CMS-10305 Medication Therapy Management (MTM) Programs (Part D) 20

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.

Note to reviewer: If the Part D sponsor has no MTM
members, then it is not required to report this data and
data validation is not required for this reporting section.

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

Reporting Section Criteria ID

Standard/Sub-standard Description

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.

1.b

No data

No data

No data
No data
No data
No data

No data

Standard/Sub-standard ID

1.a

No data
No data
No data
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.

Data Element

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

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

Data Sources:
No data
Review Results:
No data
Review Results:

Source documents create all required data fields for reporting requirements.
No data

1.c

1.d

1.e

No data

No data

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.).
All data fields have meaningful, consistent labels (e.g., label field for patient ID as Patient ID, rather than Field1 and maintain
the same field name across data sets).

Review Results:
No data
Review Results:
No data
Review Results:

Data file locations are referenced correctly.
No data

1.f

No data

Review Results:

If used, macros are properly documented.
No data

1.g

No data

Review Results:

Source documents are clearly and adequately documented.
No data

1.h

No data

Review Results:

Titles and footnotes on reports and tables are accurate.
No data

1.i

No data

Review Results:

Version control of source documents is appropriately applied.
No data

2

No data

2.a

RSC-1

A review of source documents (e.g., programming code, spreadsheet formulas, analysis plans, saved data queries, file layouts,
process flows) and census data, whichever is applicable, indicates that data elements for each reporting section are accurately
identified, processed, and calculated.
No data
The appropriate date range(s) for the reporting period(s) is captured.
Organization reports data based on the required reporting period of 1/1 through 12/31.

2.b

RSC-2

Review Results:
No data

Data are assigned at the applicable level (e.g., plan benefit package or contract level).
Organization properly assigns data to the applicable CMS contract.

*
Data Sources:

Review Results:
No data

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

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

Appropriate deadlines are met for reporting data (e.g., quarterly).
Organization meets deadline for reporting annual data to CMS by 2/27/2023.
2.c

RSC-3

2.d

RSC-4

[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
No data
review of this reporting section.]

Review Results:

Terms used are properly defined per CMS regulations, guidance, Reporting Requirements, and Technical Specifications.

2.e

RSC-5

Organization properly defines the MTM program services per CMS definitions, such as Comprehensive Medication Review
(CMR) with written summary and Targeted Medication Review (TMR) in accordance with the annual MTM Program Guidance
and Submission memo posted on the CMS MTM web page. This includes applying all relevant guidance properly when
performing its calculations and categorizations.

Review Results:

No data
*

The number of expected counts (e.g., number of members, claims, grievances, 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.

Data Sources:

RSC-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 H) is within the reporting period (between 1/1/2022 and 12/31/2022).
2.e

RSC-5.a

No data

No data
Data Element H

Review Results:
*

RSC-5: Organization accurately reports data by applying data integrity checks listed below and uploads it into CMS Systems.
2.e

RSC-5.b

b: One record is entered for each unique beneficiary i.e., only one record exists for a unique MBI number (Data Element B).

2.e

RSC-5.b

No data

Data Sources:
No data
Data Element B

Review Results:
*

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

RSC-5.c

2.e

RSC-5.c

2.e

RSC-5.d

2.e

RSC-5.d

c: Only reports beneficiaries enrolled in the contract during the reporting period, i.e. MBI Number (Data Element B) maps to a
beneficiary enrolled at any point during the reporting year for the given Contract Number (Data Element A).
No data

Data Sources:
No data
Data Element B

d: CMR received date (Data Element P) is within the beneficiary's MTM enrollment period.
No data

Review Results:
*

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

Data Sources:
No data
Data Element P

Review Results:
*

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

RSC-5.e

2.e

RSC-5.e

e. If the beneficiary was identified as cognitively impaired at time of CMS offer or delivery (Data Element F = Yes), the
beneficiary should have been offered a CMR (Data Element M = Yes).
No data

Data Sources:
No data
Data Element M

Review Results:
*

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

2.e

RSC-5.f

RSC-5.f

f: If beneficiary was offered or received a CMR (Data Element M = Yes or Data Element O = Yes), the contract should report if
beneficiary was cognitively impaired at time of CMR offer or delivery (Data Element F ≠ missing).
No data

Data Sources:
No data
Data Element F

Review Results:
*

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

RSC-5.g

g: If the beneficiary was offered or received a CMR (Data Element M = Yes or Data Element O = Yes), the contract should
report if beneficiary was in a long-term care facility at time of CMR offer or delivery (Data Element G≠ missing).

2.e

RSC-5.g

No data

Data Sources:
No data
Data Element G

Review Results:
*

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

RSC-5.h

h: If beneficiary met the specified targeting criteria per CMS-Part D Requirements in § 423.153(d)(2) (Data Element I ≠
missing), then the contract should report the date the beneficiary met the specified targeting criteria (Data Element J ≠
missing).

2.e

RSC-5.h

No data

Data Sources:
No data
Data Element J

Review Results:
*

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

2.e

RSC-5.i

RSC-5.i

i: If beneficiary did not meet the specified targeting criteria per CMS-Part D Requirements in § 423.153(d)(2) (Data Element I =
missing), then the field for ‘date meets the specified targeting criteria’ (Data Element J) should be missing.
No data

Data Sources:
No data
Data Element J

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

*

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

RSC-5.j

2.e

RSC-5.j

j: If a contract reports beneficiaries that were not eligible for MTM based on the specified targeting criteria per CMS-Part D
Requirements in § 423.153(d)(2) (Data Element I = missing), then Contract's MTM program submission information should
indicate that contract uses expanded eligibility (Targeting Criteria for Eligibility in the MTMP ≠ Only enrollees who meet the
specified targeting criteria per CMS requirements).
No data

Data Sources:

No data
Data Element I

Review Results:
*

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

RSC-5.k

2.e

RSC-5.k

k: If beneficiary opted out (Data Element K ≠ missing) then contract should provide an opt-out reason (Data Element L should
not be missing).
No data

Data Sources:
No data
Data Element L

Review Results:
*

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

RSC-5.l

2.e

RSC-5.l

l: If the beneficiary did not opt-out (Data Element K = missing), the field for opt-out reason should be missing (Data Element L =
missing).
No data

Data Sources:
No data
Data Element L

Review Results:
*

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

RSC-5.m

2.e

RSC-5.m

m: Date of MTM program opt-out (Data Element K) should not be before the date of MTM program enrollment (Data Element
H).
No data

Data Sources:
No data
Data Element K

Review Results:
*

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

RSC-5.n

2.e

RSC-5.n

2.e

RSC-5.o

n: Date of (initial) CMR offer (Data Element N) should be between the beneficiary’s MTM enrollment date (Data Element H)
and either 12/31/2021 or the beneficiary’s opt out date (Data Element K).
No data

2.e

RSC-5.o

Data Sources:
No data
Data Element N

No data

Review Results:
*

RSC-5: Organization accurately reports data by applying data integrity checks listed below and uploads it into HPMS.
o: If a CMR was offered (Data Element M = Yes), there is also a reported offer date (Data Element N ≠ missing).

Data Sources:
No data
Data Element N

Review Results:
*

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

RSC-5.p

2.e

RSC-5.p

Data Sources:

p: If a CMR was not offered (Data Element M = No), there is no reported offer date (Data Element N = missing).
No data

No data
Data Element N

Review Results:
*

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

RSC-5.q

2.e

RSC-5.q

2.e

RSC-5.r
RSC-5.r

No data
Data Element P

No data

Review Results:
*

RSC-5: Organization accurately reports data by applying data integrity checks listed below and uploads it into HPMS.
r: If a CMR was received (Data Element O = Yes), there is a reported delivery date(s) (Data Element Q ≠ missing)

2.e

Data Sources:

q: If a CMR was received (Data Element O = Yes), there is a reported date of initial CMR (Data Element P ≠ missing).
No data

Data Sources:
No data
Data Element Q

Review Results:
*

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

RSC-5.s

2.e

RSC-5.s

2.e

RSC-5.t

s: If records indicate that beneficiary received CMR (Data Element O = Yes), then indicator for CMR offered (Data element M ≠
No).
No data
No data
Data Element M

2.e

RSC-5.t

2.e

RSC-5.u

2.e

RSC-5.u

No data

2.e

RSC-5.v

2.e

RSC-5.v

No data

No data
Data Element N

No data

Review Results:
*
Data Sources:

No data
Data Element R

Review Results:
*

RSC-5: Organization accurately reports data by applying data integrity checks listed below and uploads it into HPMS.
v: If a CMR was not received (Data Element O = No), there is no reported method of CMR delivery (Data Element R = missing).

Review Results:
Data Sources:

RSC-5: Organization accurately reports data by applying data integrity checks listed below and uploads it into HPMS.
u: If a CMR was received (Data Element O = Yes), there is a reported method of delivery (Data Element R ≠ missing).

Data Sources:

*

RSC-5: Organization accurately reports data by applying data integrity checks listed below and uploads it into HPMS.
t: CMR offer date (Data Element N) is before the CMR received date (Data Element P).

Data Sources:
No data
Data Element R

Review Results:
*

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

RSC-5.w

2.e

RSC-5.w

w: If a CMR was received (Data Element O = Yes), there is a reported provider who performed the CMR (Data Element S ≠
missing).
No data

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

Data Sources:
No data
Data Element S

Review Results:

Standard/Sub-standard ID

Reporting Section Criteria ID

2.e

RSC-5.x

2.e

RSC-5.x

Standard/Sub-standard Description

Data Element

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

*

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

2.e

RSC-5.y

x: If a CMR was not received (Data Element O = No), there is no reported provider who performed the CMR (Data Element S =
missing).
No data
No data
Data Element S

2.e

RSC-5.y

2.e

RSC-5.z

2.e

RSC-5.z

No data

No data

Review Results:
Data Sources:

No data
Data Element T

Review Results:
*

RSC-5: Organization accurately reports data by applying data integrity checks listed below and uploads it into HPMS.
z: If a CMR was not received (Data Element O = No), there is no reported recipient of CMR (Data Element T = missing).

Data Sources:

*

RSC-5: Organization accurately reports data by applying data integrity checks listed below and uploads it into HPMS.
y: If a CMR was received (Data Element O = Yes), there is reported recipient of CMR (Data Element T ≠ missing).

Data Sources:
No data
Data Element T

Review Results:
*

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

RSC-5.aa

2.e

RSC-5.aa

aa: Properly identifies and includes members' date of first TMR (Data Element V) if the number of targeted medication reviews
(Data Element U) >0.
No data
No data
Data Element V

Data Sources:
Review Results:
*

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

RSC-5.bb

2.e

RSC-5.bb

2.e

RSC-6

2.e

RSC-6.a

bb: 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
2.e
2.e
2.e
2.e
2.e
2.e
2.e
2.e

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

2.e

RSC-6.b

2.e

RSC-6.b

Data Sources:

No data

No data
Data Elements A-Z

RSC-6: Organization accurately identifies data on MTM program participation and uploads it into HPMS, including the
following criteria:

No data

No data
No data
No data
No data
No data
No data
No data
No data
No data

Review Results:
Data Sources:

Data Sources:
No data
Data Element B
Data Element C
Data Element D
Data Element E
Data Element F
Data Element G
Data Element H
Data Element I
Data Element J

Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
Review Results:
*

RSC-6: Organization accurately identifies data on MTM program participation and uploads it into HPMS, including the
following criteria:

2.e

RSC-6.c

2.e
2.e
2.e
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.c
RSC-6.c
RSC-6.c
RSC-6.c

b: Includes the ingredient cost, dispensing fee, sales tax, and the vaccine administration fee (if applicable) when determining if
the total annual cost of a member’s covered Part D drugs is likely to equal or exceed the specified annual cost threshold for
MTM program eligibility.
No data
No data
Data Element I

No data
No data
No data
No data
No data
No data
No data
No data
No data
RSC-6: Organization accurately identifies data on MTM program participation and uploads it into HPMS, including the
following criteria:

2.e

RSC-6.d

d: Includes and reports each targeted member, reported once per contract year per contract file, based on the member's
most current MBI.

2.e
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.d
RSC-6.d

No data
No data
No data
No data
No data
No data
No data

Data Sources:

Review Results:
*

RSC-6: Organization accurately identifies data on MTM program participation and uploads it into HPMS, including the
following criteria:
c: Includes continuing MTM program members as well as members who were newly identified and auto-enrolled in the MTM
program at any time during the reporting period.

*
*

RSC-6: Organization accurately identifies data on MTM program participation and uploads it into HPMS, including the
following criteria:
a: Properly identifies and includes members who either met the specified targeting criteria per CMS Part D requirements in §
423.153(d)(2) or other expanded plan-specific targeting criteria at any time during the reporting period.

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

Data Sources:
No data
Data Element B
Data Element C
Data Element D
Data Element E
Data Element F
Data Element G
Data Element H
Data Element I
Data Element J

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

No data
Data Element B
Data Element C
Data Element D
Data Element E
Data Element F
Data Element G
Data Element H

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

Standard/Sub-standard ID

Reporting Section Criteria ID

2.e
2.e

RSC-6.d
RSC-6.d

2.e

RSC-6.e

2.e
2.e
2.e
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.e
RSC-6.e
RSC-6.e
RSC-6.e

2.e

RSC-6.f

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

2.e

RSC-6.g

2.e

RSC-6.g

2.e

RSC-6.h

2.e

RSC-6.h

2.e

RSC-6.i

2.e
2.e
2.e
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.i
RSC-6.i
RSC-6.i
RSC-6.i

2.e

RSC-6.j

2.e
2.e
2.e
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-6.j
RSC-6.j
RSC-6.j
RSC-6.j

2.e

RSC-7

2.e

RSC-7.a

2.e

RSC-7.a

Standard/Sub-standard Description
No data
No data
RSC-6: Organization accurately identifies data on MTM program participation and uploads it into HPMS, including the
following criteria:

Data Element
Data Element I
Data Element J

f: Includes members who receive MTM services based on plan-specific MTM criteria defined by the plan.
No data
No data
No data
No data
No data
No data
No data
No data
No data
RSC-6: Organization accurately identifies data on MTM program participation and uploads it into HPMS, including the
following criteria:
g: Properly identifies and includes members’ date of MTM program enrollment (i.e., date they were automatically enrolled)
that occurs within the reporting period.
No data
RSC-6: Organization accurately identifies data on MTM program participation and uploads it into HPMS, including the
following criteria:
h: For those members who met the specified targeting criteria per CMS Part D requirements in § 423.153(d)(2), properly
identifies the date the member met the specified targeting criteria.
No data
RSC-6: Organization accurately identifies data on MTM program participation and uploads it into HPMS, including the
following criteria:

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

Review Results:
Review Results:
*
Data Sources:

e: Excludes members deceased prior to their MTM eligibility date.
No data
No data
No data
No data
No data
No data
No data
No data
No data
RSC-6: Organization accurately identifies data on MTM program participation and uploads it into HPMS, including the
following criteria:

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

No data
Data Element B
Data Element C
Data Element D
Data Element E
Data Element F
Data Element G
Data Element H
Data Element I
Data Element J

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

No data
Data Element B
Data Element C
Data Element D
Data Element E
Data Element F
Data Element G
Data Element H
Data Element I
Data Element J

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

No data
Data Element H

Review Results:
*
Data Sources:

No data
Data Element J

Review Results:
*
Data Sources:

i: Includes members who moved between contracts in each corresponding file uploaded to HPMS. Dates of enrollment,
disenrollment elements, and other elements (e.g., TMR/CMR data) are specific to the activity that occurred for the member
within each contract.
No data
No data
No data
No data
No data
No data
No data
No data
No data
RSC-6: Organization accurately identifies data on MTM program participation and uploads it into HPMS, including the
following criteria:

No data
Data Element B
Data Element C
Data Element D
Data Element E
Data Element F
Data Element G
Data Element H
Data Element I
Data Element J

j: Counts each member who disenrolls from and re-enrolls in the same contract once.
No data
No data
No data
No data
No data
No data
No data
No data
No data

No data
Data Element B
Data Element C
Data Element D
Data Element E
Data Element F
Data Element G
Data Element H
Data Element I
Data Element J

RSC-7: Organization accurately identifies MTM eligible who are cognitively impaired at the time of CMR offer or delivery of
CMR and uploads it into HPMS, including the following criteria:

No data

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

RSC-7: Organization accurately identifies MTM eligible who are cognitively impaired at the time of CMR offer or delivery of
CMR and uploads it into HPMS, including the following criteria:
a: Properly identifies and includes whether each member was cognitively impaired and reports this status as of the date of the
No data
CMR offer or delivery of CMR.
No data
Data Element F

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

*
*

Data Sources:

Review Results:

Standard/Sub-standard ID

Reporting Section Criteria ID

2.e

RSC-8

2.e

RSC-8.a

2.e

RSC-8.a

2.e

RSC-8.b

2.e

RSC-8.b

2.e

RSC-8.c

2.e
2.e

RSC-8.c
RSC-8.c

2.e

RSC-8.d

2.e
2.e

RSC-8.d
RSC-8.d

2.e

RSC-9

Standard/Sub-standard Description
RSC-8: Organization accurately identifies data on members who opted-out of enrollment in the MTM program and uploads it
into HPMS, including the following criteria:
RSC-8: Organization accurately identifies data on members who opted-out of enrollment in the MTM program and uploads it
into HPMS, including the following criteria:
a: Properly identifies and includes members' date of MTM program opt-out that occurs within the reporting period, but prior
to 12/31.
No data
RSC-8: Organization accurately identifies data on members who opted-out of enrollment in the MTM program and uploads it
into HPMS, including the following criteria:

Data Element

No data

d: Excludes members who disenroll from and re-enroll in the same contract regardless of the duration of the gap of MTM
program enrollment
No data
No data
RSC-9: Organization accurately identifies data on CMR offers and uploads it into HPMS, including the following criteria:

No data
Data Element K

Review Results:
*
Data Sources:

Review Results:
*
Data Sources:

No data
Data Element K
Data Element L

Review Results:
Review Results:
*
Data Sources:

No data
Data Element K
Data Element L
No data

Review Results:
Review Results:
Data Sources:

RSC-9.a

2.e

RSC-9.a

a: Properly identifies and includes MTM program members who were offered a CMR per CMS Part D requirements in §
423.153(d)(2) during the reporting period.
No data

Data Sources:
No data
Data Element M

RSC-9.b

2.e

RSC-9.b

No data

2.e

RSC-10

RSC-10 Organization accurately identifies data on CMR dates and uploads it into HPMS, including the following criteria:

b: Properly identifies and includes members' date of initial offer of a CMR that occurs within the reporting period.

Review Results:
*

RSC-9: Organization accurately identifies data on CMR offers and uploads it into HPMS, including the following criteria:

2.e

Data Sources:
No data
Data Element N
No data

Review Results:
Data Sources:

2.e

RSC-10.a

2.e

RSC-10.a

No data

Data Sources:

No data
Data Element P

Review Results:
*

RSC-10 Organization accurately identifies data on CMR dates and uploads it into HPMS, including the following criteria:
2.e

RSC-10.b

b: Properly identifies and includes the method of delivery for the initial CMR received by the member; if more than one CMR is
received, the method of delivery for only the initial CMR is reported. The method of delivery must be reported as one of the
following: Face-to-Face, Telephone, Telehealth Consultation, or Other.

2.e

RSC-10.b

No data

Data Sources:
No data
Data Element R

Review Results:
*

RSC-10 Organization accurately identifies data on CMR dates and uploads it into HPMS, including the following criteria:

2.e

RSC-10.c

2.e

RSC-10.c

c: Properly identifies and includes the qualified provider who performed the initial CMR; if more than one CMR is received, the
qualified provider for only the initial CMR is reported. The qualified provider must be reported as one of the following:
Physician, Registered Nurse, Licensed Practical Nurse, Nurse Practitioner, Physician’s Assistant, Local Pharmacist, Long-Term
Care (LTC) Consultant Pharmacist, Plan Sponsor Pharmacist, Plan Benefit Manager (PBM) Pharmacist, MTM Vendor Local
Pharmacist, MTM Vendor In-house Pharmacist, Hospital Pharmacist, Pharmacist – Other, Supervised Pharmacy Intern, or
Other. Required if received annual CMR.
No data

*
*

RSC-10 Organization accurately identifies data on CMR dates and uploads it into HPMS, including the following criteria:
a: Properly identifies and includes the date the member received the initial CMR, if applicable. The date occurs within the
reporting period, is completed for every member with a “Y” entered for Field Name “Received annual CMR with written
summary in CMS standardized format,” and if more than one comprehensive medication review occurred, includes the date of
the first CMR.

*
*

RSC-9: Organization accurately identifies data on CMR offers and uploads it into HPMS, including the following criteria:
2.e

*
*

RSC-8: Organization accurately identifies data on members who opted-out of enrollment in the MTM program and uploads it
into HPMS, including the following criteria:

No data
No data
RSC-8: Organization accurately identifies data on members who opted-out of enrollment in the MTM program and uploads it
into HPMS, including the following criteria:

Data Sources:

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

Data Sources:

b: Properly identifies and includes the reason participant opted-out of the MTM program for every applicable member with an
No data
opt-out date completed (death, disenrollment, request by member, other reason).
No data
Data Element L

c: Excludes members who refuse or decline individual services without opting-out (disenrolling) from the MTM program.

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

Data Sources:

No data
Data Element S

Review Results:
*

RSC-10 Organization accurately identifies data on CMR dates and uploads it into HPMS, including the following criteria:
2.e

RSC-10.d

2.e

RSC-10.d

2.e

RSC-11

Data Sources:

d: Properly identifies the recipient of the annual CMR; if more than one CMR is received, only the recipient of the initial CMR is
reported. The recipient of the CMR interaction must be reported, not the recipient of the CMR documentation. The recipient
must be reported as one of the following: Beneficiary, Beneficiary’s Prescriber, Caregiver, or Other Authorized Individual.
No data

No data
Data Element T

RSC-11: Organization accurately identifies data on MTM medication therapy problem recommendations and uploads it into
HPMS, including the following criteria:

No data

Review Results:
Data Sources:

*

Standard/Sub-standard ID

Reporting Section Criteria ID

2.e

RSC-11.a

2.e

RSC-11.a

Standard/Sub-standard Description

Data Element

No data

Data Sources:
No data
Data Element U

Review Results:
*

RSC-11: Organization accurately identifies data on MTM medication therapy problem recommendations and uploads it into
HPMS, including the following criteria:

2.e

RSC-11.b

2.e

RSC-11.b

b: Properly identifies and includes the number of medication therapy problem recommendations made to beneficiary's
prescriber(s) as a result of MTM services within the reporting period for each applicable member, regardless of the success or
result of the recommendations, and counts these recommendations based on the number of unique recommendations made
to prescribers (e.g., the number is not equal to the total number of prescribers that received medication therapy problem
recommendations from the organization). Organization counts each individual medication therapy problem identified per
prescriber recommendation (e.g., if the organization sent a prescriber a fax identifying 3 medication therapy problems for a
member, this is reported as 3 recommendations).
No data

Data Sources:

No data
Data Element W

Review Results:
*

RSC-11: Organization accurately identifies data on MTM medication therapy problem recommendations and uploads it into
HPMS, including the following criteria:

2.e

RSC-11.c

c: Properly identifies and includes the number of medication therapy problem resolutions resulting from recommendations
made to beneficiary's prescriber(s) as a result of MTM program services within the reporting period for each applicable
member. For reporting purposes, a resolution is defined as a change or variation from the beneficiary's previous medication
therapy. Examples include, but are not limited to initiate medication, change medication (such as product in different
therapeutic class, dose, dosage form, quantity, or interval), discontinue or substitute medication (such as discontinue
medication, generic substitution, or formulary substitution), and medication compliance/adherence.
[Note to reviewer: If the resolution was observed in the calendar year after the current reporting period, but was the result of
an MTM recommendation made within the current reporting period, the resolution may be reported for the current reporting
period. However, this resolution cannot be reported again in the following reporting period.]

2.e

RSC-11.c

No data

3

No data

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

3.a

No data

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

3.a
3.a
3.a
3.a
3.a
3.a
3.a
3.a
3.a
3a.
3.a
3.a
3.a
3.a
3.a
3.a
3.a
3.a
3.a
3.a
3.a
3.a
3.a
3.a
3.a

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 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

3.b

No data

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

4

No data

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

5

No data

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

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

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.

6
7

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

RSC-11: Organization accurately identifies data on MTM medication therapy problem recommendations and uploads it into
HPMS, including the following criteria:
a: Properly identifies and includes all targeted medication reviews within the reporting period for each applicable member.

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

Data Sources:

No data
Data Element X
No data
Data Elements A
Data Element B
Data Element C
Data Element D
Data Element E
Data Element F
Data Element G
Data Element H
Data Element I
Data Element J
Data Element K
Data Element L
Data Element M
Data Element N
Data Element O
Data Element P
Data Element Q
Data Element R
Data Element S
Data Element T
Data Element U
Data Element V
Data Element W
Data Element X
Data Element Y
Data Element Z
No data
No data
No data
No data
No data

Review Results:
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*