CMS-10305 Grievances (Part D) _2022

Grievances (Part D) 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

no data3

no data4

no data5

no data
no data
Grievances (Pa no data
no data
no data

no data
no data
no data
no data

no data
no data
no data
no data

no data
no data
no data
no data

no data
no data

no data
no data

no data
no data

no data
no data

no data
no data

no data

no data

no data

no data

no data

no data

no data

no data

no data

no data

no data2

no data
no data

Reporting
Section
Criteria ID

Standard/Sub-standard Description

no data
Data Sources and Review Results:
Enter review results and/or data sources

Data Element

1

No data

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.

No data

Data Sources:

1.a

No data

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

Review Results:

1.b

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
formulas have no messages or warnings indicating errors, use correct fields,
have appropriate data selection, etc.).

No data

Review Results:

1.d

No data

All data fields have meaningful, consistent labels (e.g., label field for patient ID No data
as 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:

Enter 'Findings' using the applicable choice in the appropriate
cells. Cells marked with an '*' should not be edited.
*

Standard/Sub-standard ID

Reporting
Section
Criteria ID

Standard/Sub-standard Description

Data Sources and Review Results:
Enter review results and/or data sources

Data Element

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, No data
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.

2.a

RSC-1

Data Sources:

No data

Review Results:

Data are assigned at the applicable level (e.g., plan benefit package or contract No data
level).

Review Results:

The appropriate date range(s) for the reporting period(s) is captured.

Enter 'Findings' using the applicable choice in the appropriate
cells. Cells marked with an '*' should not be edited.

*

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

Organization properly assigns data to the applicable CMS contract.
2.c

RSC-3

Appropriate deadlines are met for reporting data (e.g., quarterly).

No data

Review Results:

No data

Review Results:

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 resubmits 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

The number of expected counts (e.g., number of members, claims, grievances, No data
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; 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).

Data Sources:

*

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-5.a

Standard/Sub-standard Description

Data Sources and Review Results:
Enter review results and/or data sources

Data Element

Enter 'Findings' using the applicable choice in the appropriate
cells. Cells marked with an '*' should not be edited.

Data Sources:

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

RSC-5.a

2.e

RSC-5.b

RSC-5: Organization accurately reports data by applying data integrity checks
listed below and uploads it into HPMS.

Data Element B

Review Results:

No data

Data Sources:

*

b: Number of expedited grievances in which timely notification was given (Data
Element D) does not exceed number of total grievances in which timely
notification was given (Data Element B).

2.e

RSC-5.b

No data

Data Element D

Review Results:

2.e

RSC-5.c

RSC-5: Organization accurately reports data by applying data integrity checks
listed below and uploads it into HPMS.

No data

Data Sources:

*

c: Number of expedited grievances (Data Element C) does not exceed total
grievances (Data Element A).

2.e

RSC-5.c

No data

Data Element C

Review Results:

2.e

RSC-5.d

RSC-5: Organization accurately reports data by applying data integrity checks
listed below and uploads it into HPMS.

No data

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

RSC-5.d

No data

Data Element D

Review Results:

2.e

RSC-5.e

RSC-5: Organization accurately reports data by applying data integrity checks
listed below and uploads it into HPMS.

No data

Data Sources:

Data Element E

Review Results:

e: Number of dismissed grievances (Data Element E) are excluded from the
total.

2.e

RSC-5.e

No data

*

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-5.f

Standard/Sub-standard Description
RSC-5: Organization accurately reports data by applying data integrity checks
listed below and uploads it into HPMS.

Data Sources and Review Results:
Enter review results and/or data sources

Data Element
No data

Data Sources:

Enter 'Findings' using the applicable choice in the appropriate
cells. Cells marked with an '*' should not be edited.
*

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.

2.e

RSC-5.f

No data

Data Elements A-E

Review Results:

2.e

RSC-6.a

RSC-6: Organization accurately calculates and uploads into HPMS the total
number of grievances, including the following criteria:

No data

Data Sources:

*

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.

2.e

RSC-6.a

No data

Data Element A

Review Results:

2.e

RSC-6.a

No data

Data Element B

Review Results:

2.e

RSC-6.a

No data

Data Element C

Review Results:

2.e

RSC-6.a

No data

Data Element D

Review Results:

2.e

RSC-6.a

No data

Data Element E

Review Results:

2.e

RSC-6.b

RSC-6: Organization accurately calculates and uploads into HPMS the total
number of grievances, including the following criteria:

No data

Data Sources:

b: If a grievance contains multiple issues filed by a single complainant, each
issue is calculated as a separate grievance.

2.e

RSC-6.b

No data

Data Element A

Review Results:

2.e

RSC-6.b

No data

Data Element B

Review Results:

*

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-6.b

No data

Data Element C

Review Results:

2.e

RSC-6.b

No data

Data Element D

Review Results:

2.e

RSC-6.b

No data

Data Element E

Review Results:

2.e

RSC-6.c

RSC-6: Organization accurately calculates and uploads into HPMS the total
number of grievances, including the following criteria:

No data

Data Sources:

Standard/Sub-standard Description

Data Sources and Review Results:
Enter review results and/or data sources

Data Element

Enter 'Findings' using the applicable choice in the appropriate
cells. Cells marked with an '*' should not be edited.

*

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

2.e

RSC-6.c

No data

Data Element A

Review Results:

2.e

RSC-6.c

No data

Data Element B

Review Results:

2.e

RSC-6.c

No data

Data Element C

Review Results:

2.e

RSC-6.c

No data

Data Element D

Review Results:

2.e

RSC-6.c

No data

Data Element E

Review Results:

2.e

RSC-6.d

RSC-6: Organization accurately calculates and uploads into HPMS the total
number of grievances, including the following criteria:

No data

Data Sources:

d: 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

RSC-6.d

No data

Data Element A

Review Results:

2.e

RSC-6.d

No data

Data Element B

Review Results:

*

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-6.d

No data

Data Element C

Review Results:

2.e

RSC-6.d

No data

Data Element D

Review Results:

2.e

RSC-6.d

No data

Data Element E

Review Results:

2.e

RSC-6.e

RSC-6: Organization accurately calculates and uploads into HPMS the total
number of grievances, including the following criteria:

No data

Data Sources:

Standard/Sub-standard Description

Data Sources and Review Results:
Enter review results and/or data sources

Data Element

Enter 'Findings' using the applicable choice in the appropriate
cells. Cells marked with an '*' should not be edited.

*

e: Includes all methods of grievance receipt (e.g., telephone, letter, fax, and in
person).

2.e

RSC-6.e

No data

Data Element A

Review Results:

2.e

RSC-6.e

No data

Data Element B

Review Results:

2.e

RSC-6.e

No data

Data Element C

Review Results:

2.e

RSC-6.e

No data

Data Element D

Review Results:

2.e

RSC-6.e

No data

Data Element E

Review Results:

2.e

RSC-6.f

RSC-6: Organization accurately calculates and uploads into HPMS the total
number of grievances, including the following criteria:

No data

Data Sources:

f: Includes all grievances regardless of who filed the grievance (e.g., member or
appointed representative).

2.e

RSC-6.f

No data

Data Element A

Review Results:

2.e

RSC-6.f

No data

Data Element B

Review Results:

*

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-6.f

No data

Data Element C

Review Results:

2.e

RSC-6.f

No data

Data Element D

Review Results:

2.e

RSC-6.f

No data

Data Element E

Review Results:

2.e

RSC-6.g

RSC-6: Organization accurately calculates and uploads into HPMS the total
number of grievances, including the following criteria:

No data

Data Sources:

Standard/Sub-standard Description

Data Sources and Review Results:
Enter review results and/or data sources

Data Element

Enter 'Findings' using the applicable choice in the appropriate
cells. Cells marked with an '*' should not be edited.

*

g: Excludes complaints received only by 1-800 Medicare or recorded only in
the CMS Complaint Tracking Module (CTM); however, complaints filed
separately as
grievances with the organization are included.
2.e

RSC-6.g

No data

Data Element A

Review Results:

2.e

RSC-6.g

No data

Data Element B

Review Results:

2.e

RSC-6.g

No data

Data Element C

Review Results:

2.e

RSC-6.g

No data

Data Element D

Review Results:

2.e

RSC-6.g

No data

Data Element E

Review Results:

2.e

RSC-6.h

RSC-6: Organization accurately calculates and uploads into HPMS the total
number of grievances, including the following criteria:

No data

Data Sources:

h: Excludes withdrawn Part D grievances.

2.e

RSC-6.h

No data

Data Element A

Review Results:

2.e

RSC-6.h

No data

Data Element B

Review Results:

*

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-6.h

No data

Data Element C

Review Results:

2.e

RSC-6.h

No data

Data Element D

Review Results:

2.e

RSC-6.h

No data

Data Element E

Review Results:

2.e

RSC-6.i

RSC-6: Organization accurately calculates and uploads into HPMS the total
number of grievances, including the following criteria:

No data

Data Sources:

Standard/Sub-standard Description

Data Sources and Review Results:
Enter review results and/or data sources

Data Element

Enter 'Findings' using the applicable choice in the appropriate
cells. Cells marked with an '*' should not be edited.

*

i: For MA-PD contracts : Includes only grievances that apply to the Part D
benefit and were processed through the Part D grievance process. If a clear
distinction cannot be made for an MA-PD, cases are calculated as Part C
grievances.
2.e

RSC-6.i

No data

Data Element A

Review Results:

2.e

RSC-6.i

No data

Data Element B

Review Results:

2.e

RSC-6.i

No data

Data Element C

Review Results:

2.e

RSC-6.i

No data

Data Element D

Review Results:

2.e

RSC-6.i

No data

Data Element E

Review Results:

2.e

RSC-6.j

RSC-6: Organization accurately calculates and uploads into HPMS the total
number of grievances, including the following criteria:

No data

Data Sources:

Data Element A

Review Results:

j: Counts grievances for the contract to which the member belongs at the time
the grievance was filed, even if the beneficiary enrolled in a new contract
before the grievance is resolved (e.g., if a grievance is resolved within the
reporting period for a member that has disenrolled from a plan and enrolled in
a new plan, then the member’s previous plan is still responsible for
investigating, resolving and reporting the grievance).
2.e

RSC-6.j

No data

*

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-6.j

No data

Data Element B

Review Results:

2.e

RSC-6.j

No data

Data Element C

Review Results:

2.e

RSC-6.j

No data

Data Element D

Review Results:

2.e

RSC-6.j

No data

Data Element E

Review Results:

2.e

RSC-7.a

RSC-7: Organization accurately calculates the number of grievances which the
Part D sponsor provided timely notification of the decision, including the
following criteria:

No data

Data Sources:

Standard/Sub-standard Description

Data Sources and Review Results:
Enter review results and/or data sources

Data Element

Enter 'Findings' using the applicable choice in the appropriate
cells. Cells marked with an '*' should not be edited.

*

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 after receipt of grievance.

Data Element B

Review Results:

2.e

RSC-7.aiii

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

Data Element B

Review Results:

3

No data

Organization implements policies and procedures for data submission,
including the following:

No data

Data Sources:

3.a

No data

Data elements are accurately 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:

*

Standard/Sub-standard ID

Reporting
Section
Criteria ID

Standard/Sub-standard Description

Data Element

Data Sources and Review Results:
Enter review results and/or data sources

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 source, intermediate, and final stage data sets and other outputs relied
upon to enter data into HPMS are archived.

No data

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
No data
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.

Review Results:

7

No data

If data collection and/or reporting for this reporting section is delegated to
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.

No data

Review Results:

Enter 'Findings' using the applicable choice in the appropriate
cells. Cells marked with an '*' should not be edited.