimore, Maryland 21244-1850. Please do not send applications, claims, payments, medical records or any documents containing sensitive
information to the PRA Reports Clearance Office. Please note that any correspondence not pertaining to the information collection burden approved
under the associated OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or concerns regarding
where to submit your documents, please contact 1-800-MEDICARE.

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table of Contents
Audit Purpose and General Guidelines .................................................................................................. 3
Universe Preparation & Submission....................................................................................................... 5
Audit Elements ....................................................................................................................................... 9
I.

Timeliness - Coverage Determinations, Appeals and Grievances (TCDAG) ............................. 9

II. Appropriateness of Clinical Decision-Making & Compliance with CDA Processing
Requirements .................................................................................................................................... 11
III. Grievances and Misclassification of Requests .......................................................................... 14
Appendix .............................................................................................................................................. 16
Appendix A—Coverage Determinations, Appeals, and Grievances (CDAG) Record Layouts....... 16
Table 1: Standard Coverage Determinations (SCD) Record Layout ............................................ 16
Table 2: Standard Coverage Determination Exception Requests (SCDER) Record Layout ........ 20
Table 3: Direct Member Reimbursement Request Coverage Determinations (DMRCD) Record
Layout ........................................................................................................................................... 24
Table 4: Expedited Coverage Determinations (ECD) Record Layout.......................................... 27
Table 5: Expedited Coverage Determination Exception Requests (ECDER) Record Layout ..... 31
Table 6: Standard Redeterminations (SRD) Record Layout ........................................................ 37
Table 7: Direct Member Reimbursement Request Redeterminations (DMRRD) Record Layout
…………………………………………………………………………………………………...40
Table 8: Expedited Redeterminations (ERD) Record Layout ...................................................... 43
Table 9: Standard IRE, ALJ or MAC Determinations (SIAM) Record Layout ........................... 47
Table 10: Direct Member Reimbursements decided by review entity other than sponsor
(DMRRE) Record Layout ............................................................................................................ 49
Table 11: Expedited IRE, ALJ or MAC Determinations (EIAM) Record Layout ....................... 51
Table 12: Standard Grievances Part D (SGD) Record Layout ..................................................... 53
Table 13: Expedited Grievances Part D (EGD) Record Layout ................................................... 55

Page 2 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST

Audit Purpose and General Guidelines
1. Purpose: To evaluate performance in the three areas outlined in this protocol related to coverage
determinations, appeals, and grievances (CDAG). The Centers for Medicare and Medicaid
Services (CMS) will perform its audit activities using these instructions (unless otherwise noted).
2. Review Period: The review period for the CDAG Program Area will be decided based on your
organization’s total enrollment. CMS reserves the right to expand the review period to ensure
sufficient universe size.
•
•
•

Plans with <50,000 enrollees: The review period will be the 3-month period preceding and
including the date of the audit engagement letter.
Plans with >50,000 but <250,000 enrollees: The review period will be the 2-month period
preceding and including the date of the audit engagement letter.
Plans with >250,000 enrollees: The review period will be the 1-month period preceding and
including the date of the audit engagement letter.

3. Responding to Documentation Requests: The sponsor is expected to present its supporting
documentation during the audit and take screen shots or otherwise upload the supporting
documentation, as requested, to the secure site using the designated naming convention and within
the timeframe specified by the CMS Audit Team.
4. Sponsor Disclosed Issues: Sponsors will be asked to provide a list of all disclosed issues of noncompliance that are relevant to the program areas being audited and may be detected during the
audit. A disclosed issue is one that has been reported to CMS prior to the receipt of the audit start
notice (which is also known as the “engagement letter”). Issues identified by CMS through ongoing monitoring or other account management/oversight activities during the plan year are not
considered disclosed.
Sponsors must provide a description of each disclosed issue as well as the status of correction and
remediation using the Pre-Audit Issue Summary template. This template is due within 5 business
days after the receipt of the audit start notice. The sponsor’s Account Manager will review the
summary to validate that “disclosed” issues were known to CMS prior to receipt of the audit start
notice.
When CMS determines that a disclosed issue was promptly identified, corrected (or is actively
undergoing correction), and the risk to beneficiaries has been mitigated, CMS will not apply the
ICAR condition classification to that condition.
5. Impact Analysis (IA): An impact analysis must be submitted as requested by CMS. The impact
analysis must identify all beneficiaries subjected to or impacted by the issue of non-compliance.
Sponsors will have up to 10 business days to complete the requested impact analysis templates.
CMS may validate the accuracy of the impact analysis submission(s). In the event an impact
analysis cannot be produced, CMS will report that the scope of non-compliance could not be fully
measured and impacted an unknown number of beneficiaries across all contracts audited.
6. Calculation of Score: CMS will determine if each condition cited is an Observation (0 points),
Corrective Action Required (CAR) (1 point) or an Immediate Corrective Action Required (ICAR)
(2 points). Invalid Data Submission (IDS) conditions will be cited when a sponsor is not able to
produce an accurate universe within 3 attempts. IDS conditions will be worth one point.

Page 3 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST

CMS will then add the score for that audit element to the scores for the remainder of the audit elements
in a given protocol and then divide that number (i.e., total score), by the number of audit elements tested
to determine the sponsor’s overall CDAG audit score. Some elements and program areas may not apply
to certain sponsors and therefore will not be considered when calculating program area and overall audit
scores. Observations will be recorded in the draft and final reports, but will not be scored and therefore
will not be included in the program area and audit scores.
7. Informing Sponsor of Results: CMS will provide daily updates regarding conditions discovered that
day (unless the case has been pended for further review). CMS will provide a preliminary summary of
its findings at the exit conference. The CMS Audit team will do its best to be as transparent and timely
as possible in its communication of audit findings. Sponsors will also receive a draft audit report which
they may formally comment on and then a final report will be issued after consideration of a sponsor’s
comments on the draft.

Page 4 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST

Universe Preparation & Submission
1. Responding to Universe Requests: The sponsor is expected to provide accurate and timely universe
submissions within 15 business days of the engagement letter date. CMS may request a revised
universe if data issues are identified. The resubmission request may occur before and/or after the
entrance conference depending on when the issue was identified. Sponsors will have a maximum of 3
attempts to provide complete and accurate universes, whether these attempts all occur prior to the
entrance conference or they include submissions prior to and after the entrance conference. However,
3 attempts may not always be feasible depending on when the data issues are identified and the
potential for impact to the audit schedule. When multiple attempts are made, CMS will only use the
last universe submitted.
If the sponsor fails to provide accurate and timely universe submissions twice, CMS will document
this as an observation in the sponsor’s program audit report. After the third failed attempt, or when the
sponsor determines after fewer attempts that they are unable to provide an accurate universe within
the timeframe specified during the audit, the sponsor will be cited an Invalid Data Submission (IDS)
condition relative to each element that cannot be tested, grouped by the type of case.
2. Pull Universes: The universes collected for this program area test whether the sponsor has deficiencies
related to timeliness, clinical decision making and appropriateness, and grievances and the
misclassification of requests in the area of CDAG. Sponsors will provide universes of all of their
expedited and standard coverage determinations (CDs) (e.g., prior authorization, step therapy
authorization, etc.), all expedited and standard CD exception requests (prior authorization exception,
non-formulary exception, tiering exception, etc.), all expedited and standard redeterminations (RDs), all
direct member reimbursement requests (initial CDs, RDs, and overturns by review entities), all
expedited and standard IRE, Administrative Law Judge (ALJ), or Medicare Appeals Council (MAC)
determinations that overturned the sponsor’s decision, and all expedited and standard grievances (e.g.,
written correspondence, calls received by customer service representatives, etc.).
Instructions for what should be included in each universe are listed above the tables listed in Appendix
A. For each respective universe, the sponsor should include all cases that match the description for that
universe for all contracts and Plan Benefit Packages (PBPs) in its organization as identified in the audit
engagement letter (e.g., all standard tiering exception CDs for all contracts and PBPs in your
organization).
The universes should be 1) all inclusive, regardless of whether the request was determined to be
favorable, partially favorable, unfavorable, auto-forwarded, dismissed, or reopened and 2) submitted
in the appropriate record layout as described in Appendix A. These record layouts include:
•
•
•
•
•
•
•
•
•
•

Table 1: Standard Coverage Determinations (SCD) Record Layout
Table 2: Standard Coverage Determination Exception Requests (SCDER) Record Layout
Table 3: Direct Member Reimbursement Request Coverage Determinations (DMRCD) Record Layout
Table 4: Expedited Coverage Determinations (ECD) Record Layout
Table 5: Expedited Coverage Determination Exception Requests (ECDER) Record Layout
Table 6: Standard Redeterminations (SRD) Record Layout
Table 7: Direct Member Reimbursement Request Redeterminations (DMRRD) Record Layout
Table 8: Expedited Redeterminations (ERD) Record Layout
Table 9: Standard IRE, ALJ or MAC Determinations (SIAM) Record Layout
Table 10: Direct Member Reimbursements decided by review entity other than sponsor (DMRRE)
Record Layout

Page 5 of 56

v. 2-2020

•
•
•

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 11: Expedited IRE, ALJ or MAC Determinations (EIAM) Record Layout
Table 12: Standard Grievances Part D (SGD) Record Layout
Table 13: Expedited Grievances Part D (EGD) Record Layout

3. Submit Universes to CMS: Sponsors 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 through 13. The sponsor should submit its
universes in whole and not separately for each contract and PBP. If the Sponsor does not have
any cases responsive to a particular universe request (e.g., if there were no direct member
reimbursement request redeterminations during the review period), the sponsor must upload an
Excel spreadsheet to the Health Plan Management System (HPMS) at the appropriate universe
level that includes a statement explaining it does not have responsive cases for this particular
universe during the requested audit period.
4. Timeliness Tests: CMS will run the tests indicated below on each universe. For the
effectuation tests, auditors will determine percentage of timely cases from a sponsor’s approvals
(favorable cases). For the notification timeliness tests, auditors will determine the percentage of
timely cases from a full universe of approvals and denials. If more than one universe tests the
same compliance standard, multiple timeliness tests results will be merged for one overall score.
TABLE
#

RECORD
LAYOUT

SCD*

UNIVERSE

Standard CDs

COMPLIANCE
STANDARD TO
APPLY

CRITERIA
(EFF. JANUARY 1, 2020)

No later than 72
hours. Late cases
must be autoforwarded to the IRE
within 24 hours of the
expiration of the
timeframe.

42 CFR § 423.568(b)
42 CFR § 423.568(d)
42 CFR § 423.568(f)
42 CFR § 423.568(h)

TEST

Effectuation

Notification

SCDER*

Standard CD
Exception
Requests

No later than 72
hours from the time
the prescriber’s
supporting statement
was received.

42 CFR § 423.568(b)
Effectuation
42 CFR § 423.568(d)
42 CFR § 423.568(f)
42 CFR § 423.568(h)
Notification
42 CFR § 423.578(c)(1)

DMRCD*

Part D Direct
Member
Reimbursement
Request CDs

No later than 14 days.
If DMR request
involves an exception
the case may not be
tolled pending receipt
of a prescriber’s
supporting statement.
No later than 24
hours. Late cases
must be autoforwarded to the IRE
within 24 hours of the
expiration of the
timeframe.

42 CFR § 423.568(c)
42 CFR § 423.568(h)

Page 6 of 56

ECD*

Expedited CDs

Notification

Reimbursement

Effectuation
42 CFR § 423.572(a)
42 CFR § 423.572(b)
42 CFR § 423.572(d)
42 CFR § 423.578(c)(1)
42 CFR § 423.572(d)
42 CFR § 423.578(c)(1) Notification

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
TABLE
#

RECORD
LAYOUT

UNIVERSE

ECDER*

Expedited CDs
Exception
Requests

No later than 24
hours from the time
the prescriber’s
supporting statement
is received

42 CFR § 423.572(a)

Effectuation

42 CFR § 423.572(b)
42 CFR § 423.572(d)
42 CFR § 423.578(c)(1)

Notification

Standard RDs

No later than 7 days.
Late cases must be
auto-forwarded to the
IRE within 24 hours
of the expiration of
the timeframe.
No later than 14 days.
Check mailed within
30 days.

42 CFR § 423.590(a)(1)
42 CFR § 423.590(a)(2)
42 CFR § 423.590(c)
42 CFR § 423.636(a)(1)
42 CFR § 423.636(a)(3)

No later than 72
hours. Late cases
must be autoforwarded to the IRE
within 24 hours of the
expiration of the
timeframe.
Effectuation of
benefit or authorized
reimbursement within
72 hours of notice
from appeal entity.
No later than 72
hours to authorize/
effectuate
reimbursement.
No later than 30 days
from date notified of
CD reversal to issue
reimbursement.

42 CFR § 423.590(d)(1) Effectuation
42 CFR § 423.590(d)(2)
42 CFR § 423.590(e)
Notification
42 CFR § 423.638(a)(1)
42 CFR § 423.638(a)(2)

SRD*

DMRRD*

Part D Direct
Member
Reimbursement
Request RDs

ERD*

Expedited RDs

SIAM*

Standard IRE,
ALJ or MAC
Determinations

DMRRE*

Part D Direct
Member
Reimbursement
Requests
decided by
review entity
other than
sponsor

Page 7 of 56

COMPLIANCE
STANDARD TO
APPLY

CRITERIA
(EFF. JANUARY 1, 2020)

TEST

Effectuation
Notification

42 CFR § 423.590(b)(1) Notification
42 CFR § 423.590(b)(2)
42 CFR § 423.590(c)
42 CFR § 423.636(a)(2) Reimbursement

42 CFR § 423.636(b)(1) Effectuation

Effectuation
42 CFR § 423.636(b)(2)

Reimbursement

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
TABLE
#

RECORD
LAYOUT

UNIVERSE

EIAM

Expedited IRE,
ALJ or MAC
Determinations

SGD

Standard
Grievances Part
D

EGD

Expedited
Grievances Part
D

COMPLIANCE
STANDARD TO
APPLY

CRITERIA
(EFF. JANUARY 1, 2020)

TEST

Effectuation of
benefit within 24
hours of notice from
appeal entity.
No later than 30 days,
plus 14 days (totaling
44 days) if an
extension is used.

42 CFR § 423.638(b)(1) Effectuation

No later than 24
hours.

42 CFR § 423.564(f)

42 CFR § 423.564(e)(1) Notification
42 CFR § 423.564(e)(2)

Notification

*These universes may be combined with at least one other universe to determine an overall compliance rate.
Merges include:
o
o
o
o
o

SCD will be combined with SCDER for effectuation and notification
ECD will be combined with ECDER for effectuation and notification
DMRRD will be combined with SRD for notification
SCD, SCDER, DMRCD, ECD, ECDER, ERD, SRD, and DMRRD will be combined for an
IRE auto-forward test
DMRRE will be combined with SIAM for effectuation

Page 8 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST

Audit Elements
I. Timeliness - Coverage Determinations, Appeals and Grievances (TCDAG)
(Performed via webinar prior to the entrance conference, results communicated to sponsor
during live portion of the audit)
1. Select Sample Cases: CMS will randomly select 5 cases from record layouts 1 through 13 for a
total of up to 65 cases.
2. Verify Universe Submission: Prior to the live portion of the audit, CMS or its contractor, when
applicable, will schedule a separate webinar with the sponsor to verify that the dates and times
provided in the universe submissions are accurate. In addition, for the exception universes
(SCDER and ECDER), CMS will be evaluating that the cases provided are actually exception
requests. The sponsor should have available the information and documents necessary to
demonstrate that the dates and times provided in the record layouts were accurate. The sponsor
will need access to the following documents during both the pre-audit webinar and the live audit
webinar and may be requested to produce screenshots of any of the following:
2.1. For requests for coverage determinations or redeterminations:
• Initial request:
 If request was received via fax/mail/email, copy of original request including
date/time stamp of receipt.
 If request was received via phone, copy of CSR notes and/or documentation of call
including date/time stamp of call and call details.
• Copy of all supplemental information submitted by the prescriber.
 If information was received via fax/mail/email, copy of documentation provided
including date/time stamp and call details.
 If information was received via phone, copy of CSR notes and/or documentation of
call including date/time stamp.
• Documentation of the decision, including:
 Documentation showing denial, partial denial, or approval notification to the
beneficiary and/or their representative and prescriber, if applicable.
 Copy of the written decision letter and documentation of date/time letter was mailed.
 If oral notification was given, copy of CSR notes and/or documentation of call
including date/time stamp.
• Any other reports, system notes, or logs that document beneficiary notification.
• Documentation of effectuation of request, including:
 Approval in coverage determinations/redeterminations system(s) and evidence of
effectuation in sponsor claims system clearly showing date and time override was
entered.
• If case was untimely, include the following:
 Documentation showing when the sponsor auto-forwarded the request to the IRE.
2.2. For cases overturned by IRE/ALJ/MAC:
• Copy of overturn notice from IRE/ALJ/MAC including date/time stamp of receipt by
sponsor.
• Documentation of effectuation including approval in coverage determinations/
redeterminations system(s) and evidence of effectuation in sponsor claims system clearly

Page 9 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST

•

showing date/time the override was entered. For approved exception requests, proof that
the approval is effective for the remainder of the plan year.
Copy of effectuation notice to IRE/ALJ/MAC including sent date/time stamp.

3. Apply Compliance Standard: At a minimum, CMS will evaluate cases against the following
criteria. CMS may review factors not specifically addressed in these questions if it is determined
that there are other related CDAG requirements not being met.
3.1. Universe Accuracy Standard: CMS will test Tables 1 – 13 by confirming the data
through the 5 selected cases (65 total cases). The integrity of the universe will be
questioned if more than 1 of the 5 sample cases observed during the audit does not match
the data provided in the universe. If this occurs CMS will request a new universe to test
timeliness for that universe. Sponsors will be expected to produce the new universe prior to
the live portion of the audit per CMS instructions. If the sponsor cannot produce an
accurate universe after three submissions, CMS will cite all applicable IDS conditions
relative to timeliness.
Are the dates and times observed during the pre-audit webinar consistent with the
timeliness fields in the universe submission?
3.2. Calculate Universe Timeliness: CMS or its contractor, when applicable, will then calculate
the applicable timeliness tests as identified in the record layout chart above. Some universes
will have two timeliness tests performed; one for effectuation of approvals and one for
notification of all requests. Other universes may only have one timeliness test performed.
For each timeliness test in the universe, the number of late cases will be divided by the total
number of cases applicable for that test in each universe. For instance, for effectuation of
standard coverage determinations, all approvals that were effectuated untimely will be
divided by all approvals in the universe. Once the percentage of late cases is determined,
CMS will calculate the percentage of timely cases (100% - % late cases) and apply the
compliance threshold for that test.
CMS has determined 3 timeliness thresholds that apply to every test in each universe.
Sponsors that fall at or above the first threshold will generally not be cited a condition.
Sponsors that fall within the second threshold will generally be cited for a corrective action
required (CAR) for unmet timeliness requirements. Sponsors falling below the third threshold
may be cited an immediate corrective action (ICAR) for unmet timeliness requirements.
Are the sponsor’s universes timely in accordance with the CMS compliance standards
referenced in the table above?
4. Inform Sponsor of Results: CMS will inform the sponsor of the results of its analysis for each
of the 13 universes supplied during the live audit portion of the review; including if any
conditions will be cited, and if so, which condition(s).

Page 10 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST

II. Appropriateness of Clinical Decision-Making & Compliance with CDA Processing
Requirements
1. Select Sample Cases: CMS will select a targeted sample of 40 cases (30 denials and 10
approvals) that appear clinically significant. CMS may select an additional 5 cases to review
dismissals and/or re-openings to assess whether the request was appropriately classified and
processed. CMS will attempt to ensure that the sample set is representative of various types of
coverage determinations (e.g., prior authorization, step therapy authorization, tiering exception,
formulary exception (including both non-formulary drugs and formulary drugs with a UM
requirement), reimbursement request, etc.). The sample set for the 40 clinical appropriateness
cases will be generally selected from the universe categories as follows:
•
•
•
•
•
•

10 coverage determination denials (standard cases)
5 redetermination denials (standard cases)
5 expedited cases (either coverage determination denials or redetermination denials)
10 IRE, ALJ, or MAC overturns
5 coverage determination approvals (standard and expedited)
5 redetermination approvals (standard and expedited)

In sampling, CMS will ensure that 15 of the 30 denial cases are protected class drug denials. If
the universe does not include a total of 15 different protected class drug denials, CMS will
include as many as are in the universe to get closest to 15.
2. Review Sample Case Documentation: CMS will review all sample case file documentation for
proper notification and clinical appropriateness of the decision. The sponsor will need access to
the following documents during the live audit webinar and may be requested to produce
screenshots of any of the following:
2.1. For requests for coverage determinations or redeterminations:
• Initial request:
 Copy of request, if request was received via fax/mail/email.
 If request was received via phone, copy of CSR notes and/or documentation of call
and call details.
• Copy of appointment of representative (AOR), or other conforming instrument, if
patient’s representative placed request and/or received response.
• Copy of all notices, letters, call logs, or other documentation showing when the sponsor
requested additional information from the prescriber. If the request was made via phone
call, copy of call log detailing what was communicated to the prescriber.
• Copy of all supplemental information submitted by the prescriber.
 If information was received via fax/mail/email, copy of documentation provided
including call details.
 If information was received via phone, copy of CSR notes and/or documentation of
call.
• Documentation of case review steps including any standard operating procedures or
standard decision trees used by clinical personnel.
• Name and title of final reviewer and rationale for the decision. Additional
documentation will include, but is not limited to: sponsor formulary/EOC, sponsor
clinical criteria, Federal Regulations, CMS Guidance, compendia, peer reviewed

Page 11 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST

•
•
•
•
•

•
•
•

•

literature (where allowed), or any other documentation used when considering the
request.
Documentation of the decision, including:
 Documentation showing denial, partial denial, or approval notification to the
beneficiary and/or their representative and prescriber, if applicable.
Copy of the written decision letter.
If oral notification was given, copy of CSR notes and/or documentation of call.
Any other reports, system notes, or logs that document denial or approval of the request
and beneficiary notification.
For approvals, documentation of effectuation of request, including:
 Approval in coverage determinations/redeterminations system(s) and evidence of
effectuation in sponsor claims system clearly showing date and time override was
entered.
 For approved exception requests, proof that the approval is effective for the
remainder of the plan year.
 Documentation showing approval notification to the beneficiary and/or their
representative and prescriber, as applicable.
If rejection, explanation for why drug rejected (i.e., refill too soon).
If there are no claims for drug after date of effectuation, narrative explaining member
has not attempted to receive the drug since date of effectuation and a screen print
showing all claims for member since date of effectuation.
For reopenings:
 Copy of any case notes as to why the decision was reopened,
 Copy of any notice sent to the enrollee regarding the reason for the reopening,
 Copy of all documentation relating to the decision of the reopening and any
subsequent notification regarding the decision.
For dismissals::
 A copy of the initial request
 Copies of any case notes as to why the case was dismissed
 Any notification regarding the dismissal.
If applicable, all documentation to support the sponsor’s decision to process an
expedited request under the standard timeframe, including any pertinent medical
documentation, and any associated notices provided to the enrollee and the requesting
provider/physician.
If applicable, notice to the enrollee that their request is not being expedited and the right
to file a grievance.

2.2. For cases overturned by IRE/ALJ/MAC:
• Copy of overturn notice from IRE/ALJ/MAC.
• Documentation of effectuation including approval in coverage determinations/
redeterminations system(s) and evidence of effectuation in sponsor claims system. For
approved exception requests, proof that the approval is effective for the remainder of the
plan year.
• Copy of effectuation notice to IRE/ALJ/MAC.
• Screen print of all claims for the requested drug after effectuation dates.
• If rejection, explanation for why drug rejected (i.e., refill too soon).
• If there are no claims for drug after date of effectuation, narrative explaining member
has not attempted to receive the drug since date of effectuation and a screen print
showing all claims for member since date of effectuation.
Page 12 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
3. Apply Compliance Standard: At a minimum, CMS will evaluate cases against the following
criteria. CMS may review factors not specifically addressed in these questions if it is determined
that there are other related CDAG requirements not being met.
3.1. Clinical Appropriateness/ Approvals:
3.1.1. Was appropriate notification (i.e., correct notice and approval language understandable
for enrollee) provided to the enrollee (or authorized representative) and
provider/physician, if applicable?
3.1.2. If representative received response, was an appointment of representative (AOR), or
other conforming instrument, on file?
3.1.3. Was approval effectuated for appropriate length of time? (i.e., duration of therapy on
CMS-approved PA criteria, end of the plan year, or prescriber-specified time)
3.2. Clinical Appropriateness/ Denials:
3.2.1. Was appropriate notification (i.e., correct notice and denial language detailed, specific
to the facts of the case, understandable for enrollee; appeal rights; etc.) provided to the
enrollee (or representative) and provider/physician, if applicable?
3.2.2. If representative received response, was an appointment of representative (AOR), or
other conforming instrument, on file?
3.2.3. Was the request reviewed by a physician or other appropriate health care professional
with sufficient medical and other expertise including knowledge of Medicare coverage
criteria?
3.2.4. Was the redetermination reviewed by a different physician with expertise in the field of
medicine that is appropriate for the services at issue?
3.2.5. Did the sponsor appropriately consider clinical information and comply with CMS
coverage and notification requirements?
3.2.6. Did the sponsor make reasonable and diligent efforts to obtain all medical records and
other pertinent documentation within the required timeframes, as necessary?
3.3. IRE, ALJ, or MAC Overturns: If a reviewer determines the IRE, ALJ or MAC reversal
was in error, the sponsor will receive a score of pass for that case. For all other IRE, ALJ and
MAC cases, apply the following compliance criteria:
3.3.1. Did the IRE, ALJ or MAC receive additional information that would have changed the
sponsor’s decision to deny the case?
3.3.2. Did the sponsor attempt to obtain that information?
3.4. For Dismissals and/or Re-openings:
3.4.1. Did the sponsor appropriately classify and process the coverage request?
3.4.2. If the request was a re-opening, did the sponsor follow 42 CFR 423 Subpart U
requirements?
4. Sample Case Results: CMS will test each of the 40 to 45 cases. If CMS requirements are not
met, conditions (findings) are cited. If CMS requirements are met, no conditions (findings) are
cited. NOTE: Cases and conditions may have a one-to-one or a one-to-many relationship. For
example, one case may have a single condition or multiple conditions of non-compliance.

Page 13 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST

III. Grievances and Misclassification of Requests
1. Select Sample Cases: CMS will select a targeted sample of 20 total grievances: 15 from the
standard grievances record layout and 5 from the expedited grievances record layout (Appendix
A, Tables 12 and 13). If the sponsor does not have enough expedited grievances, the auditors will
sample additional cases from the standard grievance universe.
2. Review Sample Case Documentation: CMS will review all sample cases file documentation to
determine that grievances were appropriately classified and that the notification properly
addressed the issue raised in the grievance. The sponsor will need access to the following
documents or audio files during the live webinar and may be requested to produce screenshots
or transcripts of any of the following:
2.1 For Grievances:
• Initial complaint:
 If complaint was received via fax/mail/email, copy of original complaint.
 If request was received via phone, copy of CSR notes and/or documentation of call
including the call details.
• Copy of appointment of representative (AOR), or other conforming instrument, if
patient’s representative filed grievance or received notification.
• Documentation explaining the grievance issue(s).
• Copy of all notices, letters, call logs, or other documentation showing when the sponsor
received the grievance and/or requested additional information from the beneficiary
and/or their representative date/time stamp of the request. If request was made via phone
call, copy of call log detailing what was communicated to the enrollee.
• If the enrollee is complaining about a specific drug or about not having received a drug,
provide any information relative to the drug in question and whether a coverage request
was initiated.
• Copy of all supplemental information submitted by beneficiary and/or their
representative.
 If information was received via fax/mail/email, copy of documentation provided.
 If information was received via phone, copy of CSR notes and/or documentation of
call.
• Documentation showing the steps the sponsor took to resolve the issue, including
appropriate correspondence with other departments within the organization, referral to
sponsor’s fraud, waste, and abuse department, outreach to network pharmacies, and
description of the final resolution.
• Documentation showing resolution notification to the beneficiary and/or their
representative.
 Copy of the written decision letter sent and documentation of date/time letter was
mailed.
 If oral notification was given, copy of CSR notes and/or documentation of call.
3. Apply Compliance Standard: At a minimum, CMS will evaluate cases against the following
criteria. CMS may review factors not specifically addressed in these questions if it is determined
that there are other related CDAG requirements not being met.
3.1. Was the case (e.g., grievance) or call correctly classified, and if not, was it quickly
transferred to the appropriate process?
Page 14 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
3.2. For grievances, did the grievance notification appropriately address all issues raised in
the complaint?
4. Sample Case Results: CMS will test each of the 20 cases. If CMS requirements are not met,
conditions (findings) are cited. If CMS requirements are met, no conditions (findings) are cited.
NOTE: Cases and conditions may have a one-to-one or a one-to-many relationship. For
example, one case may have a single condition or multiple conditions of non-compliance.

Page 15 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST

Appendix
Appendix A—Coverage Determinations, Appeals, and Grievances (CDAG) Record
Layouts
The universes for the Part D Coverage Determination, Appeals and Grievances (CDAG) program area
must be submitted in the Microsoft Excel (.xlsx) file format with a header row or Text (.txt) file format
without a header row. Do not include the Column ID variable which is shown in the record layout as a
reference for a field’s column location in an Excel or Text file. Do not include additional information
outside of what is dictated in the record layout. Submissions that do not strictly adhere to the record
layout will be rejected.
Please use a comma (,) to separate multiple values within one field if there is more than one piece of
information for a specific field. Please ensure that all case information (dates and times) are included in
the specific time zone that the case was received.
If you don’t have data for any of the fields identified below, please discuss that with your Auditor in
Charge (AIC) prior to populating or submitting your universes.
NOTE: There is a maximum of 4,000 characters per record row. Therefore, should additional
characters be needed for a variable, enter this information on the next record at the appropriate start
position.
Table 1: Standard Coverage Determinations (SCD) Record Layout
• Include all requests processed as standard coverage determinations.
• Exclude all direct member reimbursement requests, exception requests, withdrawn
requests and requests processed as expedited coverage determinations.
• Submit cases based on the date the sponsor’s decision was rendered or should have been
rendered (the date the request was initiated may fall outside of the review period).
Column
ID
A

Field Name

Field Type

Beneficiary First Name

Beneficiary Last Name

Enrollment Effective
Date

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Page 16 of 56

Field
Length
50

Description

Last name of the beneficiary.

Effective date of beneficiary’s enrollment for
the PBP that the beneficiary was enrolled in
when the coverage determination was
received. Submit in CCYY/MM/DD format
(e.g., 2020/01/01).

First name of the beneficiary.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
D

Field Name

Field Type

Enrollee ID

CHAR
Always
Required

Contract ID

Plan ID

CHAR
Always
Required
CHAR
Always
Required

Was the beneficiary
residing in a long term
care facility?

Field
Length
11

Description
Enter the Medicare Beneficiary Identifier
(MBI) of the enrollee. An MBI is the nonintelligent unique identifier that replaced the
HICN on Medicare cards as a result of The
Medicare Access and CHIP Reauthorization
Act (MACRA) of 2015. The MBI contains
uppercase alphabetic and numeric
characters throughout the 11-digit identifier
and is unique to each Medicare enrollee.
This number must be submitted excluding
hyphens or dashes.
The contract number (e.g., H1234) of the
organization.

The plan number (e.g., 001) of the
organization.

CHAR
Always
Required

Date the request was
received

CHAR
Always
Required

Time the request was
received

CHAR
Always
Required

Required AOR

AOR Receipt Date

CHAR
Always
Required
CHAR
Always
Required

AOR Receipt Time

CHAR
Always
Required

Issue Description

CHAR
Always
Required

2000

Indicate whether the beneficiary was identified
as residing in a long term care facility when
the coverage determination was received.
Valid values are:
Y = Yes
N = No
U = Unknown
Provide the date the request was received from
the enrollee, their representative, or their
prescriber. Submit in CCYY/MM/DD format
(e.g., 2020/01/01).
Provide the time of day the request was
received from the enrollee, their
representative, or their prescriber. Time is in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA if time is not available.
Yes (Y)/ No (N) indicator of whether the
request was made by a representative or
someone claiming to be a representative.
Date the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer None if no AOR was
received. Answer NA if no AOR form was
required.
Time the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in HH:MM:SS format (e.g., 23:45:59).
Answer None if no AOR was received.
Answer NA if no AOR form was required.
Provide a description of the issue and, for
denials, an explanation of why the decision
was denied.

Page 17 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
N

Field Name

Field Type

NDC

CHAR
Always
Required

Field
Length
11

Description
Enter the 11-Digit National Drug Code using
the NDC 11 format. Remove special characters
separating the labeler, product, and trade
package size.
When less than 11 characters or a blank field is
submitted by the pharmacy or delegate,
populate the field as submitted.
If the pharmacy submits a value greater than 11
characters, enter “valueXeeded” in the field.
For multi-ingredient compound claims
populate the field with the NDC of the most
expensive drug (or as submitted on the
associated PDE). When compound claims do
not include any Part D drug products,
populate the field with “00000000000”
consistent with the NDC 11 format.

Drug Name, Strength &
Dosage Form

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

150

Provide the drug name, strength, and dosage
form.

Is this a protected class
drug?

Protected class drug Yes (Y)/No (N) indicator.

Was request made
under the expedited
timeframe but
processed by the plan
under the standard
timeframe?

Yes (Y)/No (N) indicator of whether the
request made under expedited timeframe was
processed under the standard timeframe based
on plan deciding that expedited case was
unnecessary. Answer NA if the request was
made under the standard timeframe.

Request Disposition

CHAR
Always
Required

Was the request denied
for lack of medical
necessity?

CHAR
Always
Required

Status of the request. Valid values are:
approved, denied, IRE auto-forward,
dismissed, re-opened approved, or re-opened
denied. Answer NA if the request was never
resolved/processed.
Yes (Y)/No (N) indicator of whether request
denied for lack of medical necessity. Answer
NA if the request was not denied (i.e.,
approved, auto-forwarded, dismissed).

Date of plan decision

Time of plan decision

Date effectuated in the
plan's system

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Page 18 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
W

Field Name

Field Type

Time effectuated in the
plan’s system

CHAR
Always
Required

Date oral notification
provided to enrollee

CHAR
Always
Required

Time oral notification
provided to enrollee

CHAR
Always
Required

Date written
notification provided to
enrollee

CHAR
Always
Required

Time written
notification provided to
enrollee

CHAR
Always
Required

Date forwarded to IRE

CHAR
Always
Required

Time forwarded to IRE

CHAR
Always
Required

Page 19 of 56

Field
Length
8

Description
Time effectuated in the plan's system. Submit
in HH:MM:SS military time format (e.g.,
23:59:59). Answer NA for requests that were
not approved (e.g. denials/ auto-forwards).
Date oral notification provided to enrollee
(or their authorized representative). Submit
in CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if no oral
notification was provided to enrollee.
Time oral notification provided to enrollee
(or their authorized representative). Submit
in HH:MM:SS military time format (e.g.,
23:59:59). Answer NA if no oral notification
was provided to enrollee.
Date written notification provided to enrollee.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if no written
notification was provided to enrollee.
Time written notification provided to enrollee.
Submit in HH:MM:SS military time format
(e.g., 23:59:59). Answer NA if no written
notification was provided to enrollee.
Provide the date the request was forwarded
to the IRE. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Answer NA for
timely decision or if request was not
forwarded to the IRE.
Provide the time the request was forwarded
to the IRE. Submit in HH:MM:SS military
time format (e.g., 23:59:59). Answer NA for
timely decision or if request was not
forwarded to the IRE.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 2: Standard Coverage Determination Exception Requests (SCDER) Record Layout
• Include all requests processed as standard coverage determination exception requests.
• Exclude all requests processed as standard coverage determination requests, including
direct member reimbursement requests resolved under the exceptions process.
• Exclude all withdrawn requests.
• Submit cases based on the date the sponsor’s decision was rendered or should have been
rendered (the date the request was initiated may fall outside of the review period).
Field Name

Field Type

Beneficiary First
Name
Beneficiary Last
Name
Enrollment Effective
Date

CHAR Always
Required
CHAR Always
Required
CHAR Always
Required

Enrollee ID

CHAR Always
Required

Contract ID

Plan ID

Was the beneficiary
residing in a long
term care facility?

CHAR Always
Required
CHAR Always
Required
CHAR Always
Required

Date the request was
received

CHAR Always
Required

Column
ID
A
B
C

Page 20 of 56

Field
Length
50

Description

Last name of the beneficiary.

Effective date of beneficiary’s
enrollment for the PBP that the
beneficiary was enrolled in when the
coverage determination was received.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01).
Enter the Medicare Beneficiary
Identifier (MBI) of the enrollee. An
MBI is the non-intelligent unique
identifier that replaced the HICN on
Medicare cards as a result of The
Medicare Access and CHIP
Reauthorization Act (MACRA) of
2015. The MBI contains uppercase
alphabetic and numeric characters
throughout the 11-digit identifier and is
unique to each Medicare enrollee. This
number must be submitted excluding
hyphens or dashes.
The contract number (e.g., H1234) of
the organization.
The plan number (e.g., 001) of the
organization.
Indicate whether the beneficiary was
identified as residing in a long term care
facility when the coverage
determination was received. Valid
values are:
Y = Yes
N = No
U = Unknown
Provide the date the request was
received from the enrollee, their
representative, or their prescriber.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01).

3
1

First name of the beneficiary.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Field Name

Field Type

Time the request was
received

CHAR
Always
Required

Required AOR

CHAR
Always
Required

AOR Receipt Date

CHAR
Always
Required

AOR Receipt Time

CHAR
Always
Required

Issue Description

2000

NDC

CHAR
Always
Required
CHAR
Always
Required

Column
ID
I

Field
Length
8

Description
Provide the time of day the request was
received from the enrollee, their
representative, or their prescriber. Time is
in HH:MM:SS military time format (e.g.,
23:59:59).
Yes (Y)/ No (N) indicator of whether the
request was made by a representative or
someone claiming to be a representative.
Date the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer None if no AOR was
received. Answer NA if no AOR form
was required.
Time the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in HH:MM:SS format (e.g.,
23:45:59). Answer None if no AOR was
received. Answer NA if no AOR form
was required.
Provide a description of the issue and, for
denials, an explanation of why the
decision was denied.
Enter the 11-Digit National Drug Code
using the NDC 11 format. Remove
special characters separating the labeler,
product, and trade package size.
When less than 11 characters or a blank
field is submitted by the pharmacy or
delegate, populate the field as submitted.
If the pharmacy submits a value greater
than 11 characters, enter “valueXeeded”
in the field.
For multi-ingredient compound claims
populate the field with the NDC of the
most expensive drug (or as submitted on
the associated PDE). When compound
claims do not include any Part D drug
products, populate the field with
“00000000000” consistent with the NDC
11 format.

Drug Name,
Strength & Dosage
Form

Page 21 of 56

CHAR
Always
Required

150

Provide the drug name, strength, and
dosage form.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Field Name

Field Type

Is this a protected class
drug?
Was request made
under the expedited
timeframe but
processed by the
plan under the
standard timeframe?

CHAR
Always
CHAR
Always
Required

Exception Type

CHAR
Always
Required

Formulary UM
Exception
Type

CHAR
Always
Required

List expiration date
of the approval

CHAR
Always
Required

Date prescriber
supporting
statement received

CHAR
Always
Required

Time prescriber
supporting
statement received

CHAR
Always
Required

Request Disposition

CHAR
Always
Required

Was the request
denied for lack of
medical necessity?

CHAR
Always
Required

Date of plan decision

Time of plan decision

CHAR
Always
Required
CHAR
Always
Required

Column
ID
P
Q

Page 22 of 56

Field
Length
1
2

Description
Protected class drug Yes (Y)/No (N)
indicator.
Yes (Y)/No (N) indicator of whether the
request made under expedited timeframe
was processed under the standard
timeframe based on plan deciding that
expedited case was unnecessary. Answer
NA if the request was made under the
standard timeframe.
Type of exception request. Valid values
are: tiering exception, non-formulary
exception, formulary UM exception,
hospice, and safety edit exception.
If the case was a formulary UM exception;
please indicate what criteria the enrollee
was attempting to waive. Valid fields are:
PA, ST, or QL. Enter NA if the request
was not a formulary UM exception.
Expiration date of the exception approval.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if the exception
was not approved.
Date the prescriber's supporting statement
was received. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Answer NA if
no prescriber supporting statement was
received.
Time the prescriber's supporting statement
was received. Submit in HH:MM:SS
military time format (e.g., 23:59:59).
Answer NA if no prescriber supporting
statement was received.
Status of the request. Valid values are:
approved, denied, IRE auto-forward,
dismissed, re-opened approved, or reopened denied. Answer NA if the
request was never resolved/processed.
Yes (Y)/No (N) indicator of whether
request denied for lack of medical
necessity. Answer NA if the request was
not denied (i.e., approved, auto-forwarded,
dismissed).
Date of the plan decision (e.g., denied).
Submit in CCYY/MM/DD format (e.g.,
2020/01/01).
Time of the plan decision (e.g., denied).
Submit in HH:MM:SS military time
format (e.g., 23:59:59).

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Field Name

Field Type

Date effectuated in
the plan's system

CHAR
Always
Required

Time effectuated in
the plan’s system

CHAR
Always
Required

Date oral
notification
provided to enrollee

CHAR
Always
Required

Time oral
notification provided
to enrollee

CHAR
Always
Required

Date written
notification
provided to enrollee

CHAR
Always
Required

Time written
notification
provided to enrollee

CHAR
Always
Required

Date forwarded to IRE

CHAR
Always
Required

Time forwarded to IRE CHAR
Always
Required

Column
ID
AA

Page 23 of 56

Field
Length
10

Description
Date effectuated in the plan's system.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA for requests that
were not approved (e.g., denials/ autoforwards).
Time effectuated in the plan's system.
Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA for
requests that were not approved (e.g.,
denials/ auto-forwards).
Date oral notification provided to
enrollee (or their authorized
representative). Submit in
CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if no oral
notification was provided to enrollee.
Time oral notification provided to
enrollee (or their authorized
representative). Submit in HH:MM:SS
military time format (e.g., 23:59:59).
Answer NA if no oral notification was
provided to enrollee.
Date written notification provided to
enrollee. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Answer NA if
no written notification was provided to
enrollee.
Time written notification provided to
enrollee. Submit in HH:MM:SS military
time format (e.g., 23:59:59). Answer NA
if no written notification was provided to
enrollee.
Provide the date the request was forwarded
to the IRE. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Answer NA for
timely decision or if request was not
forwarded to the IRE.
Provide the time the request was
forwarded to the IRE. Submit in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA for timely
decision or if request was not forwarded
to the IRE.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 3: Direct Member Reimbursement Request Coverage Determinations (DMRCD) Record
Layout
• Include all requests processed as coverage determination direct member reimbursement
requests.
• Exclude all requests processed as standard coverage determination requests.
• Exclude all withdrawn requests.
• Submit cases based on the date the sponsor’s decision was rendered or should have been
rendered (the date the request was initiated may fall outside of the review period).
Column
ID
A

Field Name

Field Type

Field Length

Description

Beneficiary First Name

First name of the beneficiary.

Beneficiary Last Name

Last name of the beneficiary.

Enrollment Effective
Date

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Enrollee ID

CHAR
Always
Required

Contract ID

The contract number (e.g., H1234) of the
organization.

Plan ID

The plan number (e.g., 001) of the
organization.

Date the request was
received

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Required AOR

CHAR
Always
Required

Provide the date the request was received
from the enrollee, their representative, or
their prescriber. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01).
Yes (Y)/ No (N) indicator of whether the
request was made by a representative or
someone claiming to be a representative.

Page 24 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
I

Field Name

Field Type

Field Length

Description

AOR Receipt Date

CHAR
Always
Required

Authorization or Claim
Number

CHAR
Always
Required

Issue Description

2000

Was this request
processed as an
exception?
NDC

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Date the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer None if no AOR
was received. Answer NA if no AOR
form was required.
The associated claim or payment request
number assigned by the sponsor for this
request. If a claim or payment request
number is not available, please provide
your internal tracking or case number.
Answer NA if there is no claim, payment
request or other tracking numbers
available.
Provide a description of the issue and, for
denials, an explanation of why the
decision was denied.
Exception request Yes (Y)/No (N)
indicator.

Enter the 11-Digit National Drug Code
using the NDC 11 format. Remove
special characters separating the labeler,
product, and trade package size.
When less than 11 characters or a blank
field is submitted by the pharmacy or
delegate, populate the field as submitted.
If the pharmacy submits a value greater
than 11 characters, enter “valueXeeded”
in the field.
For multi-ingredient compound claims
populate the field with the NDC of the
most expensive drug (or as submitted on
the associated PDE). When compound
claims do not include any Part D drug
products, populate the field with
“00000000000” consistent with the NDC
11 format.

Drug Name, Strength &
Dosage Form

Request Disposition

Page 25 of 56

CHAR
Always
Required
CHAR
Always
Required

150

Provide the drug name, strength, and
dosage form.

Status of the request. Valid values are:
approved, denied, IRE auto-forward,
dismissed, re-opened approved, or reopened denied. Answer NA if the request
was never resolved/processed.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
P

Field Name

Field Type

Field Length

Description

Date of plan decision

Date written
notification provided to
enrollee

CHAR
Always
Required
CHAR
Always
Required

Date reimbursement
provided

CHAR
Always
Required

Date check or reimbursement 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.

Date forwarded to IRE

CHAR
Always
Required

Provide the date the request was
forwarded to the IRE. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA for timely
decision or if request was not forwarded
to the IRE.

Page 26 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 4: Expedited Coverage Determinations (ECD) Record Layout
• Include all requests processed as expedited coverage determination requests.
• Exclude all requests processed as exception requests.
• Exclude all withdrawn requests.
• Submit cases based on the date the sponsor’s decision was rendered or should have been
rendered (the date the request was initiated may fall outside of the review period).
Field Name

Field Type

Beneficiary First
Name
Beneficiary Last
Name
Enrollment Effective
Date

CHAR Always
Required
CHAR Always
Required
CHAR Always
Required

Enrollee ID

CHAR Always
Required

Contract ID

Plan ID

Was the beneficiary
residing in a long
term care facility?

CHAR Always
Required
CHAR Always
Required
CHAR Always
Required

Date the request was
received

CHAR Always
Required

Column
ID
A
B
C

Page 27 of 56

Field
Length
50

Description

Last name of the beneficiary.

Effective date of beneficiary’s
enrollment for the PBP that the
beneficiary was enrolled in when the
coverage determination was received
Submit in CCYY/MM/DD format
(e.g., 2020/01/01).
Enter the Medicare Beneficiary
Identifier (MBI) of the enrollee. An
MBI is the non-intelligent unique
identifier that replaced the HICN on
Medicare cards as a result of The
Medicare Access and CHIP
Reauthorization Act (MACRA) of
2015. The MBI contains uppercase
alphabetic and numeric characters
throughout the 11-digit identifier and
is unique to each Medicare enrollee.
This number must be submitted
excluding hyphens or dashes.
The contract number (e.g., H1234) of
the organization.
The plan number (e.g., 001) of the
organization.
Indicate whether the beneficiary was
identified as residing in a long term
care facility when the coverage
determination was received. Valid
values are:
Y = Yes
N = No
U = Unknown
Provide the date the request was
received from the enrollee, their
representative, or their prescriber.
Submit in CCYY/MM/DD format
(e.g., 2020/01/01).

3
1

First name of the beneficiary.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
I

Field Name

Field Type

Field Length

Description

Time the request
was received

CHAR
Always
Required

Required AOR

CHAR
Always
Required

AOR Receipt Date

CHAR
Always
Required

AOR Receipt Time

CHAR
Always
Required

Issue Description

2000

NDC

CHAR
Always
Required
CHAR
Always
Required

Date the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer None if no AOR
was received. Answer NA if no AOR
form was required.
Time the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in HH:MM:SS format (e.g.,
23:45:59). Answer None if no AOR was
received. Answer NA if no AOR form
was required.
Provide a description of the issue and,
for denials, an explanation of why the
decision was denied.
Enter the 11-Digit National Drug Code
using the NDC 11 format. Remove
special characters separating the labeler,
product, and trade package size.
When less than 11 characters or a blank
field is submitted by the pharmacy or
delegate, populate the field as
submitted.
If the pharmacy submits a value greater
than 11 characters, enter “valueXeeded”
in the field.
For multi-ingredient compound claims
populate the field with the NDC of the
most expensive drug (or as submitted
on the associated PDE). When
compound claims do not include any
Part D drug products, populate the field
with “00000000000” consistent with
the NDC 11 format.

Drug Name,
Strength & Dosage
Form

Page 28 of 56

CHAR
Always
Required

150

Provide the drug name, strength, and
dosage form.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
P

Field Name

Field Type

Is this a protected class CHAR
Always
drug?
Required
CHAR
Was request initially
Always
made under the
Required
standard timeframe
but processed by the
plan under the
expedited timeframe?

Field Length

Description

Protected class drug Yes (Y)/No (N)
indicator.

Yes (Y)/No (N) indicator of whether the
initial request made under the standard
timeframe was processed under the
expedited timeframe based on updated
request to expedite from enrollee, their
authorized representative, or their
prescriber, or based on medical exigency
as determined by the sponsor. Answer
NA if the initial request was made under
the expedited timeframe.
Provide the date the request was
received to upgrade the initial standard
request to expedited from the enrollee,
their authorized representative, or their
prescriber, or the sponsor determined the
request should be expedited. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if the initial
request was made under the expedited
timeframe.
Provide the time of day the request was
received to upgrade the initial standard
request to expedited from the enrollee,
their authorized representative, or their
prescriber, or the sponsor determined the
request should be expedited. Time is in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA if the initial
request was made under the expedited
timeframe.
Status of the request. Valid values are:
approved, denied, IRE auto-forward,
dismissed, re-opened approved, or reopened denied. Answer NA if the
request was never resolved/processed.

Date request was
upgraded to
expedited

CHAR
Always
Required

Time request was
upgraded to
expedited

CHAR
Always
Required

Request Disposition

CHAR
Always
Required

Was the request
denied for lack of
medical necessity?

CHAR
Always
Required

Date of plan decision

CHAR
Always
Required

Time of plan decision

CHAR
Always
Required

Page 29 of 56

Yes (Y)/No (N) indicator of whether
request denied for lack of medical
necessity. Answer NA if the request was
not denied (i.e., approved, autoforwarded, dismissed).
Date of the plan decision (e.g., denied).
Submit in CCYY/MM/DD format (e.g.,
2020/01/01).
Time of the plan decision (e.g., denied).
Submit in HH:MM:SS military time
format (e.g., 23:59:59).

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
X

Field Name

Time effectuated in
the plan’s system

Field Type

Field Length

Description

Date effectuated in the plan's system.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA for requests
that were not approved (e.g., denials/
auto-forwards).

CHAR
Always
Required

Date oral
notification
provided to
enrollee

CHAR
Always
Required

Time oral
notification
provided to enrollee

CHAR
Always
Required

Date written
notification
provided to
enrollee

CHAR
Always
Required

Time written
notification
provided to
enrollee

CHAR
Always
Required

Date forwarded to IRE CHAR
Always
Required

Time forwarded to
IRE

Time effectuated in the plan's system.
Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA for
requests that were not approved (e.g.,
denials/ auto-forwards).
Date oral notification provided to
enrollee (or their authorized
representative). Submit in
CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if no oral
notification was provided to enrollee.
Time oral notification provided to
enrollee. Submit in HH:MM:SS military
time format (e.g., 23:59:59). Answer NA
if no oral notification was provided to
enrollee.
Date written notification provided to
enrollee. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Answer NA
if no written notification was provided
to enrollee.
Time written notification provided to
enrollee. Submit in HH:MM:SS
military time format (e.g., 23:59:59).
Answer NA if no written notification
was provided to enrollee.
Provide the date the request was
forwarded to the IRE. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA for timely
decision or if request was not forwarded
to the IRE.
Provide the time the request was
forwarded to the IRE. Submit in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA for timely
decision or if request was not forwarded
to the IRE.

Date effectuated in the CHAR
Always
plan's system
Required

Page 30 of 56

CHAR
Always
Required

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 5: Expedited Coverage Determination Exception Requests (ECDER) Record Layout
• Include all request processed as expedited coverage determination exception requests.
• Exclude all requests processed as expedited coverage determination requests.
• Exclude all withdrawn requests.
• Submit cases based on the date the sponsor’s decision was rendered or should have been
rendered (the date the request was initiated may fall outside of the review period).
Field Name

Field Type

Field Length

Description

Beneficiary First
Name
Beneficiary Last
Name
Enrollment Effective
Date

CHAR
Always
CHAR
Always
CHAR
Always
Required

First name of the beneficiary.

Last name of the beneficiary.

Enrollee ID

CHAR
Always
Required

Contract ID

Plan ID

Was the beneficiary
residing in a long
term care facility?

CHAR
Always
CHAR
Always
CHAR
Always
Required

Date the request was
received

CHAR
Always
Required

Effective date of beneficiary’s
enrollment for the PBP that the
beneficiary was enrolled in when the
coverage determination was received.
Submit in CCYY/MM/DD format
(e.g., 2020/01/01).
Enter the Medicare Beneficiary
Identifier (MBI) of the enrollee. An
MBI is the non-intelligent unique
identifier that replaced the HICN on
Medicare cards as a result of The
Medicare Access and CHIP
Reauthorization Act (MACRA) of
2015. The MBI contains uppercase
alphabetic and numeric characters
throughout the 11-digit identifier and
is unique to each Medicare enrollee.
This number must be submitted
excluding hyphens or dashes.
The contract number (e.g., H1234) of
the organization.
The plan number (e.g., 001) of the
organization.
Indicate whether the beneficiary was
identified as residing in a long term
care facility when the coverage
determination was received. Valid
values are:
Y = Yes
N = No
U = Unknown
Provide the date the request was
received from the enrollee, their
representative, or their prescriber.
Submit in CCYY/MM/DD format
(e.g., 2020/01/01).

Column
ID
A
B
C

Page 31 of 56

3
1

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
I

Field Name

Field Type

Field Length

Description

Time the request was
received

CHAR
Always
Required

Required AOR

CHAR
Always
Required

AOR Receipt Date

CHAR
Always
Required

Provide the time of day the request
was received from the enrollee, their
representative, or their prescriber.
Time is in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA if
time is not available.
Yes (Y)/ No (N) indicator of whether
the request was made by a
representative or someone claiming to
be a representative.
Date the Appointment of
Representative (AOR) form or other
appropriate documentation received
by the sponsor. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01). Answer None if no
AOR was received. Answer NA if no
AOR form was required.

AOR Receipt Time

CHAR
Always
Required

Issue Description

CHAR
Always
Required

2000

Page 32 of 56

Time the Appointment of
Representative (AOR) form or other
appropriate documentation received
by the sponsor. Submit in HH:MM:SS
format (e.g., 23:45:59). Answer None
if no AOR was received. Answer NA
if no AOR form was required.
Provide a description of the issue
and, for denials, an explanation of
why the decision was denied.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
N

Field Name

Field Type

Field Length

Description

NDC

CHAR
Always
Required

Enter the 11-Digit National Drug
Code using the NDC 11 format.
Remove special characters separating
the labeler, product, and trade
package size.
When less than 11 characters or a
blank field is submitted by the
pharmacy or delegate, populate the
field as submitted.
If the pharmacy submits a value
greater than 11 characters, enter
“valueXeeded” in the field.
For multi-ingredient compound
claims populate the field with the
NDC of the most expensive drug (or
as submitted on the associated PDE).
When compound claims do not
include any Part D drug products,
populate the field with
“00000000000” consistent with the
NDC 11 format.

Drug Name, Strength
& Dosage Form

Is this a protected
class drug?

Was request initially
made under the
standard timeframe
but processed by the
plan under the
expedited timeframe?

Page 33 of 56

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

150

Provide the drug name, strength, and
dosage form.

Protected class drug Yes (Y)/No
(N) indicator.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
R

Field Name

Field Type

Field Length

Description

Date request was
upgraded to expedited

CHAR
Always
Required

Time request was
upgraded to expedited

CHAR
Always
Required

Exception Type

CHAR
Always
Required

Formulary UM
Exception Type

CHAR
Always
Required

Provide the date the request was
received to upgrade the initial
standard request to expedited from the
enrollee, their authorized
representative, or their prescriber, or
the sponsor determined the request
should be expedited. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if the initial
request was made under the expedited
timeframe.
Provide the time of day the request
was received to upgrade the initial
standard request to expedited from the
enrollee, their authorized
representative, or their prescriber, or
the sponsor determined the request
should be expedited. Time is in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA if the initial
request was made under the expedited
timeframe.
Type of exception request. Valid values
are: tiering exception, non-formulary
exception, formulary UM exception,
hospice, and safety edit exception.
If the case was a formulary UM
exception; please indicate what
criteria the enrollee was attempting
to waive. Valid fields are: PA, ST,
or QL. Enter NA if the request was
not a formulary UM exception.

Page 34 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
V

Field Name

Field Type

Field Length

Description

List expiration date of
the approval

CHAR
Always
Required

Date prescriber
supporting statement
received

CHAR
Always
Required

Time prescriber
supporting statement
received

CHAR
Always
Required

Request Disposition

CHAR
Always
Required

Was the request
denied for lack of
medical necessity?

CHAR
Always
Required

Date of plan decision

Time of plan decision

Date effectuated in
the plan's system

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Time effectuated in
the plan’s system

CHAR
Always
Required

Expiration date of the exception
approval. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Answer NA
if the exception was not approved.
Date the prescriber's supporting
statement was received. Submit
in CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if no
prescriber supporting statement
was received.
Time the prescriber's supporting
statement was received. Submit in
HH:MM:SS military time format
(e.g., 23:59:59). Answer NA if no
prescriber supporting statement was
received.
Status of the request. Valid values
are: approved, denied, IRE autoforward, dismissed, re-opened
approved, or re-opened denied.
Answer NA if the request was never
resolved/processed.
Yes (Y)/No (N) indicator of whether
request denied for lack of medical
necessity. Answer NA if the request
was not denied (i.e., approved, autoforwarded, dismissed).
Date of the plan decision (e.g.,
denied). Submit in CCYY/MM/DD
format (e.g., 2020/01/01).
Time of the plan decision (e.g.,
denied). Submit in HH:MM:SS
military time format (e.g., 23:59:59).
Date effectuated in the plan's system.
Submit in CCYY/MM/DD format
(e.g., 2020/01/01). Answer NA if
request was not approved (e.g.
denials/ auto- forwards).
Time effectuated in the plan's
system. Submit in HH:MM:SS
military time format (e.g., 23:59:59).
Answer NA if request was not
approved (e.g., denials/ autoforwards).

Date oral notification
provided to enrollee

CHAR
Always
Required

Page 35 of 56

Date oral notification provided to
enrollee (or their authorized
representative). Submit in
CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if no oral
notification was provided to enrollee.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
AF

Field Name

Field Type

Field Length

Description

Time oral notification
provided to enrollee

CHAR
Always
Required

Date written
notification provided
to enrollee

CHAR
Always
Required

Time written
notification provided
to enrollee

CHAR
Always
Required

Date forwarded to
IRE

CHAR
Always
Required

Time forwarded to
IRE

CHAR
Always
Required

Time oral notification provided to
enrollee. Submit in HH:MM:SS
military time format (e.g., 23:59:59).
Answer NA if no oral notification was
provided to enrollee.
Date written notification provided to
enrollee. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Answer
NA if no written notification was
provided to enrollee.
Time written notification provided
to enrollee. Submit in HH:MM:SS
military time format (e.g., 23:59:59).
Answer NA if no written
notification was provided to
enrollee.
Provide the date the request was
forwarded to the IRE. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA for timely
decision or if request was not
forwarded to the IRE.
Provide the time the request was
forwarded to the IRE. Submit in
HH:MM:SS military time format
(e.g., 23:59:59). Answer NA for
timely decision or if request was not
forwarded to the IRE.

Page 36 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 6: Standard Redeterminations (SRD) Record Layout
• Include all requests processed as standard pre-service redetermination requests.
• Exclude requests processed as direct member reimbursement redetermination requests or
expedited pre-service redetermination requests.
• Exclude all withdrawn requests.
• Submit cases based on the date the sponsor’s decision was rendered or should have been
rendered (the date the request was initiated may fall outside of the review period).
Column
ID
A

Field Name

Field Type

Field Length

Description

Beneficiary First Name

First name of the beneficiary.

Beneficiary Last Name

Last name of the beneficiary.

Enrollment Effective
Date

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Enrollee ID

CHAR
Always
Required

Effective date of beneficiary’s
enrollment for the PBP that the
beneficiary was enrolled in when the
redetermination was received. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01).
Enter the Medicare Beneficiary Identifier
(MBI) of the enrollee. An MBI is the
non-intelligent unique identifier that
replaced the HICN on Medicare cards as
a result of The Medicare Access and
CHIP Reauthorization Act (MACRA) of
2015. The MBI contains uppercase
alphabetic and numeric characters
throughout the 11-digit identifier and is
unique to each Medicare enrollee. This
number must be submitted excluding
hyphens or dashes.

Contract ID

The contract number (e.g., H1234) of
the organization.

Plan ID

The plan number (e.g., 001) of the
organization.

Date the request was
received

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Required AOR

CHAR
Always
Required

Page 37 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
I

Field Name

Field Type

Field Length

Description

AOR Receipt Date

CHAR
Always
Required

Issue Description

2000

NDC

CHAR
Always
Required
CHAR
Always
Required

Date the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer None if no AOR
was received. Answer NA if no AOR
form was required.
Provide a description of the issue and,
for denials, an explanation of why the
decision was denied.
Enter the 11-Digit National Drug Code
using the NDC 11 format. Remove
special characters separating the
labeler, product, and trade package size.

When less than 11 characters or a blank
field is submitted by the pharmacy or
delegate, or NDC is not applicable (e.g.,
for at-risk redeterminations), populate
the field as submitted.
If the pharmacy submits a value greater
than 11 characters, enter
“valueXeeded” in the field.
For multi-ingredient compound claims
populate the field with the NDC of the
most expensive drug (or as submitted
on the associated PDE). When
compound claims do not include any
Part D drug products, populate the field
with “00000000000” consistent with
the NDC 11 format.

Drug Name, Strength
& Dosage Form

Is this a protected class
drug?

Was request made
under the expedited
timeframe but
processed by the plan
under the standard
timeframe?

Was this request
processed as an
exception?

Page 38 of 56

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

150

Provide the drug name, strength, and
dosage form.

Protected class drug Yes (Y)/No (N)
indicator.

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the
request made under expedited timeframe
was processed under the standard
timeframe based on plan deciding that
expedited case was unnecessary.
Answer NA if the request was made
under the standard timeframe.
Exception request Yes (Y)/No (N)
indicator.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
P

Field Name

Field Type

Field Length

Description

Exception Type

CHAR
Always
Required

Type of exception request. Valid values
are: tiering exception, non-formulary
exception, formulary UM exception,
hospice and safety edit exception. Answer
NA if request was not processed as an
exception.

List expiration date of
the approval

CHAR
Always
Required

Request Disposition

CHAR
Always
Required

Was the coverage
determination request
denied for lack of
medical necessity?
Date of plan decision

CHAR
Always
Required

Expiration date of the exception
approval. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Answer NA if
request was not processed as an
exception or if the exception was not
approved.
Status of the request. Valid values are:
approved, denied, IRE auto-forward,
dismissed, re-opened approved, or reopened denied. Answer NA if the
request was never resolved/processed.
Yes (Y)/No (N) indicator of whether
initial request denied for lack of medical
necessity.

CHAR
Always
Required
CHAR
Always
Required

Date effectuated in the
plan's system

Date written
notification provided to
enrollee

CHAR
Always
Required

Date forwarded to IRE

CHAR
Always
Required

Time forwarded to IRE

CHAR
Always
Required

Page 39 of 56

Date of the plan decision (e.g., denied).
Submit in CCYY/MM/DD format (e.g.,
2020/01/01).
Date effectuated in the plan's system.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA for requests
that were not approved (e.g.
denials/auto-forwards).
Date written notification provided to
enrollee. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Answer NA
if no written notification was provided
to enrollee.
Provide the date the request was
forwarded to the IRE. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA for timely
decision or if request was not forwarded
to the IRE.
Provide the time the request was
forwarded to the IRE. Submit in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA for timely
decision or if request was not forwarded
to the IRE.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 7: Direct Member Reimbursement Request Redeterminations (DMRRD) Record Layout
• Include all requests processed as redeterminations for direct member reimbursement
requests.
• Exclude all requests processed as pre-service redetermination requests.
• Exclude all withdrawn requests.
• Submit cases based on the date the sponsor’s decision was rendered or should have been
rendered (the date the request was initiated may fall outside of the review period).
Column
ID
A

Field Name

Field Type

Field Length

Description

Beneficiary First Name

First name of the beneficiary.

Beneficiary Last Name

Last name of the beneficiary.

Enrollment Effective
Date

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Enrollee ID

CHAR
Always
Required

Effective date of beneficiary’s enrollment
for the PBP that the beneficiary was
enrolled in when the redetermination was
received. Submit in CCYY/MM/DD
format (e.g., 2020/01/01).
Enter the Medicare Beneficiary Identifier
(MBI) of the enrollee. An MBI is the nonintelligent unique identifier that replaced
the HICN on Medicare cards as a result of
The Medicare Access and CHIP
Reauthorization Act (MACRA) of 2015.
The MBI contains uppercase alphabetic
and numeric characters throughout the 11digit identifier and is unique to each
Medicare enrollee. This number must be
submitted excluding hyphens or dashes.

Contract ID

The contract number (e.g., H1234) of the
organization.

Plan ID

The plan number (e.g., 001) of the
organization.

Date the request was
received

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Required AOR

AOR Receipt Date

CHAR
Always
Required
CHAR
Always
Required

Provide the date the redetermination
request was received from the enrollee,
their representative, or their prescriber.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01).
Yes (Y)/ No (N) indicator of whether the
request was made by a representative or
someone claiming to be a representative.
Date the Appointment of Representative
(AOR) form or other appropriate
documentation received by the sponsor.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer None if no AOR
was received. Answer NA if no AOR
form was required.

Page 40 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
J

Field Name

Field Type

Field Length

Description

Authorization or Claim
Number

CHAR
Always
Required

Issue Description

2000

Was this request
processed as an
exception?
Exception Type

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

The associated claim or payment request
number assigned by the sponsor for this
request. If a claim or payment request
number is not available, please provide
your internal tracking or case number.
Answer NA if there is no claim, payment
request or other tracking numbers
available.
Provide a description of the issue and, for
denials, an explanation of why the
decision was denied.
Exception request Yes (Y)/No (N)
indicator.

List expiration date of
the approval

CHAR
Always
Required

NDC

CHAR
Always
Required

Type of exception request. Valid values
are: tiering exception, non-formulary
exception, formulary UM exception and
hospice. Answer NA if request was not
processed as an exception.
Expiration date of the exception approval.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if request was
not processed as an exception or if the
exception was not approved.
Enter the 11-Digit National Drug Code
using the NDC 11 format. Remove
special characters separating the labeler,
product, and trade package size.
When less than 11 characters or a blank
field is submitted by the pharmacy or
delegate, populate the field as submitted.
If the pharmacy submits a value greater
than 11 characters, enter “valueXeeded”
in the field.
For multi-ingredient compound claims
populate the field with the NDC of the
most expensive drug (or as submitted on
the associated PDE). When compound
claims do not include any Part D drug
products, populate the field with
“00000000000” consistent with the NDC
11 format.

Drug Name, Strength &
Dosage Form

Page 41 of 56

CHAR
Always
Required

150

Provide the drug name, strength, and
dosage form.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
Q

Field Name

Field Type

Field Length

Description

Request Disposition

CHAR
Always
Required

Status of the request. Valid values are:
approved, denied, IRE auto-forward,
dismissed, re-opened approved, or reopened denied. Answer NA if the request
was never resolved/processed.

Was the coverage
determination request
denied for lack of
medical necessity?

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether
initial request denied for lack of medical
necessity.

Date of plan decision

Date written
notification provided to
enrollee

CHAR
Always
Required
CHAR
Always
Required

Date reimbursement
provided

CHAR
Always
Required

Date forwarded to IRE

CHAR
Always
Required

Date of the plan decision (e.g., denied).
Submit in CCYY/MM/DD format (e.g.,
2020/01/01).
Date written notification provided to
enrollee. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Answer NA if
no written notification was provided to
enrollee.
Date check or reimbursement 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.
Provide the date the request was
forwarded to the IRE. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA for timely
decision or if request was not forwarded
to the IRE.

Page 42 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 8: Expedited Redeterminations (ERD) Record Layout
• Include all requests processed as expedited redetermination requests.
• Exclude all withdrawn requests.
• Submit cases based on the date the sponsor’s decision was rendered or should have been
rendered (the date the request was initiated may fall outside of the review period).
Column
ID
A

Field Name

Field Type

Field Length

Description

Beneficiary First Name

First name of the beneficiary.

Beneficiary Last Name

Last name of the beneficiary.

Enrollment Effective
Date

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Enrollee ID

CHAR
Always
Required

Effective date of beneficiary’s
enrollment for the PBP that the
beneficiary was enrolled in when the
redetermination was received. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01).
Enter the Medicare Beneficiary Identifier
(MBI) of the enrollee. An MBI is the nonintelligent unique identifier that replaced
the HICN on Medicare cards as a result of
The Medicare Access and CHIP
Reauthorization Act (MACRA) of 2015.
The MBI contains uppercase alphabetic
and numeric characters throughout the
11-digit identifier and is unique to each
Medicare enrollee. This number must be
submitted excluding hyphens or dashes.

Contract ID

The contract number (e.g., H1234) of
the organization.

Plan ID

The plan number (e.g., 001) of the
organization.

Date the request was
received

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Time the request was
received

CHAR
Always
Required

Required AOR

CHAR
Always
Required

Provide the date the redetermination
request was received from the enrollee,
their representative, or their prescriber.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01).
Provide the time of day the
redetermination request was received
from the enrollee, their authorized
representative, or their prescriber. Time
is in HH:MM:SS military time format
(e.g., 23:59:59).
Yes (Y)/ No (N) indicator of whether the
request was made by a representative or
someone claiming to be a representative.

Page 43 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
J

Field Name

Field Type

Field Length

Description

AOR Receipt Date

CHAR
Always
Required

AOR Receipt Time

CHAR
Always
Required

Issue Description

2000

NDC

CHAR
Always
Required
CHAR
Always
Required

When less than 11 characters or a blank
field is submitted by the pharmacy or
delegate, or NDC is not applicable (e.g.,
for at-risk redeterminations), populate
the field as submitted.
If the pharmacy submits a value greater
than 11 characters, enter “valueXeeded”
in the field.
For multi-ingredient compound claims
populate the field with the NDC of the
most expensive drug (or as submitted
on the associated PDE). When
compound claims do not include any
Part D drug products, populate the field
with “00000000000” consistent with
the NDC 11 format.

Drug Name, Strength
& Dosage Form

Is this a protected class
drug?

Page 44 of 56

CHAR
Always
Required
CHAR
Always
Required

150

Provide the drug name, strength, and
dosage form.

Protected class drug Yes (Y)/No (N)
indicator.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
P

Field Name

Field Type

Field Length

Description

Was request initially
made under the
standard timeframe but
processed by the plan
under the expedited
timeframe?

CHAR
Always
Required

Date request was
upgraded to expedited

CHAR
Always
Required

Time request was
upgraded to expedited

CHAR
Always
Required

Was this request
processed as an
exception?
Exception Type

CHAR
Always
Required
CHAR
Always
Required

Exception request Yes (Y)/No (N)
indicator.

List expiration date of
the approval

CHAR
Always
Required

Request Disposition

CHAR
Always
Required

Expiration date of the exception
approval. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Answer NA if
request was not processed as an
exception or if the exception was not
approved.
Status of the request. Valid values are:
approved, denied, IRE auto-forward,
dismissed, re-opened approved or reopened denied. Answer NA if the
request was never resolved/processed.

Page 45 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Field Name

Field Type

Field Length

Description

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether
initial request denied for lack of medical
necessity.

Was the coverage
determination request
denied for lack of
medical necessity?
Date of plan decision

Time of plan decision

Date effectuated in the
plan's system

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Time effectuated in the
plan’s system

CHAR
Always
Required

Date oral notification
provided to enrollee

CHAR
Always
Required

Time oral notification
provided to enrollee

CHAR
Always
Required

Date written
notification provided
to enrollee

CHAR
Always
Required

Time written
notification provided
to enrollee

CHAR
Always
Required

Date of the plan decision (e.g., denied).
Submit in CCYY/MM/DD format (e.g.,
2020/01/01).
Time of the plan decision (e.g., denied).
Submit in HH:MM:SS military time
format (e.g., 23:59:59).
Date effectuated in the plan's system.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA for requests
that were not approved (e.g.
denials/auto-forwards).
Time effectuated in the plan's system.
Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA if
the request was not approved (e.g.,
denied/ auto-forward).
Date oral notification provided to
enrollee (or their authorized
representative).
Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if no oral
notification was provided to enrollee.
Time oral notification provided to
enrollee. Submit in HH:MM:SS military
time format (e.g., 23:59:59). Answer NA
if no oral notification was provided to
enrollee.
Date written notification provided to
enrollee. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Answer NA
if no written notification was provided
to enrollee.
Time written notification provided to
enrollee. Submit in HH:MM:SS
military time format (e.g., 23:59:59).
Answer NA if no written notification
was provided to enrollee.

Date forwarded to IRE

CHAR
Always
Required

Time forwarded to IRE

CHAR
Always
Required

Column
ID
W

Page 46 of 56

Provide the date the request was
forwarded to the IRE. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA for timely
decision or if request was not forwarded
to the IRE.
Provide the time the request was
forwarded to the IRE. Submit in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA for timely
decision or if request was not forwarded
to the IRE.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 9: Standard IRE, ALJ or MAC Determinations (SIAM) Record Layout
• Include all requests processed as standard pre-service coverage determination or
redetermination requests that were overturned by the IRE, ALJ, or MAC. This includes
requests that were auto-forwarded to the IRE and overturned by the IRE, ALJ, or MAC
(i.e., a favorable decision was rendered).
• Exclude all requests processed as reimbursement requests or expedited requests.
• Exclude all withdrawn requests.
• Submit cases based on the date of receipt of the IRE, ALJ, or MAC overturn decision (the date
the request was initiated may fall outside of the review period).
Column
ID
A

Field Name

Field Type

Field Length

Description

Beneficiary First Name

First name of the beneficiary.

Beneficiary Last Name

Last name of the beneficiary.

Enrollment Effective
Date

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Enrollee ID

CHAR
Always
Required

Contract ID

Plan ID

Issue Description

Was this request
processed as an
exception?
Drug Name, Strength
& Dosage Form

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Effective date of beneficiary’s
enrollment for the PBP that the
beneficiary was enrolled in when the
coverage determination or
redetermination was received. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01).
Enter the Medicare Beneficiary
Identifier (MBI) of the enrollee. An MBI
is the non-intelligent unique identifier
that replaced the HICN on Medicare
cards as a result of The Medicare Access
and CHIP Reauthorization Act
(MACRA) of 2015. The MBI contains
uppercase alphabetic and numeric
characters throughout the 11-digit
identifier and is unique to each Medicare
enrollee. This number must be submitted
excluding hyphens or dashes.
The contract number (e.g., H1234) of
the organization.

Page 47 of 56

The plan number (e.g., 001) of the
organization.

2000

Provide a description of the issue.

Exception request Yes (Y)/No (N)
indicator.

150

Provide the drug name, strength, and
dosage form.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
J

Field Name

Field Type

Field Length

Description

Date of receipt of
IRE/ALJ/MAC
decision

CHAR
Always
Required

Time of receipt for
IRE/ALJ/MAC
decision

CHAR
Always
Required

Date effectuated in the
plan's system

CHAR
Always
Required

Time effectuated in the
plan's system

CHAR
Always
Required

List expiration date of
the exception approval

CHAR
Always
Required

Date the sponsor received the
IRE/ALJ/MAC overturn decision.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01).
Time the sponsor received the
IRE/ALJ/MAC overturn decision.
Submit in HH:MM:SS military time
format (e.g., 23:59:59).
Date overturn decision effectuated in the
plan's system. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if not
effectuated in the plan’s system.
Time overturn decision effectuated in
the plan's system. Submit in HH:MM:SS
military time format (e.g., 23:59:59).
Answer NA if not effectuated in the
plan’s system.
Expiration date of the exception
approval. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Answer NA if
request was not processed as an
exception or if the exception was not
approved.

Page 48 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 10: Direct Member Reimbursements decided by review entity other than sponsor
(DMRRE) Record Layout
• Include all requests processed as coverage determination or redetermination reimbursement
requests that were overturned by the IRE, ALJ, or MAC. This includes requests that were
auto-forwarded to the IRE and overturned by the IRE, ALJ, or MAC (i.e., a favorable
decision was rendered).
• Exclude all withdrawn requests.
• Exclude all requests processed as pre-service coverage determination or redetermination
requests.
• Submit cases based on the date of receipt of the IRE, ALJ, or MAC overturn decision (the
date the request was initiated may fall outside of the review period).
Column
ID
A

Field Name

Field Type

Field Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Enrollment Effective
Date

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Enrollee ID

CHAR
Always
Required

Effective date of beneficiary’s enrollment
for the PBP that the beneficiary was
enrolled in when the reimbursement
(coverage determination or
redetermination) was received. Submit in
CCYY/MM/DD format (e.g., 2020/01/01).
Enter the Medicare Beneficiary Identifier
(MBI) of the enrollee. An MBI is the nonintelligent unique identifier that replaced the
HICN on Medicare cards as a result of The
Medicare Access and CHIP Reauthorization
Act (MACRA) of 2015. The MBI contains
uppercase alphabetic and numeric characters
throughout the 11-digit identifier and is
unique to each Medicare enrollee. This
number must be submitted excluding
hyphens or dashes.

Contract ID

The contract number (e.g., H1234) of the
organization.

Plan ID

The plan number (e.g., 001) of the
organization.

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Page 49 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
H

Field Name

Field Type

Field Length

Description

Issue Description

2000

Provide a description of the issue.

Was this request
processed as an
exception?
Drug Name, Strength
& Dosage Form

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Exception request Yes (Y)/No (N)
indicator.

150

Provide the drug name, strength, and
dosage form.

Date the sponsor received the
IRE/ALJ/MAC overturn decision. Submit
in CCYY/MM/DD format (e.g.,
2020/01/01).
Date that appeal entity overturn was
authorized in the plan's system. Submit in
CCYY/MM/DD format (e.g., 2020/01/01).
Answer NA if reimbursement was not
authorized.
Date check or reimbursement 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.
Expiration date of the exception approval.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if request was not
processed as an exception or if the
exception was not approved.

Date of receipt of
IRE/ALJ/MAC
decision

Date sponsor
authorized
reimbursement of
overturn decision in
their system
Date reimbursement
provided

CHAR
Always
Required

List expiration date of
the exception approval

CHAR
Always
Required

Page 50 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 11: Expedited IRE, ALJ or MAC Determinations (EIAM) Record Layout
• Include all requests processed as expedited coverage determination or redetermination requests
that were overturned by the IRE, ALJ, or MAC. This includes requests that were auto-forwarded
to the IRE and overturned by the IRE, ALJ, or MAC (i.e., a favorable decision was rendered).
• Exclude all requests processed as standard coverage determination or redetermination requests
or reimbursement requests.
• Exclude all withdrawn requests.
• Submit cases based on the date of receipt of the IRE, ALJ, or MAC overturn decision (the date the
request was initiated may fall outside of the review period).
Column
ID
A

Field Name

Field Type

Field Length

Description

Beneficiary First Name

First name of the beneficiary.

Beneficiary Last Name

Last name of the beneficiary.

Enrollment Effective
Date

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Enrollee ID

CHAR
Always
Required

Contract ID

Plan ID

Issue Description

Was this request
processed as an
exception?
Drug Name, Strength
& Dosage Form

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Page 51 of 56

The plan number (e.g., 001) of the
organization.

2000

Provide a description of the issue.

Exception request Yes (Y)/No (N)
indicator.

150

Provide the drug name, strength, and
dosage form.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
J

Field Name

Field Type

Field Length

Description

Date of receipt of
IRE/ALJ/MAC
decision

CHAR
Always
Required

Time of receipt for
IRE/ALJ/MAC
decision

CHAR
Always
Required

Date effectuated in the
plan's system

CHAR
Always
Required

Time effectuated in the
plan's system

CHAR
Always
Required

List expiration date of
the exception approval

CHAR
Always
Required

Date the sponsor received the
IRE/ALJ/MAC overturn decision.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01).
Time the sponsor received the
IRE/ALJ/MAC overturn decision.
Submit in HH:MM:SS military time
format (e.g., 23:59:59).
Date overturn decision effectuated in the
plan's system. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if overturn
decision not effectuated in the plan’s
system.
Time overturn decision effectuated in
the plan's system. Submit in HH:MM:SS
military time format (e.g., 23:59:59).
Answer NA if overturn decision not
effectuated in the plan’s system.
Expiration date of the exception
approval. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Answer NA if
request was not processed as an
exception or if the exception was not
approved.

Page 52 of 56

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 12: Standard Grievances Part D (SGD) Record Layout
• Include all requests processed as standard oral and written grievances.
• Exclude CTM complaints, however if a sponsor received both a grievance and a CTM
complaint concerning the same issue, the sponsor should include the grievance.
• Exclude all withdrawn requests.
• Submit cases based on date of resolution notification of the standard oral and written
grievances (the date the grievance was received may fall outside of the review period).
Column
ID
A

Field Name

Field Type

Beneficiary First Name

Beneficiary Last Name

Enrollment Effective
Date

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Enrollee ID

CHAR
Always
Required

Contract ID

Plan ID

Date
Grievance/Complaint
was received

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

How was the
grievance/complaint
received?

CHAR
Always
Required

Page 53 of 56

Field
Length
50

Description

Last name of the beneficiary.

Effective date of beneficiary’s
enrollment for the PBP that the
beneficiary was enrolled in when the
grievance was received. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01).
Enter the Medicare Beneficiary Identifier
(MBI) of the enrollee. An MBI is the nonintelligent unique identifier that replaced
the HICN on Medicare cards as a result of
The Medicare Access and CHIP
Reauthorization Act (MACRA) of 2015.
The MBI contains uppercase alphabetic
and numeric characters throughout the 11digit identifier and is unique to each
Medicare enrollee. This number must be
submitted excluding hyphens or dashes.
The contract number (e.g., H1234) of the
organization.

First name of the beneficiary.

The plan number (e.g., 001) of the
organization.

Date the grievance/complaint was
received from the enrollee or their
authorized representative. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01).
Describe how the grievance/complaint
was first received from the enrollee or
authorized representative. Valid fields
include: Oral or Written.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
I

Field Name

Field Type

Category of the
grievance/complaint

CHAR
Always
Required

Grievance/ Complaint
Description

1800

Was this a quality of
care grievance?

Was a timeframe
extension taken?

If an extension was
taken, did the plan
notify the member of
the reason(s) for the
delay?
If the extension was
taken because the plan
needed more
information, did the
notice include how the
delay was in the best
interest of the enrollee?
Date oral notification
provided to enrollee

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the
sponsor notified the enrollee of the
delay. Answer NA if no timeframe
extension was taken.

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the
sponsor notified the enrollee of how the
extension of the timeframe was in the
interest of the enrollee. Answer NA if no
timeframe extension was taken.

CHAR
Always
Required

Date oral notification of resolution
provided to enrollee. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if no oral
notification was provided to enrollee.
Date written notification of resolution
provided to enrollee. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if no written
notification was provided to enrollee.

Field
Length
50

Date written
notification provided to
enrollee

CHAR
Always
Required

Resolution Description

CHAR
Always
Required

1800

Page 54 of 56

Description
Describe the category of the
grievance/complaint. At a minimum,
categories must include each of the
following: Enrollment/Disenrollment;
Plan Benefits; Pharmacy Access;
Marketing; Customer Service; Coverage
Determinations/Redetermination
Process; Quality of Care; CMS Issues;
or; Other.
Provide a description of the
grievance/complaint issue.
Yes (Y)/No (N) indicator of whether the
grievance was a quality of care
grievance.
Yes (Y)/No (N) indicator of whether
grievance timeframe was extended.

Provide a full description of the
grievance resolution.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Table 13: Expedited Grievances Part D (EGD) Record Layout
• Include all requests processed as expedited oral and written grievances.
• Exclude all withdrawn requests.
• Submit cases based on date of resolution notification of the expedited oral and written
grievances (the date the grievance was received may fall outside of the review period).
Column
ID
A

Field Name

Field Type

Beneficiary First Name

Beneficiary Last Name

Enrollment Effective
Date

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Enrollee ID

CHAR
Always
Required

Contract ID

Plan ID

Date
Grievance/Complaint
was received

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Time
Grievance/Complaint
was received

CHAR
Always
Required

How was the
grievance/complaint
received?

CHAR
Always
Required

Page 55 of 56

Field
Length
50

Description

Last name of the beneficiary.

First name of the beneficiary.

The plan number (e.g., 001) of the
organization.

Date the grievance/complaint was
received from the enrollee or their
authorized representative. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01).
Time of day the grievance/complaint
was received from the enrollee or their
authorized representative. Time is in
HH:MM:SS military time format (e.g.,
23:59:59).
Describe how the grievance/complaint
was received from the enrollee or
authorized representative. Valid fields
include: Oral or Written.

v. 2-2020

Part D Coverage Determinations, Appeals, and Grievances (CDAG)
AUDIT PROCESS AND DATA REQUEST
Field Name

Field Type

Field Length

Description

Category of the
grievance/complaint

CHAR
Always
Required

Grievance/Complaint
Description

1800

Date oral notification
provided to enrollee

CHAR
Always
Required
CHAR
Always
Required

Describe the category of the
grievance/complaint. If this grievance
was over the plan’s refusal to expedite a
request, indicate Refusal to Expedite in
this field. If the sponsor expedited a
grievance for any other issue, please
indicate “other”.
Provide a description of the
grievance/complaint issue.

Time oral notification
provided to enrollee

CHAR
Always
Required

Date written
notification provided to
enrollee

CHAR
Always
Required

Time written
notification provided to
enrollee

CHAR
Always
Required

Resolution Description

CHAR
Always
Required

1800

Column
ID
J

Page 56 of 56

Date oral notification of resolution
provided to enrollee. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if no oral
notification was provided to enrollee.
Time oral notification of resolution
provided to enrollee. Submit in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA if no oral
notification was provided to enrollee.
Date written notification of resolution
provided to enrollee. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if no written
notification was provided to enrollee.
Time written notification of resolution
provided to enrollee. Submit in
HH:MM:SS military time format (e.g.,
23:59:59). Answer NA if no written
notification was provided to enrollee.
Provide a full description of the
grievance resolution.

v. 2-2020

File Type	application/pdf
File Title	Part D Coverage Determinations, Appeals and Grievances (CDAG) Program Area
Subject	AUDIT PROCESS AND DATA REQUEST
Author	CMS
File Modified	2020-02-06
File Created	2020-02-06