CMS-10305 Grievances (Part C)_2022

Grievances (Part C) 2022

Organization Name:
Contract Number:
Reporting Section:

Last Updated:
Date of Site Visit (on-site or virtual):
Name of Reviewer:
Name of Peer Reviewer:
Instructions:
1) In the "Data Sources and Review Results:" column,
enter the review results and/or data sources used for
each standard or sub-standard.
2) Enter "Y" if the requirements for the standard or substandard have been completely met. If any requirement
for the standard or sub-standard has not been met,
enter "N". If any standard or sub-standard does not
apply, enter "N/A".
3) For standards 1c, 1d, 1e, 1g, 1h, and 2e, enter
'Findings' as follows based on the five-point scale: Select
"1" if plan data has more than 20% error, select "2" if
plan data has between 15.1% - 20.0% error, select "3" if
plan data has between 10.1% - 15.0% error, select "4" if
plan data has between 5.1% - 10.0% error, select "5" if
plan data has less than or equal to a 5% error. Enter
"N/A" if standard does not apply.

Standard/Sub-standard ID

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Grievances (Part no data

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Reporting
Section
Criteria ID

Standard/Sub-standard Description

Data Element

Data Sources and Review Results: Enter 'Findings' using the applicable choice in
Enter review results and/or data the appropriate cells. Cells marked with an '*'
sources
should not be edited.

A review of source documents (e.g., programming code, spreadsheet formulas,
analysis plans, saved data queries, file layouts, process flows) indicates that all
source documents accurately capture required data fields and are properly
documented.
Source documents are properly secured so that source documents can be
retrieved at any time to validate the information submitted to CMS via HPMS.

No data

Data Sources:

No data

Review Results:

No data

Source documents create all required data fields for reporting requirements.

No data

Review Results:

1.c

No data

Source documents are error-free (e.g., programming code and spreadsheet
No data
formulas have no messages or warnings indicating errors, use correct fields, have
appropriate data selection, etc.).

Review Results:

1.d

No data

All data fields have meaningful, consistent labels (e.g., label field for patient ID as No data
Patient ID, rather than Field1 and maintain the same field name across data
sets).

Review Results:

1.e

No data

Data file locations are referenced correctly.

No data

Review Results:

1.f

No data

If used, macros are properly documented.

No data

Review Results:

1.g

No data

Source documents are clearly and adequately documented.

No data

Review Results:

1.h

No data

Titles and footnotes on reports and tables are accurate.

No data

Review Results:

1.i

No data

Version control of source documents is appropriately applied.

No data

Review Results:

2

No data

A review of source documents (e.g., programming code, spreadsheet formulas,
analysis plans, saved data queries, file layouts, process flows) and census or
sample data, whichever is applicable, indicates that data elements for each
reporting section are accurately identified, processed, and calculated.

No data

Data Sources:

1

No data

1.a

No data

1.b

*

*

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.a

RSC-1

Standard/Sub-standard Description
The appropriate date range(s) for the reporting period(s) is captured.

Data Element

Data Sources and Review Results: Enter 'Findings' using the applicable choice in
Enter review results and/or data the appropriate cells. Cells marked with an '*'
sources
should not be edited.

No data

Review Results:

No data

Review Results:

No data

Review Results:

No data

Review Results:

Organization reports data based on the periods of 1/1 through 3/31, 4/1 through
6/30, 7/1 through 9/30, and 10/1 through 12/31.
2.b

RSC-2

2.c

RSC-3

Data are assigned at the applicable level (e.g., plan benefit package or contract
level).
Organization properly assigns data to the applicable CMS contract.
Appropriate deadlines are met for reporting data
Organization meets deadlines for reporting data to CMS by 2/6/2023.
[Note to reviewer: If the organization has, for any reason, re-submitted its data
to CMS for this reporting section, the reviewer should verify that the
organization’s original data submissions met the CMS deadline in order to have a
finding of “yes” for this reporting section criterion. However, if the organization
re-submits data for any reason and if the re-submission was completed by 3/31
of the data validation year, the reviewer should use the organization’s corrected
data submission for the review of this reporting section.]

2.d

RSC-4

Terms used are properly defined per CMS regulations, guidance, Reporting
Requirements, and Technical Specifications.
Organization properly defines the term “Grievance” in accordance with 42 CFR
§422.564 and the Parts C & D Enrollee Grievances, Organization/Coverage
Determinations and Appeals Manual. This includes applying all relevant guidance
properly when performing its calculations.

2.e

RSC-5.a

Data Sources:

*

Data Element B
No data

Review Results:
Data Sources:

*

Data Element D

Review Results:

The number of expected counts (e.g., number of members, claims, grievances,
Data Element B
procedures) are verified; ranges of data fields are verified; all calculations (e.g.,
derived data fields) are verified; missing data has been properly addressed;
reporting output matches corresponding source documents (e.g., programming
code, saved queries, analysis plans); version control of reported data elements is
appropriately applied; Quality Assurance (QA) checks/thresholds are applied to
detect outlier or erroneous data prior to data submission.
RSC-5: Organization accurately reports data by applying data integrity checks
listed below and uploads it into HPMS.
a: Number of total grievances in which timely notification was given (Data
Element B) does not exceed number of total grievances (Data Element A).

2.e
2.e

RSC-5.a
RSC-5.b

No data
RSC-5: Organization accurately reports data by applying data integrity checks
listed below and uploads it into HPMS.
b: Number of expedited grievances in which timely notification was given (Data
Element D) does not exceed number of total grievnaces in which timely
notification was given (Data Element B).

2.e

RSC-5.b

No data

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-5.c

2.e
2.e

RSC-5.c
RSC-5.d

Standard/Sub-standard Description
RSC-5: Organization accurately reports data by applying data integrity checks
listed below and uploads it into HPMS.
c: Number of expedited grievances (Data Element C) does not exceed total
grievances (Data Element A)
No data
RSC-5: Organization accurately reports data by applying data integrity checks
listed below and uploads it into HPMS.

Data Element

Data Sources and Review Results: Enter 'Findings' using the applicable choice in
Enter review results and/or data the appropriate cells. Cells marked with an '*'
sources
should not be edited.

No data

Data Sources:

*

Data Element C
No data

Review Results:
Data Sources:

*

Data Element D
No data

Review Results:
Data Sources:

*

Data Element E
No data

Review Results:
Data Sources:

*

Data Elements A-E
No data

Review Results:
Data Sources:

*

Data Element A
Data Element B
Data Element C
Data Element D
Data Element E
No data

Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
Data Sources:

*

Data Element A
Data Element B
Data Element C
Data Element D
Data Element E
No data

Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
Data Sources:

*

d: Number of expedited grievances in which timely notification was given (Data
Element D) does not exceed total expedited grievances (Data Element C).
2.e
2.e

RSC-5.d
RSC-5.e

No data
RSC-5: Organization accurately reports data by applying data integrity checks
listed below and uploads it into HPMS.
e: Number of dismissed grievances (Data Element E) are excluded from the total.

2.e
2.e

RSC-5.e
RSC-5.f

No data
RSC-5: Organization accurately reports data by applying data integrity checks
listed below and uploads it into HPMS.
f: If the organization received a CMS outlier/data integrity notice, validate
whether or not an internal procedure change was warranted or resubmission
through HPMS (Data Elements A-E).

2.e
2.e

2.e
2.e
2.e
2.e
2.e
2.e

RSC-5.f
RSC-6.a

RSC-6.a
RSC-6.a
RSC-6.a
RSC-6.a
RSC-6.a
RSC-6.b

No data
RSC-6: Organization accurately calculates the total number of grievances,
including the following criteria:
a: Includes all grievances that were completed (i.e., organization has notified
member of its decision) during the reporting period, regardless of when the
grievance was received.
No data
No data
No data
No data
No data
RSC-6: Organization accurately calculates the total number of grievances,
including the following criteria:
b: Includes all grievances reported by or on behalf of members who were
previously eligible, regardless of whether the member was eligible on the date
that the grievance was reported to the organization.

2.e
2.e
2.e
2.e
2.e
2.e

RSC-6.b
RSC-6.b
RSC-6.b
RSC-6.b
RSC-6.b
RSC-6.c

No data
No data
No data
No data
No data
RSC-6: Organization accurately calculates the total number of grievances,
including the following criteria:
c: If a grievance contains multiple issues filed by a single complainant, each issue
is calculated as a separate grievance.

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e
2.e
2.e
2.e
2.e
2.e

RSC-6.c
RSC-6.c
RSC-6.c
RSC-6.c
RSC-6.c
RSC-6.d

Standard/Sub-standard Description
No data
No data
No data
No data
No data
RSC-6: Organization accurately calculates the total number of grievances,
including the following criteria:

Data Element

Data Sources and Review Results: Enter 'Findings' using the applicable choice in
Enter review results and/or data the appropriate cells. Cells marked with an '*'
sources
should not be edited.

Data Element A
Data Element B
Data Element C
Data Element D
Data Element E
No data

Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
Data Sources:

*

Data Element A
Data Element B
Data Element C
Data Element D
Data Element E
No data

Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
Data Sources:

*

Data Element A
Data Element B
Data Element C
Data Element D
Data Element E
No data

Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
Data Sources:

*

Data Element A
Data Element B
Data Element C
Data Element D
Data Element E
No data

Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
Data Sources:

*

Data Element A
Data Element B
Data Element C
Data Element D
Data Element E

Review Results:
Review Results:
Review Results:
Review Results:
Review Results:

d: If a member files a grievance and then files a subsequent grievance on the
same issue prior to the organization’s decision or the deadline for decision
notification (whichever is earlier), then the issue is counted as one grievance.
2.e
2.e
2.e
2.e
2.e
2.e

RSC-6.d
RSC-6.d
RSC-6.d
RSC-6.d
RSC-6.d
RSC-6.e

No data
No data
No data
No data
No data
RSC-6: Organization accurately calculates the total number of grievances,
including the following criteria:
e: If a member files a grievance and then files a subsequent grievance on the
same issue after the organization’s decision or deadline for decision notification
(whichever is earlier), then the issue is counted as a separate grievance.

2.e
2.e
2.e
2.e
2.e
2.e

RSC-6.e
RSC-6.e
RSC-6.e
RSC-6.e
RSC-6.e
RSC-6.f

No data
No data
No data
No data
No data
RSC-6: Organization accurately calculates the total number of grievances,
including the following criteria:
f: Includes all methods of grievance receipt (e.g., telephone, letter, fax, and inperson).

2.e
2.e
2.e
2.e
2.e
2.e

RSC-6.f
RSC-6.f
RSC-6.f
RSC-6.f
RSC-6.f
RSC-6.g

No data
No data
No data
No data
No data
RSC-6: Organization accurately calculates the total number of grievances,
including the following criteria:
g: Includes all grievances regardless of who filed the grievance (e.g., member or
appointed representative).

2.e
2.e
2.e
2.e
2.e

RSC-6.g
RSC-6.g
RSC-6.g
RSC-6.g
RSC-6.g

No data
No data
No data
No data
No data

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-6.h

Standard/Sub-standard Description
RSC-6: Organization accurately calculates the total number of grievances,
including the following criteria:

Data Element

Data Sources and Review Results: Enter 'Findings' using the applicable choice in
Enter review results and/or data the appropriate cells. Cells marked with an '*'
sources
should not be edited.

No data

Data Sources:

*

Data Element A
Data Element B
Data Element C
Data Element D
Data Element E
No data

Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
Data Sources:

*

Data Element A
Data Element B
Data Element C
Data Element D
Data Element E
No data

Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
Data Sources:

*

Data Element A
Data Element B
Data Element C
Data Element D
Data Element E
No data

Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
Data Sources:

*

h: Includes only grievances that are filed directly with the organization (e.g.,
excludes all complaints that are only forwarded to the organization from the
CMS Complaint Tracking Module (CTM) and not filed directly with the
organization). If a member files the same complaint both directly with the
organization and via the CTM, the organization includes only the grievance that
was filed directly with the organization and excludes the identical CTM
complaint.
2.e
2.e
2.e
2.e
2.e
2.e

RSC-6.h
RSC-6.h
RSC-6.h
RSC-6.h
RSC-6.h
RSC-6.i

No data
No data
No data
No data
No data
RSC-6: Organization accurately calculates the total number of grievances,
including the following criteria:
i: For MA-PD contracts: Includes only grievances that apply to the Part C benefit
(If a clear distinction cannot be made for an MA-PD, cases are reported as Part C
grievances).

2.e
2.e
2.e
2.e
2.e
2.e

RSC-6.i
RSC-6.i
RSC-6.i
RSC-6.i
RSC-6.i
RSC-6.j

2.e
2.e
2.e
2.e
2.e
2.e

RSC-6.j
RSC-6.j
RSC-6.j
RSC-6.j
RSC-6.j
RSC-7.a

No data
No data
No data
No data
No data
RSC-6: Organization accurately calculates the total number of grievances,
including the following criteria:
j: Excludes withdrawn grievances.
No data
No data
No data
No data
No data
RSC-7: Organization accurately calculates the number of grievances for which it
provided timely notification of the decision, including the following criteria:
a: Includes only grievances for which the member is notified of decision
according to the following timelines:

2.e

RSC-7.ai

RSC-7.a.i. For standard grievances: no later than 30 days after receipt of
grievance.

Data Element B

Review Results:

2.e

RSC-7.aii

RSC-7.aii: For standard grievances with an extension taken: no later than 44 days Data Element B
after receipt of grievance.

Review Results:

2.e

RSC-7.aiii

RSC-7.aiii: For expedited grievances: no later than 24 hours after receipt of
grievance.

Review Results:

Data Element B

Standard/Sub-standard ID

Reporting
Section
Criteria ID

Standard/Sub-standard Description

Data Element

Data Sources and Review Results: Enter 'Findings' using the applicable choice in
Enter review results and/or data the appropriate cells. Cells marked with an '*'
sources
should not be edited.

3

No data

Organization implements policies and procedures for data submission, including No data
the following:

Data Sources:

3.a

No data

Data elements are accurately entered/uploaded into HPMS and entries match
corresponding source documents.

Data Element A

Review Results:

3.a

No data

No data

Data Element B

Review Results:

3.a

No data

No data

Data Element C

Review Results:

3.a

No data

No data

Data Element D

Review Results:

3.a

No data

No data

Data Element E

Review Results:

3.b

No data

All sources, intermediate, and final stage data sets and other outputs relied upon No data
to enter data into HPMS are archived.

Review Results:

4

No data

Organization implements policies and procedures for periodic data system
updates (e.g., changes in enrollment, provider/pharmacy status, and claims
adjustments).

No data

Review Results:

5

No data

Organization implements policies and procedures for archiving and restoring
data in each data system (e.g., disaster recovery plan).

No data

Review Results:

6

No data

If organization’s data systems underwent any changes during the reporting
period (e.g., because of a merger, acquisition, or upgrade): Organization
provided documentation on the data system changes and, upon review, there
were no issues that adversely impacted data reported.

No data

Review Results:

7

No data

If data collection and/or reporting for this reporting section is delegated to
No data
another entity: Organization regularly monitors the quality and timeliness of the
data collected and/or reported by the delegated entity or first tier/downstream
contractor.

Review Results:

*