CMS-10305 Organization Determinations/Reconsiderations (Part C) 20

Organization
Determinations/Reconsiderations (Part
C) 2022

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Date of Site Visit (on-site or virtual):
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Name of Reviewer:
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Name of Peer Reviewer:
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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.

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Organization Name:
Contract Number:
Reporting Section:

Organization
Determination
s/Reconsiderat
no data
ions (Part C)

Last Updated:

1

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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.

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no data
no data
Data Sources and Review
Enter 'Findings' using the applicable
Results:
choice in the appropriate cells. Cells
Enter review results and/or
marked with an '*' should not be edited.
data sources
Data Sources:
*

1.a

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Source documents are properly secured so that source documents can be
retrieved at any time to validate the information submitted to CMS via HPMS.

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Review Results:

1.b

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Source documents create all required data fields for reporting requirements.

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Review Results:

1.c

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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.).

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Review Results:

Standard/Sub-standard ID

Reporting
Section
Criteria ID

Standard/Sub-standard Description

Data Element

1.d

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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).

No data

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

1.e

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Data file locations are referenced correctly.

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Review Results:

1.f

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If used, macros are properly documented.

No data

Review Results:

1.g

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Source documents are clearly and adequately documented.

No data

Review Results:

1.h

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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.

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Review Results:

2

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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:

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

No data

Review Results:

No data

Review Results:

No data

Review Results:

Standard/Sub-standard ID

2.a

Reporting
Section
Criteria ID

RSC-1

Standard/Sub-standard Description

Data Element

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 (e.g., quarterly).
Organization meets deadlines for reporting data to CMS by 02/27/2023.
[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.]

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

2.d

RSC-4

Standard/Sub-standard Description
Terms used are properly defined per CMS regulations, guidance, Reporting
Requirements, and Technical Specifications.

Data Element
No data

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

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

Organization properly defines the term “Organization Determinations” in
accordance with 42 C.F.R. Part 422, Subpart M, and the Parts C & D Enrollee
Grievances, Organization/Coverage Determinations and Appeals Manual. This
includes applying all relevant guidance properly when performing its
calculations and categorizations.
Organization properly defines the term “Reconsideration” in accordance with 42
C.F.R. Part 422, Subpart M, and the Parts C & D Enrollee Grievances,
Organization/Coverage Determinations and Appeals Manual. This includes
applying all relevant guidance properly when performing its calculations and
categorizations.
2.e

RSC-5.a

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 have 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: The total number of organization determinations (Subsection #1, Data
Element A) is equal to sum of organization determinations by outcome
(Subsection #2, Data Elements A-L).
2.e

RSC-5.a

No data

2.e

RSC-5.b

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

Subsection #1, Data
Element A,
Subsection #2, Data
Elements A-L
No data

Review Results:

Data Sources:

*

b: The total number of reconsiderations (Subsection#3, Data Element A) is equal
to sum of reconsiderations by outcome (Subsection #4, Data Elements A-L).
2.e

RSC-5.b

No data

Subsection #3, Data
Review Results:
Element A, Subsection
#4, Data Elements A-L

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:

Subsection #5, Data
Element A

Review Results:

c: The total number of reopened decisions (Subsection #5, Data Element A) is
equal to the number of records reported in the data file with a disposition of
reopened.
2.e

RSC-5.c

No data

*

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

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.

Data Element
No data

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

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

d: The date each case was reopened (Subsection #5, Data Element K) is after the
date of its original disposition (Subsection #5, Data Element F).
2.e

RSC-5.d

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Subsection #5, Data
Element K

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:

*

e: The date of disposition for each reopening (Subsection #5, Data Element N) is
after the date of the original disposition (Subsection #5, Data Element F).
2.e

RSC-5.e

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Subsection #5, Data
Element N

Review Results:

2.e

RSC-5.f

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

No data

Data Sources:

*

f: The date of disposition for each reopening (Subsection #5, Data Element N) is
after the date the case was reopened (Subsection #5, Data Element K).
2.e

RSC-5.f

No data

Subsection #5, Data
Element N

Review Results:

2.e

RSC-5.g

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

No data

Data Sources:

*

g: The date of disposition for each reopening (Subsection #5, Data Element N) is
within the reporting quarter.
2.e

RSC-5.g

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Subsection #5, Data
Element N

Review Results:

2.e

RSC-5.h

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

No data

Data Sources:

*

h: Verify that there is a valid value submitted for date of original disposition as
MM/DD/YYYY format (Subsection #5, Data Element F).
2.e

RSC-5.h

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Subsection #5, Data
Element F

Review Results:

2.e

RSC-5.i

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

No data

Data Sources:

i: Verify that there is a valid value submitted for case level (Organization
Determination or Reconsideration) (Subsection #5, Data Element E)

*

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

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-5.i

No data

Subsection #5, Data
Element E

2.e

RSC-5.j

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

No data

Data Sources:

Standard/Sub-standard Description

Data Element

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

*

j: Verify that there is a valid value submitted for reopening disposition (Fully
Favorable; Partially Favorable; Adverse or Pending (Subsection #5, Data Element
O).
2.e

RSC-5.j

No data

Subsection #5, Data
Element O

Review Results:

2.e

RSC-5.k

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

No data

Data Sources:

Subsection #1, Data
Elements A-G,
Subsection #2, Data
Elements A-L,
Subsection #3, Data
Elements A-G,
Subsection #4, Data
Elements A-L,
Subsection #5, Data
Elements A, E, F, G, N,
and O
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Review Results:

*

k: 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.k

No data

2.e

RSC-6.a

RSC-6: Organization accurately calculates the total number of organization
determinations, including the following criteria:

Data Sources:

a: Includes all completed organization determinations (Part C only) for services
requested by an enrollee/representative, a provider on behalf of the enrollee, or
a non-contract provider, and all organization determinations for claims
submitted by enrollee/representative or non-contract provider with a date of
member notification of the final decision that occurs during the reporting
period, regardless of when the request for organization determination was
received.
2.e

RSC-6.a

No data

Subsection #1, Data
Element A

Review Results:

2.e

RSC-6.a

No data

Subsection #1, Data
Element D

Review Results:

*

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

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-6.a

No data

Subsection #1, Data
Element E

2.e

RSC-6.a

No data

Subsection #1, Data
Element F

Review Results:

2.e

RSC-6.a

No data

Subsection #1, Data
Element G

Review Results:

2.e

RSC-6.a

No data

Subsection #2, Data
Element I

Review Results:

2.e

RSC-6.a

No data

Subsection #2, Data
Element J

Review Results:

2.e

RSC-6.a

No data

Subsection #2, Data
Element K

Review Results:

2.e

RSC-6.a

No data

Subsection #2, Data
Element L

Review Results:

2.e

RSC-6.b

RSC-6: Organization accurately calculates the total number of organization
determinations, including the following criteria:

No data

Data Sources:

Standard/Sub-standard Description

Data Element

b: Includes adjudicated claims with a date of adjudication that occurs during the
reporting period.
2.e

RSC-6.b

No data

Subsection #1, Data
Element A

Review Results:

2.e

RSC-6.b

No data

Subsection #1, Data
Element D

Review Results:

2.e

RSC-6.b

No data

Subsection #1, Data
Element E

Review Results:

2.e

RSC-6.b

No data

Subsection #1, Data
Element F

Review Results:

2.e

RSC-6.b

No data

Subsection #1, Data
Element G

Review Results:

2.e

RSC-6.b

No data

Subsection #2, Data
Element I

Review Results:

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

*

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

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-6.b

No data

Subsection #2, Data
Element J

2.e

RSC-6.b

No data

Subsection #2, Data
Element K

Review Results:

2.e

RSC-6.b

No data

Subsection #2, Data
Element L

Review Results:

2.e

RSC-6.c

RSC-6: Organization accurately calculates the total number of organization
determinations, including the following criteria:

No data

Data Sources:

Standard/Sub-standard Description

Data Element

c: Includes all claims submitted for payment including those that pass through
the adjudication system that may not require determination by the staff of the
organization or its delegated entity.
2.e

RSC-6.c

No data

Subsection #1, Data
Element A

Review Results:

2.e

RSC-6.c

No data

Subsection #1, Data
Element D

Review Results:

2.e

RSC-6.c

No data

Subsection #1, Data
Element E

Review Results:

2.e

RSC-6.c

No data

Subsection #1, Data
Element F

Review Results:

2.e

RSC-6.c

No data

Subsection #1, Data
Element G

Review Results:

2.e

RSC-6.c

No data

Subsection #2, Data
Element I

Review Results:

2.e

RSC-6.c

No data

Subsection #2, Data
Element J

Review Results:

2.e

RSC-6.c

No data

Subsection #2, Data
Element K

Review Results:

2.e

RSC-6.c

No data

Subsection #2, Data
Element L

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

2.e

RSC-6.d

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

Data Element
No data

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

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

d: Includes decisions made on behalf of the organization by a delegated entity.
2.e

RSC-6.d

No data

Subsection #1, Data
Element A

Review Results:

2.e

RSC-6.d

No data

Subsection #1, Data
Element D

Review Results:

2.e

RSC-6.d

No data

Subsection #1, Data
Element E

Review Results:

2.e

RSC-6.d

No data

Subsection #1, Data
Element F

Review Results:

2.e

RSC-6.d

No data

Subsection #1, Data
Element G

Review Results:

2.e

RSC-6.d

No data

Subsection #2, Data
Element I

Review Results:

2.e

RSC-6.d

No data

Subsection #2, Data
Element J

Review Results:

2.e

RSC-6.d

No data

Subsection #2, Data
Element K

Review Results:

2.e

RSC-6.d

No data

Subsection #2, Data
Element L

Review Results:

2.e

RSC-6.e

RSC-6: Organization accurately calculates the total number of organization
determinations, including the following criteria:

No data

Data Sources:

e: Includes organization determinations that are filed directly with the
organization or its delegated entities for services requested by an
enrollee/representative, or a provider on behalf of the enrollee, or non-contract
provider, and claims submitted either by an enrollee/representative or noncontract provider. If a member requests an organization determination directly
with the organization and files an identical complaint via the CTM, the
organization includes only the organization determination that was filed directly
with the organization and excludes the identical CTM complaint.

*

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

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-6.e

No data

Subsection #1, Data
Element A

2.e

RSC-6.e

No data

Subsection #1, Data
Element D

Review Results:

2.e

RSC-6.e

No data

Subsection #1, Data
Element E

Review Results:

2.e

RSC-6.e

No data

Subsection #1, Data
Element F

Review Results:

2.e

RSC-6.e

No data

Subsection #1, Data
Element G

Review Results:

2.e

RSC-6.e

No data

Subsection #2, Data
Element I

Review Results:

2.e

RSC-6.e

No data

Subsection #2, Data
Element J

Review Results:

2.e

RSC-6.e

No data

Subsection #2, Data
Element K

Review Results:

2.e

RSC-6.e

No data

Subsection #2, Data
Element L

Review Results:

2.e

RSC-6.f

RSC-6: Organization accurately calculates the total number of organization
determinations, including the following criteria:

No data

Data Sources:

Standard/Sub-standard Description

Data Element

f: Includes all methods of organization determination request receipt (e.g.,
telephone, letter, fax, in-person).
2.e

RSC-6.f

No data

Subsection #1, Data
Element A

Review Results:

2.e

RSC-6.f

No data

Subsection #1, Data
Element D

Review Results:

2.e

RSC-6.f

No data

Subsection #1, Data
Element E

Review Results:

2.e

RSC-6.f

No data

Subsection #1, Data
Element F

Review Results:

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

*

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

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-6.f

No data

Subsection #1, Data
Element G

2.e

RSC-6.f

No data

Subsection #2, Data
Element I

Review Results:

2.e

RSC-6.f

No data

Subsection #2, Data
Element J

Review Results:

2.e

RSC-6.f

No data

Subsection #2, Data
Element K

Review Results:

2.e

RSC-6.f

No data

Subsection #2, Data
Element L

Review Results:

2.e

RSC-6.g

RSC-6: Organization accurately calculates the total number of organization
determinations, including the following criteria:

No data

Data Sources:

Standard/Sub-standard Description

Data Element

g: Includes all organization determinations for services requested by an
enrollee/representative, or provider on behalf of the enrollee, or a non-contract
provider, and claims submitted by either enrollee/representative or noncontract provider.
2.e

RSC-6.g

No data

Subsection #1, Data
Element A

Review Results:

2.e

RSC-6.g

No data

Subsection #1, Data
Element D

Review Results:

2.e

RSC-6.g

No data

Subsection #1, Data
Element E

Review Results:

2.e

RSC-6.g

No data

Subsection #1, Data
Element F

Review Results:

2.e

RSC-6.g

No data

Subsection #1, Data
Element G

Review Results:

2.e

RSC-6.g

No data

Subsection #2, Data
Element I

Review Results:

2.e

RSC-6.g

No data

Subsection #2, Data
Element J

Review Results:

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

*

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

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-6.g

No data

Subsection #2, Data
Element K

2.e

RSC-6.g

No data

Subsection #2, Data
Element L

Review Results:

2.e

RSC-6.h

RSC-6: Organization accurately calculates the total number of organization
determinations, including the following criteria:

No data

Data Sources:

Standard/Sub-standard Description

Data Element

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

*

h: Includes supplemental benefits (i.e., non- Medicare covered item or service)
provided as a part of a plan’s Medicare benefit package.
2.e

RSC-6.h

No data

Subsection #1, Data
Element A

Review Results:

2.e

RSC-6.h

No data

Subsection #1, Data
Element D

Review Results:

2.e

RSC-6.h

No data

Subsection #1, Data
Element E

Review Results:

2.e

RSC-6.h

No data

Subsection #1, Data
Element F

Review Results:

2.e

RSC-6.h

No data

Subsection #1, Data
Element G

Review Results:

2.e

RSC-6.h

No data

Subsection #2, Data
Element I

Review Results:

2.e

RSC-6.h

No data

Subsection #2, Data
Element J

Review Results:

2.e

RSC-6.h

No data

Subsection #2, Data
Element K

Review Results:

2.e

RSC-6.h

No data

Subsection #2, Data
Element L

Review Results:

2.e

RSC-6.i

RSC-6: Organization accurately calculates the total number of organization
determinations, including the following criteria:

No data

Data Sources:

i: Excludes dismissals and withdrawals.

*

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

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-6.i

No data

Subsection #1, Data
Element A

2.e

RSC-6.i

No data

Subsection #1, Data
Element D

Review Results:

2.e

RSC-6.i

No data

Subsection #1, Data
Element E

Review Results:

2.e

RSC-6.i

No data

Subsection #1, Data
Element F

Review Results:

2.e

RSC-6.i

No data

Subsection #1, Data
Element G

Review Results:

2.e

RSC-6.i

No data

Subsection #2, Data
Element I

Review Results:

2.e

RSC-6.i

No data

Subsection #2, Data
Element J

Review Results:

2.e

RSC-6.i

No data

Subsection #2, Data
Element K

Review Results:

2.e

RSC-6.i

No data

Subsection #2, Data
Element L

Review Results:

2.e

RSC-6.j

RSC-6: Organization accurately calculates the total number of organization
determinations, including the following criteria:

No data

Data Sources:

Standard/Sub-standard Description

Data Element

j: Excludes Independent Review Entity (IRE) Decisions.
2.e

RSC-6.j

No data

Subsection #1, Data
Element A

Review Results:

2.e

RSC-6.j

No data

Subsection #1, Data
Element D

Review Results:

2.e

RSC-6.j

No data

Subsection #1, Data
Element E

Review Results:

2.e

RSC-6.j

No data

Subsection #1, Data
Element F

Review Results:

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

*

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

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-6.j

No data

Subsection #1, Data
Element G

2.e

RSC-6.j

No data

Subsection #2, Data
Element I

Review Results:

2.e

RSC-6.j

No data

Subsection #2, Data
Element J

Review Results:

2.e

RSC-6.j

No data

Subsection #2, Data
Element K

Review Results:

2.e

RSC-6.j

No data

Subsection #2, Data
Element L

Review Results:

2.e

RSC-6.k

RSC-6: Organization accurately calculates the total number of organization
determinations, including the following criteria:

No data

Data Sources:

Standard/Sub-standard Description

Data Element

k: Excludes Quality Improvement Organization (QIO) reviews of a member’s
request to continue Medicare-covered services (e.g., a SNF stay).
2.e

RSC-6.k

No data

Subsection #1, Data
Element A

Review Results:

2.e

RSC-6.k

No data

Subsection #1, Data
Element D

Review Results:

2.e

RSC-6.k

No data

Subsection #1, Data
Element E

Review Results:

2.e

RSC-6.k

No data

Subsection #1, Data
Element F

Review Results:

2.e

RSC-6.k

No data

Subsection #1, Data
Element G

Review Results:

2.e

RSC-6.k

No data

Subsection #2, Data
Element I

Review Results:

2.e

RSC-6.k

No data

Subsection #2, Data
Element J

Review Results:

2.e

RSC-6.k

No data

Subsection #2, Data
Element K

Review Results:

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

*

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

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-6.k

No data

Subsection #2, Data
Element L

2.e

RSC-6.l

RSC-6: Organization accurately calculates the total number of organization
determinations, including the following criteria:

No data

Data Sources:

Standard/Sub-standard Description

Data Element

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

*

l: Excludes duplicate payment requests concerning the same service or item.
2.e

RSC-6.l

No data

Subsection #1, Data
Element A

Review Results:

2.e

RSC-6.l

No data

Subsection #1, Data
Element D

Review Results:

2.e

RSC-6.l

No data

Subsection #1, Data
Element E

Review Results:

2.e

RSC-6.l

No data

Subsection #1, Data
Element F

Review Results:

2.e

RSC-6.l

No data

Subsection #1, Data
Element G

Review Results:

2.e

RSC-6.l

No data

Subsection #2, Data
Element I

Review Results:

2.e

RSC-6.l

No data

Subsection #2, Data
Element J

Review Results:

2.e

RSC-6.l

No data

Subsection #2, Data
Element K

Review Results:

2.e

RSC-6.l

No data

Subsection #2, Data
Element L

Review Results:

2.e

RSC-6.m

RSC-6: Organization accurately calculates the total number of organization
determinations, including the following criteria:

No data

Data Sources:

m: Excludes payment requests returned to an enrollee/representative or noncontract provider in which a substantive decision (fully favorable, partially
favorable or adverse) has not yet been made due to error (e.g., payment
requests or forms that are incomplete, invalid or do not meet the requirements
for a Medicare claim).

*

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

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-6.m

No data

Subsection #1, Data
Element A

2.e

RSC-6.m

No data

Subsection #1, Data
Element D

Review Results:

2.e

RSC-6.m

No data

Subsection #1, Data
Element E

Review Results:

2.e

RSC-6.m

No data

Subsection #1, Data
Element F

Review Results:

2.e

RSC-6.m

No data

Subsection #1, Data
Element G

Review Results:

2.e

RSC-6.m

No data

Subsection #2, Data
Element I

Review Results:

2.e

RSC-6.m

No data

Subsection #2, Data
Element J

Review Results:

2.e

RSC-6.m

No data

Subsection #2, Data
Element K

Review Results:

2.e

RSC-6.m

No data

Subsection #2, Data
Element L

Review Results:

2.e

RSC-7.a

RSC-7: Organization accurately calculates the number of organization
determinations, including the following criteria:

No data

Data Sources:

Standard/Sub-standard Description

Data Element

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

*

a: Includes all service organization determinations requested by
enrollee/representative, provider on behalf of enrollee, or non-contract
provider.
2.e

RSC-7.a

No data

Subsection #1, Data
Element D

Review Results:

2.e

RSC-7.a

No data

Subsection #1, Data
Element F

Review Results:

2.e

RSC-7.b

RSC-7: Organization accurately calculates the number of organization
determinations, including the following criteria:

No data

Data Sources:

b: Includes all payment (claim) organization determinations submitted by
enrollee/representative or non-contract provider.

*

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

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-7.b

No data

Subsection #1, Data
Element E

2.e

RSC-7.b

No data

Subsection #1, Data
Element G

Review Results:

2.e

RSC-8.a

RSC-8: Organization accurately calculates the number of adverse (e.g., denial of
entire request resulting in no coverage of the item or service) organization
determinations, including the criteria below. All non-adverse organization
determinations must be either partially or fully favorable organization
determinations.

No data

Data Sources:

2.e

RSC-8.a

No data

Subsection #2, Data
Element I

Review Results:

2.e

RSC-8.a

No data

Subsection #2, Data
Element J

Review Results:

2.e

RSC-8.b

RSC-8: Organization accurately calculates the number of adverse (e.g., denial of
entire request resulting in no coverage of the item or service) organization
determinations, including the criteria below. All non-adverse organization
determinations must be either partially or fully favorable organization
determinations.

No data

Data Sources:

2.e

RSC-8.b

No data

Subsection #2 Data
Element K

Review Results:

2.e

RSC-8.b

No data

Subsection #2 Data
Element L

Review Results:

2.e

RSC-9.a

RSC-9: Organization accurately calculates “Withdrawn Organization
Determination” according to the following criteria:

No data

Data Sources:

Standard/Sub-standard Description

Data Element

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

*

*

*

a: Includes an organization determination that is withdrawn upon the enrollee’s
request, the enrollee representative's request, or the enrollee provider's request
but excludes appeals that the organization forwards to the IRE for dismissal.
2.e

RSC-9.a

No data

Subsection #1, Data
Element B

Review Results:

2.e

RSC-10.a

RSC-10: Organization accurately calculates “Organization Determinations Dismissals” according to the following criteria:

No data

Data Sources:

a: Includes dismissals that were processed in accordance with the Parts C & D
Enrollee Grievances, Organization/Coverage Determinations and Appeals
Manual.

*

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-10.a

No data

2.e

RSC-11.a

RSC-11: Organization accurately calculates the total number of reconsiderations, No data
including the following criteria:

Standard/Sub-standard Description

Data Element
Subsection #1, Data
Element C

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

Data Sources:

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

*

a: Includes all completed reconsiderations (Part C only) both for services
requested by an enrollee/representative, or provider on behalf of the enrollee,
or non-contract provider, and claims submitted either by
enrollee/representative or non-contract provider with a date of member
notification of the final decision that occurs during the reporting period,
regardless of when the request for reconsideration was received.
2.e

RSC-11.a

No data

Subsection #3, Data
Element A

Review Results:

2.e

RSC-11.a

No data

Subsection #3, Data
Element D

Review Results:

2.e

RSC-11.a

No data

Subsection #3, Data
Element E

Review Results:

2.e

RSC-11.a

No data

Subsection #3, Data
Element F

Review Results:

2.e

RSC-11.a

No data

Subsection #3, Data
Element G

Review Results:

2.e

RSC-11.a

No data

Subsection #4, Data
Element I

Review Results:

2.e

RSC-11.a

No data

Subsection #4, Data
Element J

Review Results:

2.e

RSC-11.a

No data

Subsection #4, Data
Element K

Review Results:

2.e

RSC-11.a

No data

Subsection #4, Data
Element L

Review Results:

2.e

RSC-11.b

RSC-11: Organization accurately calculates the total number of reconsiderations, No data
including the following criteria:
b: Includes decisions made on behalf of the organization by a delegated entity.

Data Sources:

*

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

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-11.b

No data

Subsection #3, Data
Elements A

2.e

RSC-11.b

No data

Subsection #3, Data
Element D

Review Results:

2.e

RSC-11.b

No data

Subsection #3, Data
Element E

Review Results:

2.e

RSC-11.b

No data

Subsection #3, Data
Element F

Review Results:

2.e

RSC-11.b

No data

Subsection #3, Data
Element G

Review Results:

2.e

RSC-11.b

No data

Subsection #4, Data
Element I

Review Results:

2.e

RSC-11.b

No data

Subsection #4, Data
Element J

Review Results:

2.e

RSC-11.b

No data

Subsection #4, Data
Element K

Review Results:

2.e

RSC-11.b

No data

Subsection #4, Data
Element L

Review Results:

2.e

RSC-11.c

RSC-11: Organization accurately calculates the total number of reconsiderations, No data
including the following criteria:

Standard/Sub-standard Description

Data Element

Data Sources:

c: Includes all methods of reconsideration request receipt (e.g., telephone,
letter, fax, and in-person).
2.e

RSC-11.c

No data

Subsection #3, Data
Elements A

Review Results:

2.e

RSC-11.c

No data

Subsection #3, Data
Element D

Review Results:

2.e

RSC-11.c

No data

Subsection #3, Data
Element E

Review Results:

2.e

RSC-11.c

No data

Subsection #3, Data
Element F

Review Results:

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

*

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

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-11.c

No data

Subsection #3, Data
Element G

2.e

RSC-11.c

No data

Subsection #4, Data
Element I

Review Results:

2.e

RSC-11.c

No data

Subsection #4, Data
Element J

Review Results:

2.e

RSC-11.c

No data

Subsection #4, Data
Element K

Review Results:

2.e

RSC-11.c

No data

Subsection #4, Data
Element L

Review Results:

2.e

RSC-11.d

RSC-11: Organization accurately calculates the total number of reconsiderations, No data
including the following criteria:

Standard/Sub-standard Description

Data Element

Data Sources:

d: Includes all reconsiderations for services requested by an
enrollee/representative, or provider on behalf of the enrollee, or non-contract
provider, and claims submitted either by enrollee/representative or noncontract provider.
2.e

RSC-11.d

No data

Subsection #3, Data
Element A

Review Results:

2.e

RSC-11.d

No data

Subsection #3, Data
Element D

Review Results:

2.e

RSC-11.d

No data

Subsection #3, Data
Element E

Review Results:

2.e

RSC-11.d

No data

Subsection #3, Data
Element F

Review Results:

2.e

RSC-11.d

No data

Subsection #3, Data
Element G

Review Results:

2.e

RSC-11.d

No data

Subsection #4, Data
Element I

Review Results:

2.e

RSC-11.d

No data

Subsection #4, Data
Element J

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

2.e

RSC-11.d

No data

Subsection #4, Data
Element K

2.e

RSC-11.d

No data

Subsection #4, Data
Element L

2.e

RSC-11.e

RSC-11: Organization accurately calculates the total number of reconsiderations, No data
including the following criteria:

Standard/Sub-standard Description

Data Element

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

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

Review Results:

Data Sources:

e: Includes reconsiderations that are filed directly with the organization or its
delegated entities for services requested by an enrollee/representative, or
provider on behalf of the enrollee, or non-contract provider, and claims
submitted either by enrollee/representative or non-contract provider. If a
member requests a reconsideration directly with the organization and files an
identical complaint via the CTM, the organization includes only the
reconsideration that was filed directly with the organization and excludes the
identical CTM complaint.
2.e

RSC-11.e

No data

Subsection #3, Data
Element A

Review Results:

2.e

RSC-11.e

No data

Subsection #3, Data
Element D

Review Results:

2.e

RSC-11.e

No data

Subsection #3, Data
Element E

Review Results:

2.e

RSC-11.e

No data

Subsection #3, Data
Element F

Review Results:

2.e

RSC-11.e

No data

Subsection #3, Data
Element G

Review Results:

2.e

RSC-11.e

No data

Subsection #4, Data
Element I

Review Results:

2.e

RSC-11.e

No data

Subsection #4, Data
Element J

Review Results:

2.e

RSC-11.e

No data

Subsection #4, Data
Element K

Review Results:

2.e

RSC-11.e

No data

Subsection #4, Data
Element L

Review Results:

*

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-11.f

Standard/Sub-standard Description

Data Element

RSC-11: Organization accurately calculates the total number of reconsiderations, No data
including the following criteria:

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

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

f: Includes supplemental benefits (i.e., non- Medicare covered item or service)
provided as a part of a plan’s Medicare benefit package.
2.e

RSC-11.f

No data

Subsection #3, Data
Element A

Review Results:

2.e

RSC-11.f

No data

Subsection #3, Data
Element D

Review Results:

2.e

RSC-11.f

No data

Subsection #3, Data
Element E

Review Results:

2.e

RSC-11.f

No data

Subsection #3, Data
Element F

Review Results:

2.e

RSC-11.f

No data

Subsection #3, Data
Element G

Review Results:

2.e

RSC-11.f

No data

Subsection #4, Data
Element I

Review Results:

2.e

RSC-11.f

No data

Subsection #4, Data
Element J

Review Results:

2.e

RSC-11.f

No data

Subsection #4, Data
Element K

Review Results:

2.e

RSC-11.f

No data

Review Results:

2.e

RSC-11.g

Subsection #4, Data
Element L
RSC-11: Organization accurately calculates the total number of reconsiderations, No data
including the following criteria:

Data Sources:

g: Excludes dismissals and withdrawals.
2.e

RSC-11.g

No data

Subsection #3, Data
Element A

Review Results:

2.e

RSC-11.g

No data

Subsection #3, Data
Element D

Review Results:

*

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

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-11.g

No data

Subsection #3, Data
Element E

2.e

RSC-11.g

No data

Subsection #3, Data
Element F

Review Results:

2.e

RSC-11.g

No data

Subsection #3, Data
Element G

Review Results:

2.e

RSC-11.g

No data

Subsection #4, Data
Element I

Review Results:

2.e

RSC-11.g

No data

Subsection #4, Data
Element J

Review Results:

2.e

RSC-11.g

No data

Subsection #4, Data
Element K

Review Results:

2.e

RSC-11.g

No data

Subsection #4, Data
Element L

Review Results:

2.e

RSC-11.h

RSC-11: Organization accurately calculates the total number of reconsiderations, No data
including the following criteria:

Standard/Sub-standard Description

Data Element

Data Sources:

h: Excludes IRE Decisions.
2.e

RSC-11.h

No data

Subsection #3, Data
Element A

Review Results:

2.e

RSC-11.h

No data

Subsection #3, Data
Element D

Review Results:

2.e

RSC-11.h

No data

Subsection #3, Data
Element E

Review Results:

2.e

RSC-11.h

No data

Subsection #3, Data
Element F

Review Results:

2.e

RSC-11.h

No data

Subsection #3, Data
Element G

Review Results:

2.e

RSC-11.h

No data

Subsection #4, Data
Element I

Review Results:

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

*

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

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-11.h

No data

Subsection #4, Data
Element J

2.e

RSC-11.h

No data

Subsection #4, Data
Element K

Review Results:

2.e

RSC-11.h

No data

Subsection #4, Data
Element L

Review Results:

2.e

RSC-11.i

RSC-11: Organization accurately calculates the total number of reconsiderations, No data
including the following criteria:

Standard/Sub-standard Description

Data Element

Data Sources:

i: Excludes QIO reviews of a member’s request to continue Medicare-covered
services (e.g., a SNF stay).
2.e

RSC-11.i

No data

Subsection #3, Data
Element A

Review Results:

2.e

RSC-11.i

No data

Subsection #3, Data
Element D

Review Results:

2.e

RSC-11.i

No data

Subsection #3, Data
Element E

Review Results:

2.e

RSC-11.i

No data

Subsection #3, Data
Element F

Review Results:

2.e

RSC-11.i

No data

Subsection #3, Data
Element G

Review Results:

2.e

RSC-11.i

No data

Subsection #4, Data
Element I

Review Results:

2.e

RSC-11.i

No data

Subsection #4, Data
Element J

Review Results:

2.e

RSC-11.i

No data

Subsection #4, Data
Element K

Review Results:

2.e

RSC-11.i

No data

Subsection #4, Data
Element L

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

2.e

RSC-11.j

Standard/Sub-standard Description

Data Element

RSC-11: Organization accurately calculates the total number of reconsiderations, No data
including the following criteria:

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

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

j: Excludes duplicate payment requests concerning the same service or item.
2.e

RSC-11.j

No data

Subsection #3, Data
Element A

Review Results:

2.e

RSC-11.j

No data

Subsection #3, Data
Element D

Review Results:

2.e

RSC-11.j

No data

Subsection #3, Data
Element E

Review Results:

2.e

RSC-11.j

No data

Subsection #3, Data
Element F

Review Results:

2.e

RSC-11.j

No data

Subsection #3, Data
Element G

Review Results:

2.e

RSC-11.j

No data

Subsection #4, Data
Element I

Review Results:

2.e

RSC-11.j

No data

Subsection #4, Data
Element J

Review Results:

2.e

RSC-11.j

No data

Subsection #4, Data
Element K

Review Results:

2.e

RSC-11.j

No data

Subsection #4, Data
Element L

Review Results:

2.e

RSC-11.k

RSC-11: Organization accurately calculates the total number of reconsiderations, No data
including the following criteria:

Data Sources:

k: Excludes payment requests returned to an enrollee/representative or noncontract provider in which a substantive decision (Fully Favorable, Partially
Favorable or Adverse) has not yet been made due to error (e.g., payment
requests or forms that are incomplete, invalid or do not meet the requirements
for a Medicare claim).
2.e

RSC-11.k

No data

Subsection #3, Data
Element A

Review Results:

*

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

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-11.k

No data

Subsection #3, Data
Element D

2.e

RSC-11.k

No data

Subsection #3, Data
Element E

Review Results:

2.e

RSC-11.k

No data

Subsection #3, Data
Element F

Review Results:

2.e

RSC-11.k

No data

Subsection #3, Data
Element G

Review Results:

2.e

RSC-11.k

No data

Subsection #4, Data
Element I

Review Results:

2.e

RSC-11.k

No data

Subsection #4, Data
Element J

Review Results:

2.e

RSC-11.k

No data

Subsection #4, Data
Element K

Review Results:

2.e

RSC-11.k

No data

Subsection #4, Data
Element L

Review Results:

2.e

RSC-12.a

RSC-12: Organization accurately calculates the number of adverse (e.g., denial of No data
entire request resulting in no coverage of the item or service) reconsiderations,
including the criteria below. All non-adverse organization reconsiderations must
be either partially or fully favorable organization determinations:

2.e

RSC-12.a

a: Includes all adverse service reconsideration determinations requested by
No data

2.e

RSC-12.a

No data

2.e

RSC-12.b

RSC-12: Organization accurately calculates the number of adverse (e.g., denial of No data
entire request resulting in no coverage of the item or service) reconsiderations,
including the criteria below. All non-adverse organization reconsiderations must
be either partially or fully favorable organization determinations:

2.e

RSC-12.b

Standard/Sub-standard Description

b: Includes all adverse payment (claim) reconsideration determinations
No data

Data Element

Data Sources:

Subsection #4, Data
Element I

Review Results:

Subsection #4, Data
Element J

Review Results:

Subsection #4, Data
Element K

Data Sources:

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

2.e

RSC-12.b

No data

2.e

RSC-12.c

RSC-12: Organization accurately calculates the number of adverse (e.g., denial of No data
entire request resulting in no coverage of the item or service) reconsiderations,
including the criteria below. All non-adverse organization reconsiderations must
be either partially or fully favorable organization determinations:

2.e

RSC-12.c

No data

2.e

RSC-12.c

2.e

Standard/Sub-standard Description

Data Element
Subsection #4, Data
Element L

h

d

f

b

d

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

Data Sources:

Subsection #4, Data
Element I

Review Results:

No data

Subsection #4, Data
Element J

Review Results:

RSC-12.c

No data

Subsection #4, Data
Element K

Review Results:

2.e

RSC-12.c

No data

Subsection #4, Data
Element L

Review Results:

2.e

RSC-13.a

RSC-13: Organization accurately calculates “Withdrawn Reconsiderations”
according to the following criteria:

No data

Data Sources:

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

*

*

a: Includes a Reconsideration that is withdrawn upon the enrollee’s request, the
enrollee representative's request, or the enrollee provider's request.
2.e

RSC-13.a

No data

Subsection #3, Data
Element B

Review Results:

2.e

RSC-14.a

RSC-14: Organization accurately calculates “Reconsiderations Dismissals”
according to the following criteria:

No data

Data Sources:

*

a: Includes reconsiderations dismissals that were processed in accordance with
the Parts C & D Enrollee Grievances, Organization/Coverage Determinations and
Appeals Manual.
2.e

RSC-14.a

No data

Subsection #3, Data
Element C

Review Results:

2.e

RSC-15.a

RSC-15: Organization accurately calculates the total number of reopened
decisions according to the following criteria:

No data

Data Sources:

a: Includes a remedial action taken to change a final determination or decision
even though the determination or decision was correct based on the evidence of
record.

*

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

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-15.a

No data

Subsection #5, Data
Element A

2.e

RSC-16.a

RSC-16: The organization accurately reports the following information for each
reopened case:

No data

Data Sources:

Standard/Sub-standard Description

Data Element

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

*

a: Contract Number
2.e

RSC-16.a

No data

Subsection #5, Data
Element B

Review Results:

2.e

RSC-16.b

RSC-16: The organization accurately reports the following information for each
reopened case:

No data

Data Sources:

*

b: Date of original disposition
2.e

RSC-16.b

No data

Subsection #5, Data
Element F

Review Results:

2.e

RSC-16.c

RSC-16: The organization accurately reports the following information for each
reopened case:

No data

Data Sources:

*

c: Original disposition (Fully Favorable; Partially Favorable; or Adverse)
2.e

RSC-16.c

No data

Subsection #5, Data
Element G

Review Results:

2.e

RSC-16.d

RSC-16: The organization accurately reports the following information for each
reopened case:

No data

Data Sources:

*

d: Case Level (Organization Determination or Reconsideration)
2.e

RSC-16.d

No data

Subsection #5, Data
Element E

Review Results:

2.e

RSC-16.e

RSC-16: The organization accurately reports the following information for each
reopened case:

No data

Data Sources:

Subsection #5, Data
Element K
No data

Review Results:

*

e: Date case was reopened
2.e

RSC-16.e

No data

2.e

RSC-16.f

RSC-16: The organization accurately reports the following information for each
reopened case:
f: Reason (s) for reopening (Clerical Error, Other Error, New and Material
Evidence, Fraud or Similar Fault, or Other)

Data Sources:

*

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

Standard/Sub-standard ID

Reporting
Section
Criteria ID

2.e

RSC-16.f

No data

Subsection #5, Data
Element L

2.e

RSC-16.g

RSC-16: The organization accurately reports the following information for each
reopened case:

No data

Data Sources:

Standard/Sub-standard Description

Data Element

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

*

g: Date of reopening disposition (revised decision)
2.e

RSC-16.g

No data

Subsection #5, Data
Element N

Review Results:

2.e

RSC-16.h

RSC-16: The organization accurately reports the following information for each
reopened case:

No data

Data Sources:

Subsection #5, Data
Element O

Review Results:

*

h: Reopening disposition (Fully Favorable; Partially Favorable, Adverse, or
Pending)
2.e

RSC-16.h

No data

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.

Subsection #1, Data
Element A

Review Results:

3.a

No data

No data

Subsection #1, Data
Element B

Review Results:

3.a

No data

No data

Subsection #1, Data
Element C

Review Results:

3.a

No data

No data

Subsection #1, Data
Element D

Review Results:

3.a

No data

No data

Subsection #1, Data
Element E

Review Results:

3.a

No data

No data

Subsection #1, Data
Element F

Review Results:

3.a

No data

No data

Subsection #1, Data
Element G

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
Review Results:

3.a

No data

No data

Subsection #2, Data
Element I

3.a

No data

No data

Subsection #2, Data
Element J

Review Results:

3.a

No data

No data

Subsection #2, Data
Element K

Review Results:

3.a

No data

No data

Subsection #2, Data
Element L

Review Results:

3.a

No data

No data

Subsection #3, Data
Element A

Review Results:

3.a

No data

No data

Subsection #3, Data
Element B

Review Results:

3.a

No data

No data

Subsection #3, Data
Element C

Review Results:

3.a

No data

No data

Subsection #3, Data
Element D

Review Results:

3.a

No data

No data

Subsection #3, Data
Element E

Review Results:

3.a

No data

No data

Subsection #3, Data
Element F

Review Results:

3.a

No data

No data

Subsection #3, Data
Element G

Review Results:

3.a

No data

No data

Subsection #4, Data
Element I

Review Results:

3.a

No data

No data

Subsection #4, Data
Element J

Review Results:

3.a

No data

No data

Subsection #4, Data
Element K

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 Element

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

3.a

No data

No data

Subsection #4, Data
Element L

3.a

No data

No data

Subsection #5, Data
Element A

Review Results:

3.a

No data

No data

Subsection #5, Data
Element B

Review Results:

3.a

No data

No data

Subsection #5, Data
Element E

Review Results:

3.a

No data

No data

Subsection #5, Data
Element F

Review Results:

3.a

No data

No data

Subsection #5, Data
Element G

Review Results:

3.a

No data

No data

Subsection #5, Data
Element H

Review Results:

3.a

No data

No data

Subsection #5, Data
Element I

Review Results:

3.a

No data

No data

Subsection #5, Data
Element J

Review Results:

3.a

No data

No data

Subsection #5, Data
Element K

Review Results:

3.a

No data

No data

Subsection #5, Data
Element L

Review Results:

3.a

No data

No data

Subsection #5, Data
Element M

Review Results:

3.a

No data

No data

Subsection #5, Data
Element N

Review Results:

3.a

No data

No data

Subsection #5, Data
Element O

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 Element

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

3.b

No data

All source, intermediate, and final stage data sets and other outputs relied upon No data
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, 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:

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