60 Day Public Comment Response

60-Day Comment Response Document
Overview of Comments
CMS received one comment from Part D sponsor regarding the following reporting sections: Medication Therapy Management and Improving Drug Utilization reviews.
Summary of Comments

Section

MTM

Comment
With respect to the standards listed in Subsection 5, the reference letters used for the section are
misaligned (Reporting Section Criteria (RSC) 5 in the 2022 Data Valuation CY 2023 DV Appendix
B_Draft_20220308_508). RSC 5b in the 2022 Manual is now RSC 5a in the 2023 Manual. This
misalignment of the standards is an error because it is not reflected in Appendix J that is used for scoring.
Appendix B, RSC Section 5 in 2022:
5. Organization accurately reports data by applying data integrity checks listed below and
uploads it into HPMS:
a. Date of MTM program enrollment (Data Element I) is within the reporting period (between
1/1/2021 and 12/31/2021).
b. One record is entered for each unique beneficiary, i.e., only one record exists for a unique
MBI number (Data Element B).
c. Only reports beneficiaries enrolled in the contract during the reporting period, i.e., MBI
(Data Element B) maps to a beneficiary enrolled at any point during the reporting year for the
given Contract Number (Data Element A).
Appendix B, RSC Section 5 in 2023:
Organization accurately reports data by applying data integrity checks listed below and
uploads it into HPMS:
5. Date of MTM program enrollment (Data Element H) is within the reporting period (between
1/1/2022 and 12/31/2022).
a. One record is entered for each unique beneficiary i.e., only one record exists for a unique
MBI number (Data Element B).
b. Only reports beneficiaries enrolled in the contract during the reporting period, i.e., MBI
(data Element B) maps to a beneficiary enrolled at any point during the reporting year for the
given Contract Number (Data Element A).
c. CMR received date (Data Element P) is within the beneficiary’s MTM enrollment period.

Commenter's Recommendation
The misalignment in Appendix B needs to
be fixed. UHC recommends that CMS
update the numbering in Appendix B, RSC
Subsection 5 so that it will align with
Appendix J which is used for auditor
scoring.

CMS Response
The misalignment in Appendix B has been corrected as follows:

Revised Requirements/Documents

Revised Burden Estimates

Yes

No

Yes

No

RSC 5 Organization accurately reports data by applying data integrity
checks listed below and uploads it into HPMS
5a. Date of MTM program enrollment (Data Element H) is within the
reporting period (between 1/1/2022 and 12/31/2022).
The subsequent RSC codes have been revised to align accordingly as well.

[Comment abbreviated due to space constraint]
Reporting Section Criteria (RSC): Section 5q and 5r
In addition to the misalignment mentioned above, RSC 5q is a duplicate of RSC 5r. UHC has
concerns about this duplication because it is not reflected in Appendix J that is used for scoring.
When the auditors look for RSC 5q in Appendix B, it will not match RSC 5q in Appendix J.
Appendix B, RSC Section 5q and 5r in 2022:
• RSC 5q. If a CMR was received (Data Element Q = Yes), there is a reported date of initial
CMR (Data Element R ≠ missing).
• RSC 5r. If a CMR was received (Data Element Q = Yes), there is a reported delivery
date(s) (Data Element S ≠ missing).

MTM

Appendix B, RSC Section 5q and 5r in 2023:
• RSC 5q. If a CMR was received (Data Element O = Yes), there is a reported delivery
date(s) (Data Element Q ≠ missing).
• RSC 5r. If a CMR was received (Data Element O = Yes), there is a reported delivery
date(s) (Data Element Q ≠ missing).
Appendix J, RSC Section 5q and 5r in 2023:
• RSC 5q. If a CMR was received (Data Element O = Yes), there is a reported date of initial
CMR (Data Element P ≠ missing).
• RSC 5r. If a CMR was received (Data Element O = Yes), there is a reported delivery
date(s) (Data Element Q ≠ missing)
[Comment abbreviated due to space constraint]

UHC recommends that CMS update the
numbering in Appendix B, RSC Section 5
and remove the duplicated RSC 5q so that
it aligns with Appendix J which is used for
auditor scoring

RSC 5r definition "If a CMR was received (Data Element O = Yes), there is
a reported delivery date(s) (Data Element Q ≠ missing)" was repeated
twice in DV 2023 Appendix B. The second instance has been deleted and
the subsequent RSC codes have been revised to align accordingly as well.

Section

MTM

Comment
Reporting Section Criteria (RSC): Section 5v
UHC has identified a gap between RSC 5v in Appendix B and Appendix J as compared to the CY
2022 Reporting Requirements document.
In addition to the misalignment mentioned above under Subsection 5, validations for Element P (If
offered a CMR, recipient of (initial) offer) that were removed for CY 2022 in the Reporting Requirements
document were not removed in Appendix B and Appendix J. Instead, the data element was updated to
Element T (Recipient of initial CMR); however, Element T is for the recipient of the completed CMR, not
the CMR offer. This error could cause the auditors to evaluate and score plans incorrectly based on a
data element that no longer exists.

Commenter's Recommendation

CMS Response

Revised Requirements/Documents

Revised Burden Estimates

Yes

No

CMS agrees. RSC Section 11c is updated to reflect Data Element X in
Appendix B and J.

Yes

No

As per the Technical Specifications, appeals are not included in
cumulative hard MME edit/opioid naïve days supply safety edit. The
language in RSCs 8, 9, and 10 has been updated to remove appeals.

Yes

No

UHC recommends that CMS update RSC
CMS agrees. RSC 5v has been deleted from Appendix B and Appendix J.
Section 5v in Appendix B and Appendix J to
remove the
validation for Element T (previously P in CY
2021 - If offered a CMR, recipient of (initial)
offer) to align
with the removal in the CY 2022 Reporting
Requirements

[Comment abbreviated due to space constraint]

MTM

The element letter for the number of medication therapy problem resolutions in Appendix B and
UHC recommends that CMS update
Appendix J was incorrectly updated to Element Y (Number of communications sent to beneficiary
Element Y in RSC Section 11c to Element X
regarding safe disposal). Per the CY 2022 Reporting Requirements document, the correct element letter in both Appendix B and J.
is Element X (Number of medication therapy problem resolutions). Element Y is for safe disposal and
does not relate to the recommendations made to the beneficiary’s prescriber(s).
Additionally, per the CY 2021 Bene-level MTMP Submission Instructions, Element X (shown as Element Z
for 2021 below) is a subset of Element W (shown as Element Y for 2021) and cannot be greater than
Element W (Number of medication therapy problem recommendations). However, it is possible for
Element Y to be populated with a number greater than zero while Element X and W are not. When this
occurs, it will cause our number of medication therapy problem resolutions to appear higher than our
number of medication therapy problem recommendations when this is not the case.
UHC has concerns that this update could cause the auditors to evaluate and score plans incorrectly
based on the wrong data element.
[Comment abbreviated due to space constraint]

DUR

For the Part D Improving Drug Utilization Review Controls, there are discrepancies between data
element descriptions. Appeals are inconsistently listed within the criteria in Appendix J and the Part D
Reporting Requirements do not include Appeals within the reporting data element description.
• DVA Appendix J 2.e RSC 8, 8.a, and 8.b requires a favorable Coverage Determination or Appeal.
• DVA Appendix J 2.e RSC 8.aii and 8.bii requires a favorable Coverage Determination or Appeal.
• DVA Appendix J 2.e RSC 9.a and 9.b requires a favorable Coverage Determination but does not include
Appeals.
The Part D Plan Reporting Requirements for Hard MME Elements do not mention Appeal requests:
T. Of the total reported in element R and not in element S, the number of unique
beneficiaries who requested a coverage determination for the prescription(s) subject to the
edit.
U. Of the total reported in element T, the number of unique beneficiaries that had a favorable
(either full or partial) coverage determination for the prescription(s) subject to the edit.
Similarly, the Naïve Safety edit also does not mention appeal request:
EE. The number of unique beneficiaries with an opioid naïve days supply edit claim rejection
who requested a coverage determination for the prescription(s) subject to the edit.
FF. Of the total in element EE, the number of unique beneficiaries with an opioid naïve days
supply edit claim rejection who had a favorable (either full or partial) coverage determination
for the prescription(s) subject to the edit.

UHC is seeking clarification if appeal
requests should be included when
reporting the DUR elements
for Hard or Naïve data elements (T, U, EE,
FF).