CMS-10191 ODAD Audit Process and Data Request

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

Attachment IV ODAGAuditProcessDataRequest

Medicare Parts C and D Program Audit Protocols and Data Requests

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Part C Organization
Determinations, Appeals, and
Grievances (ODAG) Program
Area
AUDIT PROCESS AND DATA REQUEST

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST

Table of Contents
Audit Purpose and General Guidelines ......................................................................................................... 3
Universe Preparation & Submission ............................................................................................................. 5
Audit Elements .............................................................................................................................................. 8
I. Timeliness - Organization Determinations, Appeals and Grievances (TODAG) .................................. 8
II. Appropriateness of Clinical Decision-Making & Compliance with ODA Processing Requirements10
III. Grievances and Misclassification of Requests .................................................................................. 13
IV. Dismissals ......................................................................................................................................... 15
Appendix ..................................................................................................................................................... 16
Appendix A—Organization Determinations, Appeals and Grievances (ODAG) Record Layouts ......... 16
Table 1: Standard Pre-service Organization Determinations (SOD) Record Layout .......................... 16
Table 2: Expedited Pre-service Organization Determinations (EOD) Record Layout ........................ 20
Table 3: Requests for Payment Organization Determinations (Claims) Record Layout ..................... 23
Table 4: Direct Member Reimbursement (DMR) Requests Record Layout ....................................... 25
Table 5: Standard Pre-service Reconsiderations (SREC) Record Layout ........................................... 27
Table 6: Expedited Pre-service Reconsiderations (EREC) Record Layout......................................... 30
Table 7: Requests for Payment Reconsiderations (PREC) Record Layout ......................................... 34
Table 8: Pre-service IRE Cases Requiring Effectuation (IREEFF) Record Layout ............................ 36
Table 9: IRE Payment Cases Requiring Effectuation (IREClaimsEFF) Record Layout..................... 38
Table 10: All Part C ALJ and MAC Cases Requiring Effectuation (ALJMACEFF) Record Layout 40
Table 11: Part C Oral & Written Standard Grievances (GRV_S) Record Layout .............................. 42
Table 12: Part C Oral & Written Expedited Grievances (GRV_E) Record Layout ............................ 44
Table 13: Dismissals Record Layout................................................................................................... 46

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST

Audit Purpose and General Guidelines
1. Purpose: To evaluate performance in the four areas outlined in this protocol related to Part C
Organization Determinations, Appeals and Grievances (ODAG). 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 ODAG 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 on-going
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.

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
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.
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 ODAG 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.

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
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, dismissals and
grievances and the misclassification of requests in the area of ODAG. The sponsor will provide
universes of all of its organization determinations (both payment and pre-service, both expedited and
standard), all sponsor reconsiderations (both payment and pre-service, both expedited and standard),
all requests for direct member reimbursement, all IRE, ALJ and MAC cases that required
effectuation, as well as all expedited and standard grievances.
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 ODs 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 or dismissed and 2) submitted in the
appropriate record layout as described in Appendix A. Please note that for audit purposes, partially
favorable decisions are treated as denials. These record layouts include:
•
•
•
•
•
•
•
•
•
•
•
•

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Table 1: Standard Pre-Service Organization Determinations (SOD)
Table 2: Expedited Pre-Service Organization Determinations (EOD)
Table 3: Requests for Part C Payment Organization Determinations (Claims)
Table 4: Direct Member Reimbursement (DMR) Requests
Table 5: Standard Pre-Service Reconsiderations (SREC)
Table 6: Expedited Pre-Service Reconsiderations (EREC)
Table 7: Requests for Payment Reconsiderations (PREC)
Table 8: Pre-Service IRE Cases Requiring Effectuation (IREEFF)
Table 9: IRE Payment Cases Requiring Effectuation (IREClaimsEFF)
Table 10: All ALJ and MAC Cases Requiring Effectuation (ALJMACEFF)
Table 11: Part C Oral and Written Standard Grievances (GRV_S)
Table 12: Part C Oral and Written Expedited Grievances (GRV_E)

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
•

Table 13: Dismissals (DIS)

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 1-13. 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 requests 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, as applicable.
TABLE
#

RECORD
LAYOUT

UNIVERSE

COMPLIANCE STANDARD TO
APPLY

CRITERIA
(EFF. JANUARY 1, 2020)

Standard Preservice ODs

No later than 14 days, plus 14
days (totaling 28 days) if an
extension is used.

42 CFR § 422.568(b)

EOD

Expedited Preservice ODs

No later than 72 hours, plus 14
days (totaling 17 days) if an
extension is used.

42 CFR § 422.572(a)
42 CFR § 422.572(b)
42 CFR § 422.572(c)

Claims

Requests for Part
C payment ODsClaims
(designate if the
request was a
clean claim or an
unclean claim)

SOD

DMR

SREC

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Requests for
Payment ODsDirect Member
Reimbursement
Requests
Standard Preservice
Reconsiderations

TEST

DecisionMaking
Notification
DecisionMaking
Notification
Effectuation

95% in 30 days for clean
claims and 60 days for all
other claims from noncontracted providers.

No later than 60 days.

No later than 30 days, plus 14
days (totaling 44 days) if an
extension is used for services
or items. Late and
unfavorable cases must be
forwarded to the IRE within
these timeframes.

42 CFR § 422.568(c)
42 CFR § 422.520(a)(1)
42 CFR § 422.520(a)(3)

Notification

42 CFR § 422.568(c)
42 CFR § 422.520(a)(1)
42 CFR § 422.520(a)(3)

Effectuation

42 CFR § 422.590(a)
42 CFR § 422.590(c)
42 CFR § 422.590(d)

Effectuation

Notification

IRE AutoForward
Notification

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
UNIVERSE
CRITERIA
RECORD
COMPLIANCE STANDARD TO
APPLY
(EFF. JANUARY 1, 2020)
LAYOUT

TABLE
#

EREC

PREC

IREEFF
8

IREClaimsEFF

Expedited Preservice
Reconsiderations

Requests for
Payment
Reconsiderations

Pre-service IRE
Cases Requiring
Effectuation

IRE Payment
Cases Requiring
Effectuation

ALJMACEFF

All ALJ and
MAC Cases
Requiring
Effectuation

GRV_S

Part C Oral &
Written Standard
Grievances

GRV_E

Part C Oral &
Written
Expedited
Grievances

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No later than 72 hours, plus 14
days (totaling 17 days) if an
extension is used, for services
or items. Late cases must be
forwarded to the IRE within
these timeframes.

42 CFR § 422.590(e)
42 CFR § 422.590(f)
42 CFR § 422.590(g)

No later than 60 days.
Requests that are processed
outside the required timeframe
must be forwarded to the IRE
within this timeframe.

42 CFR § 422.590(b)

No later than 14 days (for
standard requests for service),
or 72 hours (for expedited
requests for service) after
receipt of the notice of IRE
reversal.
Payment must be made no
later than 30 days after receipt
of the notice of IRE reversal.

Effectuation
IRE AutoForward
Notification

42 CFR § 422.618(b)(1)
42 CFR § 422.618(b)(3)
42 CFR § 422.619(b)

Effectuation

Effectuation
42 CFR § 422.618(b)(2)

The sponsor must pay for,
authorize, or provide the
42 CFR § 422.618(c)
service under dispute no later
42 CFR § 422.619(c)
than 60 calendar days from the
date it receives notice
reversing the initial
organization determination.
No later than 30 days plus 14
days if an extension is used
42 CFR § 422.564(e)(1)
(totaling 44 days).
42 CFR § 422.564(e)(2)

No later than 24 hours.

TEST

42 CFR § 422.564(f)

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Effectuation

Notification

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST

Audit Elements
I. Timeliness - Organization Determinations, Appeals and Grievances (TODAG)
(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 12 for a total
of 60 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. 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 the live webinar and CMS
may request the sponsor to produce screenshots of any of the following:
2.1. For requests for organization determinations or reconsiderations:
• Original pre-service or payment (i.e., claim) or reconsideration request.
• Letters, emails or documentation confirming the sponsor’s receipt of the request:
o If request was received via fax/mail/email, copy of original request including
date/time stamp of receipt.
o If request was received via phone, copy of Customer Service Representative (CSR)
notes and/or documentation of call including date/time stamp of call and call details.
• Description of the service/benefit requested from the provider/physician or the enrollee.
• Documentation of effectuation including approval in organization
determinations/reconsiderations systems and evidence of effectuation in sponsor’s claims
adjudication system, clearly showing date and time override was entered.
• Documentation showing approval notification to the enrollee and/or their representative and
physician/provider, as applicable.
o Copy of the written decision letter and documentation of date/time letter was printed
and mailed.
o If oral notification was given, copy of CSR notes and/or documentation of call
including date/time of call.
• Records indicating that payments were made/issued such as Electronic Fund Transfer (EFT)
records.
• Documentation showing denial notification to the enrollee and/or their representative and
provider/physician, if applicable:
o Copy of written decision letter and documentation of date/time letter was printed and
mailed;
o If oral notification was given, copy of CSR notes and/or documentation of call
including date/time of call.
• 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 a reconsidered case was untimely, include the following:
o Documentation showing when the sponsor auto-forwarded the request to the IRE.
2.2. For cases overturned by the 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 organization
determinations/reconsiderations system(s) and evidence of effectuation in sponsor claims
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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
system clearly showing date/time the override was entered.
Copy of reconsideration effectuation notice to IRE including sent date/time stamp.
 Screen print of all claims for the requested service after approval date
• If denied, explanation why the service was denied (i.e., exceeds authorized number of
visits).
• If there are no claims for service after date of effectuation, narrative explaining
member has not attempted to receive the service since the date of effectuation and a
screen print showing all claims for members since date of effectuation.

3. Apply Compliance Standards: 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 ODAG requirements not being met.
3.1. Universe Accuracy Standard: CMS will test each of the 12 universes by confirming the data
through the 5 selected cases (60 total cases). The integrity of the universe will be questioned if
the timeliness data on more than 1 of the 5 selected 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.
3.1.1.

Are the dates and times observed during the webinar in the sponsor’s systems
consistent with the universe submission?

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 organization
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.
3.2.1.

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
12 universes supplied during the live audit portion of the review; including if any conditions will be
cited, and if so which condition(s).

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
II. Appropriateness of Clinical Decision-Making & Compliance with Organization
Determinations and Appeals Processing Requirements
1. Select Sample Cases: CMS will select a targeted sample of 35 cases total that appear clinically
significant from the pre-service and payment requests and IRE/ALJ/MAC reversal record layouts
(Appendix A, Tables 1 through 10). CMS will attempt to ensure, to the extent possible, that the
sample set is representative of various medical services (e.g., ER services, outpatient hospital,
inpatient hospital, urgent care, etc.). CMS will generally select the sample set from the universe
categories as follows:
•
•
•
•

10 organization determination denials (5 pre-service and 5 payment);
10 reconsideration denials (5 pre-service and 5 payment);
10 IRE, ALJ, or MAC overturns (5 pre-service and 5 payment); and
5 reconsideration approvals (standard and expedited).

Note: For audit purposes, partially favorable decisions are treated as denials.
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 webinar and CMS may request the sponsor to produce
screenshots of any of the following:
2.1. For requests for organization determinations or reconsiderations:
• Original pre-service or payment (i.e., claim or reimbursement request) or reconsideration
request.
• Letters, emails or documentation confirming the sponsor’s receipt of the request:
o If request was received via fax/mail/email, copy of original request.
o If request was received via phone, copy of CSR notes and/or documentation of call.
• Description of the service/benefit requested from the provider/physician or the enrollee.
• Notices, letters, call logs or other documentation showing the sponsor requested additional
information (if applicable) from the requesting provider/physician, including type of
communication. If the request was made via phone call, copy of the call log detailing what
was communicated to the physician/provider.
• All supplemental information submitted by the requesting provider/physician or enrollee.
o If information was received via fax/mail/email, copy of original request.
o If information was received via phone, copy of CSR notes and/or documentation of
call.
• Documentation of case review steps including name and title of final reviewer; rationale for
denial; any reference to CMS guidance, Federal Regulations, clinical criteria, peer reviewed
literature (where allowed), and sponsor documents (e.g., EOC); or any other documentation
used when considering the request.
• Documentation of effectuation including approval in organization
determinations/reconsiderations systems and evidence of effectuation in sponsor’s claims
adjudication system.
• Documentation showing approval notification to the enrollee and/or their representative and
physician/provider, as applicable.
o Copy of the written decision letter;
o If oral notification was given, copy of CSR notes and/or documentation of call.
• Records indicating that payments were made/issued such as EFT records.

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
•

•

•
•

Documentation showing denial notification to the enrollee and/or their representative and
provider/physician, if applicable:
o Copy of written decision letter;
o If oral notification was given, copy of CSR notes and/or documentation of call.
Documentation showing reconsideration denial notification to the enrollee and/or their
representative and provider/physician, if applicable:
o Copy of written decision letter;
o If oral notification was given, copy of CSR notes and/or documentation of call.
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 reconsidered case was untimely, include the following:
o Documentation showing the sponsor auto-forwarded the request to the IRE.

2.2. IRE, ALJ or MAC Overturns:
• Copy of overturn notice from IRE/ALJ/MAC.
• Documentation of effectuation including approval in organization
determinations/reconsiderations system(s) and evidence of effectuation in sponsor claims
system.
• Copy of effectuation notice to IRE.
• Screen print of all claims for the requested service after approval date
• If denied, explanation why the service was denied (i.e., exceeds authorized
number of visits).
• If there are no claims for service after date of effectuation, narrative
explaining member has not attempted to receive the service since the date
of effectuation and a screen print showing all claims for members since
date of effectuation.
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 ODAG requirements not being met.
3.1. Clinical Appropriateness/Approvals:
3.1.1.

3.1.2.
3.1.3.
3.1.4.
3.1.5.

Was appropriate notification (i.e., correct notice and approval language understandable
for enrollee) provided to the enrollee (or representative) and provider/physician, if
applicable?
If representative received response, was an appointment of representative (AOR), or
other conforming instrument, on file?
Did the sponsor appropriately consider clinical information and comply with CMS
coverage and notification requirements?
Did the sponsor make reasonable and diligent efforts to obtain all medical records and
other pertinent documentation within the required timeframes, as necessary?
Did the sponsor effectuate the request in its system?

3.2. Clinical Appropriateness/Denials:
3.2.1.

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Was appropriate notification (i.e., correct notice and denial language understandable for
enrollee; appeal rights for non-contract providers) provided to the enrollee (or
representative) and provider/physician, if applicable?

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3.2.2.
3.2.3.

3.2.4.
3.2.5.
3.2.6.
3.2.7.

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
If representative received response, was an appointment of representative (AOR), or
other conforming instrument, on file?
Was the organization determination request reviewed by a physician or other appropriate
health care professional with sufficient medical and other expertise including knowledge
of Medicare coverage criteria?
Was the reconsideration reviewed by a different physician with expertise in the field of
medicine that is appropriate for the services at issue?
Did the sponsor appropriately consider clinical information and comply with CMS
coverage and notification requirements?
Did the sponsor make reasonable and diligent efforts to obtain all medical records and
other pertinent documentation within the required timeframes, as necessary?
If care or services were provided by a contract provider or a provider referred by a
contract provider, was the member held harmless, unless notice was provided that
services would not be covered?

3.3. IRE, ALJ or MAC Overturns: If a reviewer determines the IRE, ALJ or MAC reversal was in
error, the case will pass. For all other IRE, ALJ and MAC cases, apply the following compliance
criteria:
3.3.1.
3.3.2.

Did the IRE, ALJ or MAC receive additional information that would have changed the
sponsor’s decision to deny the case?
Did the sponsor attempt to obtain that information?

4. Sample Case Results: CMS will test each of the 35 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.

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
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 11 and 12). If the sponsor does not have enough expedited grievances, the auditors sample
additional cases from the standard grievance universe.
2. Review Sample Case Documentation: CMS will review all sample case 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 CMS may request the sponsor to produce screenshots or
transcripts of any of the following:
2.1. For Grievances:
• Initial Complaint:
o If complaint was received via fax/mail/email, copy of original complaint
including date/time stamp of receipt;
o If complaint was received via phone, copy of CSR notes and/or documentation of
call including date/time of call and call details.
• Any documentation explaining the issue.
• Where applicable, copy of all notices, letters, call logs, or other documentation If the request was
made via phone call, copy of the CSR notes and/or documentation of call, as well as what was
communicated to the enrollee.
• Documentation of all supplemental information submitted by enrollee and/or their representative:
o If information was received via fax/mail/email, copy of documentation
provided including date/time stamp of receipt;
o If information was received via phone, copy of CSR notes and/or documentation of
call including date/time of call and call details.
• Documentation showing the steps the sponsor took to resolve the issue and a description of
the final resolution. Documentation showing the steps the sponsor took to resolve the issue
may include, but is not limited to, appropriate correspondence with other departments within
the organization; referral to the sponsor’s fraud, waste, and abuse department; and outreach to
providers.
• Documentation showing the sponsor’s investigation, follow-up steps, and description of the
final grievance outcome. Include all notices, letters, and beneficiary communications.
• Documentation showing resolution notification to the enrollee and/or their representative:
o Copy of the written decision letter sent and documentation of date/time letter was
printed and mailed.
o If oral notification was given, copy of CSR notes and/or documentation of call
including date/time stamp.
• For quality of care grievances: provide documentation that supports that an investigation
and appropriate follow up (including issuance of written notice) took place.
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 ODAG requirements not being met.
3.1. Was the grievance or call correctly classified, and, if not, was it transferred to the
appropriate process?
3.2. For grievances, did the grievance notification appropriately address all issues raised in
the complaint?
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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.

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IV. Dismissals
1. Select Sample Cases: CMS will select a targeted sample of 15 dismissals as follows:
•
•
•

5 pre-service dismissals;
5 payment dismissals; and
5 grievances.

2. Review Sample Case Documentation: For each case, the sponsor must be able to access all relevant
documentation during the webinar and provide screen shots of any applicable documentation,
including, but not limited to:
• The pre-service or payment (i.e., claim) organization determination request.
• The pre-service or payment reconsideration request.
• Letters, emails or documentation confirming the sponsor’s receipt of the request.
• Notices, letters, or other documentation showing the sponsor requested additional information
and/or attempted to obtain the missing documentation (i.e., the Waiver of Liability (WOL) or
Appointment of Representative (AOR), or other conforming instrument) from the requesting
provider/physician or purported representative, including date, time and type of communication.
• All supplemental information submitted by the requesting provider/physician or representative,
including documentation showing when the information was received by the sponsor.
• Written notice of dismissal.
• If applicable, providing timely notification of dismissals to enrollees or another party, and
informing enrollees and other parties about the right to request IRE review of the
dismissal since sponsors will no longer automatically forward such reconsideration cases
to the IRE for review.
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 ODAG requirements not being met.
3.1. Did the sponsor make a reasonable effort to obtain the AOR (or other conforming
instrument) or WOL and document those efforts in the case file?
3.2. Did the sponsor send a written notice of the dismissal to the parties at their last known
addresses within the applicable adjudication timeframe pursuant to the requirements of 42
CFR Part 422, Subpart M?
3.3. Did the dismissal notice state the reason for the dismissal?
3.4. Did the dismissal notice explain the right to request IRE review of the dismissal within 60
calendar days after receipt of the written notice of the sponsor’s dismissal?
3.5. If applicable, did the sponsor assemble and forward the case file to the IRE within 24 hours
of receiving the IRE’s case file request?
4. Sample Case Results: CMS will test each of the 15 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.

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Appendix
Appendix A—Organization Determinations, Appeals, and Grievances (ODAG)
Record Layouts
The universes for the Part C Organization Determination, Appeals and Grievances (ODAG) program
area must be submitted as a Microsoft Excel (.xlsx) file with a header row reflecting the field names or
Text (.txt) file without a header row. 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 cases in your universes are populated based on the
time zone where the request was received.
If you do not 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 and spaces count toward this 4,000
character limit. Therefore, should additional characters be needed for a variable, enter this information on
the next record at the appropriate start position.
Table 1: Standard Pre-service Organization Determinations (SOD) Record Layout
• Include all requests processed as standard pre-service organization determinations, including
all supplemental services, such as dental and vision, and include all approvals and denials.
• Exclude payment requests, dismissals, reopenings, withdrawn requests, all requests processed as
expedited organization determinations, and all requests that do not require a prior authorization.
• Exclude requests for concurrent review for inpatient hospital and SNF services, post-service
reviews, and notifications of admissions.
• 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).
• If a standard pre-service organization determination includes more than one service include all
of the request’s line items in a single row and enter the multiple line items as a single
organization determination request.
Column
ID

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

CHAR
Always
Required
CHAR
Always
Required

Last name of the beneficiary.

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Column
ID

Field Name

Field Type

Field
Length

Description

Enrollee ID

CHAR
Always
Required

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

Who made the
request?

CHAR
Always
Required

The associated authorization number assigned by
the sponsor for this request. If an authorization
number is not available, please provide your
internal tracking or case number. Answer NA if
there is no authorization or other tracking number
available.
Indicate whether the pre-service request was
made by a contract provider (CP), non-contract
provider (NCP), beneficiary (B) or beneficiary’s
representative (BR).
Note: the term “provider” encompasses
physicians and facilities.
Indicate whether the provider performing the
service is a contract provider (CP) or non-contract
provider (NCP).

Provider Type

CHAR
Always
Required

Date the request was
received

CHAR
Always
Required

Provide the date the request was received by your
organization. Submit in CCYY/MM/DD format
(e.g., 2020/01/01).

Diagnosis

CHAR
Always
Required

100

Issue description and
type of service

CHAR
Always
Required

2,000

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Column ID Field Name

Field Type

Field
Length

Description

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the request
was made under an expedited timeframe but was
processed under the standard timeframe.

CHAR
Always
Required
CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the sponsor
extended the timeframe to make the organization
determination.
Yes (Y)/No (N) indicator of whether the sponsor
notified the beneficiary of the delay. Answer NA
if no extension was taken.

CHAR
Always
Required

Was request made
under the expedited
timeframe but
processed by the plan
under the standard
timeframe?
Was a timeframe
extension taken?
If an extension was
taken, did the sponsor
notify the member of
the reason(s) for the
delay and of their right
to file an expedited
grievance?
Request Disposition

Date of sponsor
decision

CHAR
Always
Required

Was the request
denied for lack of
medical necessity?

CHAR
Always
Required

Date oral notification
provided to enrollee

CHAR
Always
Required

Date written
notification provided
to enrollee

CHAR
Always
Required

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

Date service
authorization
entered/effectuated in
the sponsor's system
AOR receipt date

CHAR
Always
Required

Date service authorization entered in the sponsor's
system. Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA for denials.

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 NA if no AOR form
was required.

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Column
ID

Field Name

Field Type

Field
Length

Description

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Insert the name of the First Tier, Downstream,
and Related Entity that processed the standard
pre-service organization determination (e.g.,
Independent Physician Association, Physicians
Medical Group or Third Party Administrator).
Answer NA if not applicable.

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Table 2: Expedited Pre-service Organization Determinations (EOD) Record Layout
• Include all requests processed as expedited pre-service organization determinations, including all
supplemental services, such as dental and vision, and include all approvals and denials.
• Exclude payment requests, dismissals, reopenings, withdrawn requests, all requests processed as
standard organization determinations, and all requests that do not require a prior authorization.
• Exclude requests for concurrent review for inpatient hospital and SNF services, post-service
reviews, and notifications of admissions.
• 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).
• If an expedited pre-service organization determination includes more than one service include all
of the request’s line items in a single row and enter the multiple line items as a single
organization determination request.
Column
ID

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Enrollee ID

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Contract ID

Plan ID

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

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.

Who made the
request?

CHAR
Always
Required

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

The associated authorization number assigned by
the sponsor for this request. If an authorization
number is not available, please provide your
internal tracking or case number. Answer NA if
there is no authorization or other tracking number
available.
Indicate whether the pre-service request was made
by a contract provider (CP), non-contract provider
(NCP), beneficiary (B) or beneficiary’s
representative (BR).
Note: the term “provider” encompasses physicians
and facilities.

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Column
ID

Field Name

Field Type

Field
Length

Description

Provider Type

CHAR
Always
Required

Indicate whether the provider performing the service
is a contract provider (CP) or non-contract provider
(NCP).

Date the request was
received

CHAR
Always
Required

Provide the date the request was received by your
organization. Submit in CCYY/MM/DD format
(e.g., 2020/01/01).
Note: If the request was received as a standard
organization determination request, but later
expedited, enter the date of the request to expedite
the organization determination.

Time the request was
received

CHAR
Always
Required

Diagnosis

CHAR
Always
Required

100

Issue description and
type of service

CHAR
Always
Required

2,000

Was a timeframe
extension taken?

If an extension was
taken, did the sponsor
notify the member of
the reason(s) for the
delay and of their right
to file an expedited
grievance?
Request
Disposition

CHAR
Always
Required
CHAR
Always
Required

CHAR
Always
Required

Date of sponsor
decision

Page 21 of 47

CHAR
Always
Required

Provide the time the request was received by your
organization. Submit in HH:MM:SS military time
format (e.g., 23:59:59).
Note: If the request was received as a standard
organization determination request, but later
expedited, enter the time of the request to expedite
the organization determination.
Provide the enrollee diagnosis/diagnoses ICD-10
codes related to this request. If the ICD codes are
unavailable, provide a description of the diagnosis,
or for drugs provide the 11-digit National Drug
Code (NDC) as well as the ICD-10 code related to
the request.
Provide a description of the service, medical
supply or drug requested and why it was requested
(if known). For denials, also provide an
explanation of why the expedited pre-service
request was denied.
Yes (Y)/No (N) indicator of whether the Sponsor
extended the timeframe to make the organization
determination.
Yes (Y)/No (N) indicator of whether the sponsor
notified the beneficiary of the delay. Answer NA if
no extension was taken.

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Time of sponsor
decision

CHAR
Always
Required

Was the request
denied for lack of
medical necessity?

CHAR
Always
Required

Date oral notification
provided to enrollee

CHAR
Always
Required

Time of the sponsor decision (e.g., approved,
denied). Submit in HH:MM:SS military time
format (e.g., 23:59:59). Sponsors should answer
NA for untimely cases that are still open.
Yes (Y)/No (N) indicator of whether the request
was denied for lack of medical necessity. Answer
NA if the request was approved. Answer No if the
request was denied because it was untimely.
Date oral notification provided to enrollee. Submit
in CCYY/MM/DD format (e.g., 2020/01/01).
Answer NA if no oral notification.

Time oral notification
provided to enrollee

Date written
notification provided
to enrollee

CHAR
Always
Required
CHAR
Always
Required

Time written
notification provided
to enrollee

CHAR
Always
Required

Date service
authorization
entered/effectuated in
the sponsor's system
Time service
authorization
entered/effectuated in
the sponsor's system
AOR receipt date

CHAR
Always
Required

AOR receipt time

CHAR
Always
Required

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Page 22 of 47

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.
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.
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.
Date service authorization was entered in the
sponsor's system. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Answer NA for denials.
Time service authorization entered in the
sponsor's system. Submit in HH:MM:SS military
time format (e.g., 23:59:59). Answer NA for
denials.
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 NA if no AOR form
was required.
Time the Appointment of Representative (AOR)
form or other appropriate documentation received
by sponsor. Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA if no AOR
form was required.
Insert the name of the First Tier, Downstream,
and Related Entity that processed the expedited
organization determination (e.g., Independent
Physician Association, Physicians Medical Group
or Third Party Administrator). Answer NA if not
applicable.

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 3: Requests for Payment Organization Determinations (Claims) Record Layout
• Include all requests processed as both contract and non-contract provider denied claims and only
non-contract provider paid claims.
• Exclude all requests processed as direct member reimbursements, dismissals, duplicate claims
and payment adjustments to claims, reopenings, claims denied for invalid billing codes, denied
claims for beneficiaries who are not enrolled on the date of service, withdrawn requests and
claims denied due to recoupment of payment.
• Submit payment organization determinations (claims) based on the date the claim was paid, or
should have been paid, or the notification date of the denial, or the date the denial notification
should have been sent (the date the request was initiated may fall outside of the review period).
• If a claim has more than one line item, include all of the claim’s line items in a single row and
enter the multiple line items as a single claim.
Column
ID

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Enrollee ID

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Contract ID

Plan ID

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

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.

Provider Type

CHAR
Always
Required

Is this a clean claim?

Page 23 of 47

CHAR
Always
Required

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

Note: the term “provider” encompasses physicians
and facilities.
Yes/No indicator flag to indicate whether the claim
is clean (Y) or unclean (N). Answer NA for
untimely requests that are still open or if clean
status has not yet been determined.

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
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Column
ID

Field Name

Field Type

Field
Length

Description

Date the request was
received

CHAR
Always
Required

Provide the date the payment request was received
by your organization. Submit in CCYY/MM/DD
format (e.g., 2020/01/01).

Diagnosis

CHAR
Always
Required

100

Issue description and
type of service

CHAR
Always
Required

2,000

Request Disposition

CHAR
Always
Required

Date the claim was
paid

CHAR
Always
Required

Was interest paid on
the claim?

Was the request
denied for lack of
medical necessity?

CHAR
Always
Required
CHAR
Always
Required

Date written
notification provided
to enrollee

CHAR
Always
Required

Date written
notification provided
to provider

CHAR
Always
Required

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Page 24 of 47

Status of the request. Valid values are: approved,
or denied. Sponsors should note any requests that
are untimely and not yet resolved (still
outstanding) as denied.
All untimely and pending cases should be treated
as denials for the purposes of populating the rest
of this record layout’s fields.
Date the claim was paid. Submit in
CCYY/MM/DD format (e.g., 2020/01/01).
Answer DENIED for claims that were denied.
Answer NA for untimely cases that are still open.
Yes (Y)/No (N) indicator of whether interest was
paid on the claim.
Yes (Y)/No (N) indicator of whether the request
was denied for lack of medical necessity. Answer
NA if the request was approved. Answer No if the
request was denied because it was untimely.
Date written notification provided to enrollee.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer Pending if written
notification has not yet been provided, but is
anticipated to be provided in a forthcoming EOB
or IDN notice. Answer NA if no written
notification provided to the enrollee.
Date written notification provided to the provider.
Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if no written notification
was provided.
Insert the name of the First Tier, Downstream,
and Related Entity that processed the claim (e.g.,
Independent Physician Association, Physicians
Medical Group or Third Party Administrator).
Answer NA if not applicable.

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
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Table 4: Direct Member Reimbursement (DMR) Requests Record Layout
• Include all requests processed as direct member reimbursements, including approvals, denials,
partial approvals, reconsiderations and non-contract provider claim reconsiderations submitted
by beneficiaries.
• Exclude all requests processed as contract and non-contract provider claims, reopenings
and dismissals.
• Exclude requests for concurrent review for inpatient hospital and SNF services, post-service
reviews, withdrawn requests, and notifications of admissions.
• Submit direct member reimbursement requests based on the date the reimbursement was
issued, or should have been issued, or the notification date of the denial, or the date the
denial notification should have been sent (the date the request was initiated may fall outside
of the review period).
• If a reimbursement request has more than one line item, include all of the request’s line items
in a single row and enter the multiple line items as a single reimbursement request.
Column
ID

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Enrollee ID

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

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.

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Person who made the
request

Provider Type

CHAR
Always
Required
CHAR
Always
Required

Page 25 of 47

Indicate whether the provider who performed the
service is a contract provider (CP) or non-contract
provider (NCP).

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Date the request was
received

CHAR
Always
Required

Provide the date the reimbursement request was
received by your organization. Submit in
CCYY/MM/DD format (e.g., 2020/01/01).

Diagnosis

CHAR
Always
Required

100

Issue description and
type of service

CHAR
Always
Required

2,000

Request Disposition

CHAR
Always
Required

Date reimbursement
paid

CHAR
Always
Required

Was interest paid on
the reimbursement
request?

CHAR
Always
Required

Date written
notification provided
to enrollee

CHAR
Always
Required

Date forwarded to IRE
if denied or untimely

CHAR
Always
Required

AOR receipt date

CHAR
Always
Required

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Page 26 of 47

Status of the request. Valid values are: approved,
denied, denied with IRE auto forward or IRE autoforward due to untimely decision. Sponsors should
note any requests that are untimely and not yet
resolved (still outstanding) as denied.
All untimely and pending cases should be treated as
denials for the purposes of populating the rest of this
record layout’s fields.
Date the sponsor issued payment to the member or
provider. Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer DENIED for reimbursement
requests that were denied. Sponsors should answer
NA for untimely cases that are still open.
Yes (Y)/No (N) indicator of whether interest was paid
on the reimbursement request.
Date written notification provided to enrollee.
Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Answer Pending if written notification has not yet
been provided, but is anticipated to be provided in a
forthcoming EOB notice. Answer Untimely if
reimbursement request was not timely paid or denied.
Date the sponsor forwarded request to the IRE if
request denied or untimely. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Answer
NA if approved, request was an organization
determination or not forwarded to IRE.
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 NA if no AOR form was
required.
Insert the name of the First Tier, Downstream, and
Related Entity that processed the direct member
reimbursement request (e.g., Independent Physician
Association, Physicians Medical Group or Third Party
Administrator). Answer NA if not applicable.

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Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 5: Standard Pre-service Reconsiderations (SREC) Record Layout
• Include all requests processed as standard pre-service reconsiderations.
• Exclude all requests processed as expedited reconsiderations, dismissals, reopenings
and withdrawn reconsideration requests.
• Exclude requests for concurrent review for inpatient hospital and SNF services, post-service
reviews, and notifications of admissions.
• 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

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Enrollee ID

CHAR
Always
Required
CHAR
Always
Required
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.

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Who made the
request?

CHAR
Always
Required

Provider Type

CHAR
Always
Required

Date the request was
received

CHAR
Always
Required

Page 27 of 47

Note: the term “provider” encompasses physicians
and facilities.
Indicate whether the provider performing the service
is a contract provider (CP) or non-contract provider
(NCP).
Provide the date the request was received by your
organization. Submit in CCYY/MM/DD format (e.g.,
2020/01/01).

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Diagnosis

CHAR
Always
Required

100

Issue description and
type of service

CHAR
Always
Required

2,000

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

CHAR
Always
Required

CHAR
Always
Requested

Was a timeframe
extension taken?

If an extension was
taken, did the sponsor
notify the member of
the reason(s) for the
delay and of their right
to file an expedited
grievance?
Request Disposition

CHAR
Always
Required
CHAR
Always
Required

Provide a description of the service, medical supply or
drug requested and why it was requested (if known).
For denials, also provide an explanation of why the
pre-service reconsideration was denied.
Yes (Y)/No (N) indicator of whether the request made
under an expedited timeframe was processed under
the standard timeframe (e.g., based on the sponsor
deciding that the expedited pre-service request was
unnecessary). Answer NA if the request was received
as a standard request.
If an expedited timeframe was requested, indicate
who requested the expedited reconsideration
timeframe: non-contract provider (NCP), beneficiary
(B) or beneficiary’s representative (BR). Answer NA
if no expedited timeframe was requested. Answer BR
if a contract provider submitted an expedited
reconsideration request as the enrollee’s
representative.
Yes (Y)/No (N) indicator of whether the Sponsor
extended the timeframe to make the determination.

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

CHAR
Always
Required

Date of sponsor
decision

CHAR
Always
Required

Was the
organization
determination
denied for lack of
medical necessity?

CHAR
Always
Required

Page 28 of 47

All untimely and pending cases should be treated as
denials for the purposes of populating the rest of this
record layout’s fields.
Date of the sponsor decision. Submit in
CCYY/MM/DD format (e.g., 2020/01/01).
Sponsors should answer NA for untimely cases that
are still open.
Yes (Y)/No (N) indicator of whether the initial
request was denied for lack of medical necessity.
Answer No if the initial request was denied because
it was untimely.

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Date written
notification provided
to enrollee/provider

CHAR
Always
Required

Date written notification provided to enrollee, if the
decision was favorable, or if applicable, the noncontract provider. Submit in CCYY/MM/DD format
(e.g., 2020/01/01). Otherwise, answer NA if denied
or no written notification was provided.

Date service
authorization
entered/effectuated in
the sponsor's system
Date forwarded to IRE
if denied or untimely

CHAR
Always
Required

Date authorization entered in the sponsor's system.
Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Answer NA for denials and IRE auto-forwards.

CHAR
Always
Required

AOR receipt date

CHAR
Always
Required

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Date the sponsor forwarded request to the IRE if
request denied or untimely. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Answer
NA if approved or not forwarded to IRE.
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 NA if no AOR form was
required.
Insert the name of the First Tier, Downstream, and
Related Entity that processed the standard pre-service
reconsideration (e.g., Independent Physician
Association, Physicians Medical Group or Third Party
Administrator). Answer NA if not applicable.

Page 29 of 47

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 6: Expedited Pre-service Reconsiderations (EREC) Record Layout
• Include all requests processed as expedited pre-service reconsiderations.
• Exclude all requests processed as standard reconsiderations, dismissals, reopenings
and withdrawn reconsideration requests.
• Exclude requests for concurrent review for inpatient hospital and SNF services, post-service
reviews, and notifications of admissions.
• 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

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Enrollee ID

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Contract ID

Plan ID

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Who made the
request?

CHAR
Always
Required

Provider Type

Page 30 of 47

CHAR
Always
Required

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

Note: the term “provider” encompasses physicians
and facilities.
Indicate whether the provider performing the service
is a contract provider (CP) or non-contract provider
(NCP).

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Date the request was
received

CHAR
Always
Required

Time the request was
received

CHAR
Always
Required

Provide the date the request was received by your
organization. Submit in CCYY/MM/DD format (e.g.,
2020/01/01).
Note: If the request was received as a standard
reconsideration request, but later expedited, enter the
date of the request to expedite the reconsideration.
Provide the time the request was received by your
organization. Submit in HH:MM:SS military time
format (e.g., 23:59:59).
Note: If the request was received as a standard
reconsideration request, but later expedited, enter the
time of the request to expedite the reconsideration.

Diagnosis

CHAR
Always
Required

100

Issue description and
type of service

CHAR
Always
Required

2,000

Request for expedited
timeframe

CHAR
Always
Requested

Was a timeframe
extension taken?

If an extension was
taken, did the sponsor
notify the member of
the reason(s) for the
delay and of their right
to file an expedited
grievance?
Request Disposition

CHAR
Always
Required
CHAR
Always
Required

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

CHAR
Always
Required

Provide the enrollee diagnosis/diagnoses ICD-10
codes related to this request. If the ICD codes are
unavailable, provide a description of the diagnosis, or
for drugs provide the 11-digit National Drug Code
(NDC) as well as the ICD-10 code related to the
request.
Provide a description of the service, medical supply
or drug requested and why it was requested (if
known). For denials, also provide an explanation of
why the expedited pre-service reconsideration was
denied.
If an expedited timeframe was requested, indicate
who requested the expedited reconsideration
timeframe: contract provider (CP), non-contract
provider (NCP), beneficiary (B), beneficiary’s
representative (BR) or sponsor (S). Answer BR if a
contract provider submitted the expedited
reconsideration request on behalf of an enrollee.
Yes (Y)/No (N) indicator of whether the Sponsor
extended the timeframe to make the determination.

All untimely and pending cases should be treated as
denials for the purposes of populating the rest of this
record layout’s fields.

Page 31 of 47

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Date of sponsor
decision

CHAR
Always
Required

Time of sponsor
decision

CHAR
Always
Required

Was the
organization
determination
denied for lack of
medical necessity?
Date oral notification
provided to enrollee

CHAR
Always
Required

Date of the sponsor decision. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Sponsors
should answer NA for untimely cases that are still
open.
Time of the sponsor decision (e.g., approved or
denied). Submit in HH:MM:SS military time format
(e.g., 23:59:59). Sponsors should answer NA for
untimely cases that are still open.
Yes (Y)/No (N) indicator of whether the initial
request was denied for lack of medical necessity.
Answer No if the initial request was denied because
it was untimely.

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 service
authorization
entered/effectuated in
the sponsor's system
Time service
authorization
entered/effectuated in
the sponsor's system
Date forwarded to IRE
if denied or untimely

CHAR
Always
Required

AOR receipt date

CHAR
Always
Required

Page 32 of 47

Date oral notification provided to enrollee, if
decision was favorable. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Otherwise, answer NA if
no oral notification was provided.
Time oral notification provided to enrollee, if
decision was favorable. Submit in HH:MM:SS
military time format (e.g., 23:59:59). Otherwise,
answer NA if no oral notification was provided.
Date written notification provided to enrollee, if the
decision was favorable. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Otherwise, answer NA if
denied or no written notification was provided.
Time written notification provided to enrollee, if
decision was favorable. Submit in HH:MM:SS military
time format (e.g., 23:59:59). Otherwise, answer NA if
denied or no written notification was provided.
Date authorization entered/effectuated in the sponsor's
system. Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA for denials and IRE autoforwards.
Time authorization entered/effectuated in the
sponsor's system. Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA for denials and
IRE auto-forwards.
Date the sponsor forwarded request to the IRE if
request denied or untimely. Submit in
CCYY/MM/DD format (e.g., 2020/01/01).
Answer NA if the request was favorable or was not
forwarded to the IRE.
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 NA if no AOR form
was required.

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

AOR receipt time

CHAR
Always
Required

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Time the Appointment of Representative (AOR)
form or other appropriate documentation received by
sponsor. Submit in HH:MM:SS military time format
(e.g., 23:59:59). Answer NA if no AOR form was
required.
Insert the name of the First Tier, Downstream, and
Related Entity that processed the expedited preservice reconsideration (e.g., Independent Physician
Association, Physicians Medical Group or Third Party
Administrator). Answer NA if not applicable.

Page 33 of 47

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 7: Requests for Payment Reconsiderations (PREC) Record Layout
• Include all requests processed as payment reconsiderations from non-contract providers.
• Exclude all requests processed as direct member reimbursements and direct member
reimbursement reconsideration requests, dismissals, reopenings, duplicate reconsideration
requests and payment adjustments to reconsideration requests, reopenings, reconsideration
requests denied for invalid billing codes, denied reconsideration requests for beneficiaries
who are not enrolled on the date of service and reconsideration requests denied due to
recoupment of payment.
• Exclude requests for concurrent review for inpatient hospital and SNF services, post-service
reviews, withdrawn requests, and notifications of admissions.
• Submit payment reconsiderations based on the date the reconsideration was paid or denied, or
should have been paid or denied (the date the request was initiated may fall outside of the
review period).
• If a reconsideration request has more than one line item, include all of the request’s line items
in a single row and enter the multiple line items as a single request.
Column
ID

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Enrollee ID

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Contract ID

Plan ID

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Date the request was
received

CHAR
Always
Required

Page 34 of 47

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

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Diagnosis

CHAR
Always
Required

100

Issue description and
type of service

CHAR
Always
Required

2,000

Request Disposition

CHAR
Always
Required

Provide the enrollee diagnosis/diagnoses ICD-10
codes related to this request. If the ICD codes are
unavailable, provide a description of the diagnosis,
or for drugs provide the 11-digit National Drug
Code (NDC) as well as the ICD-10 code related to
the request.
Provide a description of the service, medical
supply or drug requested and why it was requested
(if known). For denials, also provide an
explanation of why the claim reconsideration was
denied.
Status of the request. Valid values are: approved,
denied, denied with IRE auto forward or IRE autoforward due to untimely decision. Sponsors should
note any requests that are untimely and not yet
resolved (still outstanding) as denied.
All untimely and pending cases should be treated as
denials for the purposes of populating the rest of this
record layout’s fields.
Date the reconsideration request was paid. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Sponsors
should answer NA for untimely cases that are still
open.

Date the
reconsideration
request was paid

CHAR
Always
Required

Was interest paid on
the reconsideration
request?
Was the
organization
determination
denied for lack of
medical necessity?
Date written
notification provided
to provider

CHAR
Always
Required
CHAR
Always
Required

Yes (Y)/No (N) indicator of whether interest was paid
on the reconsideration request.

Yes (Y)/No (N) indicator of whether the initial
request was denied for lack of medical necessity.
Answer No if the request was denied because it was
untimely.

CHAR
Always
Required

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

Date forwarded to IRE
if denied or untimely

CHAR
Always
Required

WOL Receipt date

CHAR
Always
Required

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Date the sponsor forwarded request to the IRE if
request denied or untimely. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Answer
NA if reconsideration was approved.
Date the Waiver of Liability (WOL) form received by
the sponsor. Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if no WOL form was
required.
Insert the name of the First Tier, Downstream, and
Related Entity that processed the payment
reconsideration (e.g., Independent Physician
Association, Physicians Medical Group or Third Party
Administrator). Answer NA if not applicable.

Page 35 of 47

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 8: Pre-service IRE Cases Requiring Effectuation (IREEFF) Record Layout
• Include all requests processed as pre-service cases overturned by the IRE, including standard
and expedited cases (i.e., a favorable decision was rendered by the IRE).
• Exclude all requests processed as dismissals, requests for payment and unfavorable
requests where the IRE upheld the denial.
• Exclude requests for concurrent review for inpatient hospital and SNF services, post-service
reviews, withdrawn requests, and notifications of admissions.
• Submit cases based on the date of receipt of the IRE overturn decision (the date the request
was initiated may fall outside of the review period).
Column
ID

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Enrollee ID

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Contract ID

Plan ID

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Diagnosis

CHAR
Always
Required

100

Issue description and
type of service

CHAR
Always
Required

2,000

Request for expedited
timeframe

CHAR
Always
Requested

Page 36 of 47

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

The associated authorization number assigned by the
sponsor for this request. If an authorization number is
not available, please provide your internal tracking or
case number. Answer NA if there is no authorization
or other tracking number available.
Provide the enrollee diagnosis/diagnoses ICD-10
codes related to this request. If the ICD codes are
unavailable, provide a description of the diagnosis, or
for drugs provide the 11-digit National Drug Code
(NDC) as well as the ICD-10 code related to the
request.
Provide a description of the service, medical supply
or drug requested and why it was requested (if
known). For denials, also provide an explanation of
why the request was denied before going to the IRE.
Indicate whether the pre-service request was
processed under the expedited (E) timeframe or
standard (S) timeframe.

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Date of receipt of IRE
decision

CHAR
Always
Required

Date the sponsor received the IRE overturn
decision. Submit in CCYY/MM/DD format (e.g.,
2020/01/01).

Time of receipt of IRE
decision

CHAR
Always
Required

Provide the time the sponsor received the IRE
overturn decision. Submit in HH:MM:SS military
time format (e.g., 23:59:59). Answer NA if the
request was not expedited.

Date service
authorization
entered/effectuated in
the sponsor's system
Time service
authorization
entered/effectuated in
the sponsor's system
Date written
notification provided
to IRE
First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Date the IRE determination was effectuated in the
sponsor's system. Submit in CCYY/MM/DD format
(e.g., 2020/01/01).

CHAR
Always
Required

Time effectuated in the sponsor's system. Submit in
HH:MM:SS military time format (e.g., 23:59:59).
Answer NA if the request was not expedited.

CHAR
Always
Required
CHAR
Always
Required

Date written notification of sponsor’s effectuation
sent to IRE. Submit in CCYY/MM/DD format (e.g.,
2020/01/01).
Insert the name of the First Tier, Downstream, and
Related Entity that processed the effectuation (e.g.,
Independent Physician Association, Physicians
Medical Group or Third Party Administrator).
Answer NA if not applicable.

Page 37 of 47

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 9: IRE Payment Cases Requiring Effectuation (IREClaimsEFF) Record Layout
• Include all requests overturned by the IRE that were processed as non-contract provider
payment or direct member reimbursement requests (i.e., a favorable decision was rendered by
the IRE).
• Exclude all requests processed as dismissals, pre-service requests and unfavorable requests
where the IRE upheld the denial.
• Exclude requests for concurrent review for inpatient hospital and SNF services, post-service
reviews, withdrawn requests, and notifications of admissions.
• Submit cases based on the date of receipt of the IRE overturn decision (the date the request
was initiated may fall outside of the review period).
Column
ID

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Enrollee ID

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Contract ID

Plan ID

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

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.

Diagnosis

CHAR
Always
Required

100

Issue description and
type of service

CHAR
Always
Required

2,000

Page 38 of 47

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

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 number available.
Provide the enrollee diagnosis/diagnoses ICD-10
codes related to this request. If the ICD codes are
unavailable, provide a description of the diagnosis,
or for drugs provide the 11-digit National Drug Code
(NDC) as well as the ICD-10 code related to the
request.
Provide a description of the service, medical supply
or drug requested and why it was requested (if
known). For denials, also provide an explanation of
why the request was denied before going to the IRE.

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Was interest paid on
the claim or
reimbursement
request?
Date of receipt of
IRE decision

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether interest was
paid on the claim or reimbursement request.

CHAR
Always
Required

Date service
authorization
entered/effectuated in
the sponsor's system
Date written
notification provided
to IRE

CHAR
Always
Required

Date the sponsor received the IRE overturn
decision. Submit in CCYY/MM/DD format (e.g.,
2020/01/01).
Date the IRE overturn decision was effectuated in
the sponsor's system. Submit in CCYY/MM/DD
format (e.g., 2020/01/01).

CHAR
Always
Required

Date written notification of sponsor’s effectuation
sent to IRE. Submit in CCYY/MM/DD format
(e.g., 2020/01/01).

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Insert the name of the First Tier, Downstream, and
Related Entity that processed the effectuation (e.g.,
Independent Physician Association, Physicians
Medical Group or Third Party Administrator).
Answer NA if not applicable.

Page 39 of 47

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 10: All Part C ALJ and MAC Cases Requiring Effectuation (ALJMACEFF) Record Layout
• Include all requests processed as overturned by the ALJ or MAC, including standard and
expedited cases, both pre-service and payment (i.e., a favorable decision was rendered by the
ALJ or MAC).
• Exclude all requests processed as dismissals and unfavorable requests where the ALJ or
MAC upheld the denial.
• Exclude requests for concurrent review for inpatient hospital and SNF services, post-service
reviews, withdrawn requests, and notifications of admissions.
• Submit cases based on the date of receipt of the ALJ or MAC overturn decision (the date
the request was initiated may fall outside of the review period).
Column
ID

Field Name

Field Type

Field
Length

Description

Beneficiary First
Name

First name of the beneficiary.

Beneficiary Last
Name

Last name of the beneficiary.

Enrollee ID

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Contract ID

Plan ID

Authorization or
Claim Number

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

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.

Diagnosis

CHAR
Always
Required

100

Issue description and
type of service

CHAR
Always
Required

2,000

Page 40 of 47

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

The associated authorization, claim or payment
request number assigned by the sponsor for this
request. If an authorization, claim or payment
request number is not available, please provide your
internal tracking or case number. Answer NA if
there is no authorization, claim, payment request or
other tracking number available.
Provide the enrollee diagnosis/diagnoses ICD-10
codes related to this request. If the ICD codes are
unavailable, provide a description of the diagnosis,
or for drugs provide the 11-digit National Drug Code
(NDC) as well as the ICD-10 code related to the
request.
Provide a description of the service, medical supply
or drug requested and why it was requested (if
known). For denials, also provide an explanation of
why the request was denied before going to the
ALJ/MAC.

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Field Name

Field Type

Field
Length

Description

Request for
expedited timeframe

CHAR
Always
Requested

Was interest paid on
the claim or
reimbursement
request?
Date of receipt of
ALJ/MAC decision

CHAR
Always
Required

Indicate whether the pre-service request was
processed under the expedited (E) timeframe or
standard (S) timeframe. Answer NA for payment
requests.
Yes (Y)/No (N) indicator of whether interest was
paid on the claim or reimbursement request. Answer
NA if a pre-service request.

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Did sponsor appeal
ALJ decision to
MAC?
Date written
notification provided
to enrollee

Date service
authorization
entered/effectuated in
the sponsor's system

CHAR
Always
Required

Date written
notification provided
to IRE
First Tier,
Downstream, and
Related Entity

CHAR
Always
Required
CHAR
Always
Required

Page 41 of 47

Date the sponsor received the ALJ/MAC overturn
decision. Submit in CCYY/MM/DD format (e.g.,
2020/01/01).
Yes (Y)/No (N) indicator of whether the sponsor
appealed the ALJ decision to the MAC.
If sponsor appealed the ALJ’s decision to the MAC,
provide the date written notification provided to
enrollee. Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer NA if the ALJ’s decision was
not appealed to the MAC.
Date the ALJ/MAC overturn decision was
effectuated in the sponsor's system. Submit in
CCYY/MM/DD format (e.g., 2020/01/01).
Date written notification of sponsor’s effectuation
sent to IRE. Submit in CCYY/MM/DD format
(e.g., 2020/01/01).
Insert the name of the First Tier, Downstream, and
Related Entity that processed the effectuation (e.g.,
Independent Physician Association, Physicians
Medical Group or Third Party Administrator).
Answer NA if not applicable.

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 11: Part C Oral & Written Standard Grievances (GRV_S) Record Layout
• Include all requests processed as standard oral and written grievances.
• Exclude all requests processed as expedited oral and written grievances, dismissals,
withdrawn requests, and CTM complaints.
• Submit cases based on the date the resolution notification was issued or the date the resolution
notification should have been issued (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

Enrollee ID

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Contract ID

Plan ID

Person who made the
request

Field
Length
50

Description

Last name of the beneficiary.

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.

First name of the beneficiary.

CHAR
Always
Required
CHAR
Always
Required

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

Date
Grievance/Complaint
was Received

CHAR
Always
Required
CHAR
Always
Required

How was the
grievance/complaint
received?

CHAR
Always
Required

Indicate whether the grievance was submitted by a
beneficiary (B) or a beneficiary’s representative
(BR).
Date the grievance/complaint was received from the
beneficiary 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 beneficiary or authorized
representative. Valid values include: Oral or Written.

Category of the
grievance/complaint

CHAR
Always
Required

Grievance/complaint
Description

CHAR
Always
Required

1,800

Page 42 of 47

Category of the grievance/complaint. At a minimum
categories must include each of the following:
Enrollment/Disenrollment, Benefit Package, Access,
Marketing, Customer Service, Organization
Determination and Reconsideration Process, Quality
of Care, Grievances Related to “CMS” Issues, and
Other.
Provide a description of the grievance/complaint
issue.

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
K

Field Name

Field Type

Field
Length
1

Description

Was this a quality of
care grievance?

CHAR
Always
Required

Was a timeframe
extension taken?

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the Sponsor
extended the timeframe to respond to the
grievance/complaint.

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

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the sponsor
notified the beneficiary of the delay. Answer NA if
an extension was not taken.

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the sponsor
notified the beneficiary of how the extension of the
timeframe was in the interest of the beneficiary.
Answer NA if an extension was not taken.

CHAR
Always
Required

Date written
notification of
resolution provided to
enrollee

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 the 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 the enrollee.

Resolution Description

CHAR
Always
Required

1,800

Provide a full description of the grievance
resolution.

AOR receipt date

CHAR
Always
Required

First Tier,
Downstream, and
Related Entity

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 NA if no AOR form was
required.
Insert the name of the First Tier, Downstream, and
Related Entity that processed the
grievance/complaint (e.g., Independent Physician
Association, Physicians Medical Group or Third
Party Administrator). Answer NA if not applicable.

Page 43 of 47

Yes (Y)/No (N) indicator of whether the grievance
was a quality of care grievance.

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 12: Part C Oral & Written Expedited Grievances (GRV_E) Record Layout
• Include all requests processed as expedited oral and written grievances.
• Exclude all requests processed as standard oral and written grievances, dismissals,
withdrawn requests, and CTM complaints.
• Submit cases based on the date the resolution notification was issued or the date the resolution
notification should have been issued (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

Enrollee ID

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Contract ID

Plan ID

Person who made the
request

Field
Length
50

Description

Last name of the beneficiary.

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.

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Date
Grievance/Complaint
was Received

First name of the beneficiary.

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

Indicate whether the grievance was submitted by a
beneficiary (B) or a beneficiary’s representative
(BR).

CHAR
Always
Required

Time
Grievance/Complaint
was Received

CHAR
Always
Required

How was the
grievance/complaint
received?

CHAR
Always
Required

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

Page 44 of 47

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID

Filed Name

Field Type

Field
Length

Description

Category of the
grievance/complaint

CHAR
Always
Required

Category of the grievance/complaint. Indicate
whether the expedited grievance was submitted
by the enrollee because the plan declined to
process a case on the expedited timeframe
(ETD) or whether it was submitted due to the
enrollee’s dissatisfaction with the plan taking a
processing timeframe extension (PTE).

Grievance/complaint
Description

1,800

Provide a description of the grievance/complaint
issue.

Date oral notification
of resolution provided
to enrollee

CHAR
Always
Required
CHAR
Always
Required

Time oral notification
of resolution provided
to enrollee

CHAR
Always
Required

Date written
notification of
resolution provided to
enrollee

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
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
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.

CHAR
Always
Required

Time written
notification of
resolution provided to
enrollee
Resolution Description

CHAR
Always
Required

1,800

AOR receipt date

CHAR
Always
Required

AOR receipt time

CHAR
Always
Required

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Page 45 of 47

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 a full description of the grievance resolution.

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 NA if no AOR form was
required.
Time the Appointment of Representative (AOR)
Form or other appropriate documentation received
by sponsor. Submit in HH:MM:SS military time
format (e.g., 23:59:59). Answer NA if no AOR form
was required.
Insert the name of the First Tier, Downstream, and
Related Entity that processed the
grievance/complaint (e.g., Independent Physician
Association, Physicians Medical Group or Third
Party Administrator). Answer NA if not applicable.

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Table 13: Dismissals Record Layout
• Include all requests processed as sponsor dismissals.
• Submit cases based on the dismissal date (the date the request was initiated may fall outside
of the review period), or based on the date the IRE requested information from the plan for a
case that was appealed to the IRE after it was dismissed by the plan.
Column
ID
A

Field Name

Field Type

Field
Length
50

Description

Beneficiary First
Name

Beneficiary Last
Name

Enrollee ID

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Last name of the beneficiary.

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

CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

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

Plan ID

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

Authorization or
Claim Number

Who made the
request?

CHAR
Always
Required

The associated authorization number assigned by the
sponsor for this request. If an authorization number
is not available, please provide your internal tracking
or case number. Answer NA if there is no
authorization or other tracking number available.
Indicate whether the request was made by a contract
provider (CP), non-contract provider (NCP),
beneficiary (B) or beneficiary’s representative (BR).

Type of Request

CHAR
Always
Required

Provider Type

CHAR
Always
Required

Date the request was
received

CHAR
Always
Required

Page 46 of 47

First name of the beneficiary.

Identify the type of request that was dismissed. Valid
values are: grievance, pre-service organization
determination, pre-service reconsideration, noncontract provider claim, direct member
reimbursement request, non-contract provider
payment reconsideration, or DMR reconsideration.
Indicate whether the provider who has or will be
performing the service is a contract provider (CP) or
non-contract provider (NCP). Answer NA for
grievances that do not involve providers or if a
request was dismissed before it was possible to
determine whether the provider was contract or noncontract provider.
Provide the date the request was received by your
organization. Submit in CCYY/MM/DD format (e.g.,
2020/01/01).

v. 12-2019

Part C Organization Determinations, Appeals, and Grievances (ODAG)
AUDIT PROCESS AND DATA REQUEST
Column
ID
K

Field Name

Field Type

Field
Length
300

Description

Description of the
Issue

CHAR
Always
Required

Is this an expedited or
standard request?

CHAR
Always
Required

Answer E if request was an expedited request or S if
a request was a standard request.

Was a timeframe
extension taken?

CHAR
Always
Required

Yes (Y)/No (N) indicator of whether the sponsor
extended the timeframe before dismissing the
request.

Date the request was
dismissed

CHAR
Always
Required

Provide the date the request was dismissed by your
organization. Submit in CCYY/MM/DD format (e.g.,
2020/01/01).

Reason for Dismissal

CHAR
Always
Required

300

Provide a description of why the request was
dismissed.

Provide a description of the service requested, and
why it was requested (if known).

Valid values include, but are not limited to:
• No AOR form
• No WOL
• Untimely filing
Provide the date the dismissal notice was sent to the
enrollee or provider. Submit in CCYY/MM/DD
format (e.g., 2020/01/01).

Date written
notification provided
to enrollee/provider

CHAR
Always
Required

Appealed to IRE?

CHAR
Always
Required

Yes (Y) / No (N) indicator of whether the dismissal
was appealed to the IRE.

Date forwarded to IRE

CHAR
Always
Required

Provide the date the case file was forwarded to the
IRE. Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Answer “NA” if the case was not
appealed to the IRE.

First Tier,
Downstream, and
Related Entity

CHAR
Always
Required

Insert the name of the First Tier, Downstream, and
Related Entity that processed the dismissal (e.g.,
Independent Physician Association, Physicians
Medical Group or Third Party Administrator).
Answer NA if not applicable.

Page 47 of 47

v. 12-2019

File Type	application/pdf
File Title	Attachment IV ODAG Audit Process and Data Request
Subject	2017 PRA package
Author	NICHOLAS PROY
File Modified	2019-12-11
File Created	2019-12-11