CMS-10305 Special Needs Plans (SNPs) Care Management 2022

Special Needs Plans (SNPs) Care Management 2022
Organization Name:
Contract Number:
Reporting Section:

no data

Special Needs
Plans (SNPs) Care
Management
2022

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 sub-standard have
been completely met. If any requirement for the standard or substandard
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.
no data
Standard/Sub-standard ID

Reporting
Section Criteria
ID

no data2

no data3

no data4

no data5

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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

Standard/Sub-standard Description

Data Element

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

1

No data

A review of source documents (e.g., programming code, spreadsheet formulas, No data
analysis plans, saved data queries, file layouts, process flows) indicates that all
source documents accurately capture required data fields and are properly
documented.

Data Sources:

1.a

No data

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

No data

Review Results:

1.b

No data

Source documents create all required data fields for reporting requirements.

No data

Review Results:

1.c

No data

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

No data

Review Results:

1.d

No data

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

No data

Review Results:

1.e

No data

Data file locations are referenced correctly.

No data

Review Results:

1.f

No data

If used, macros are properly documented.

No data

Review Results:

1.g

No data

Source documents are clearly and adequately documented.

No data

Review Results:

1.h

No data

Titles and footnotes on reports and tables are accurate.

No data

Review Results:

Enter

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
No data

1.i

No data

Version control of source documents is appropriately applied.

2

No data

A review of source documents (e.g., programming code, spreadsheet formulas, No data
analysis plans, saved data queries, file layouts, process flows) and census or
sample data, whichever is applicable, indicates that data elements for each
reporting section are accurately identified, processed, and calculated.

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

Enter

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

Review Results:

Data Sources:

2.a

RSC-1

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.

No data

Review Results:

2.b

RSC-2

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

Review Results:

2.c

RSC-3

*

Organization properly assigns data to the applicable CMS plan benefit package.
Appropriate deadlines are met for reporting data (e.g., quarterly).

No data

Review Results:

No data

Review Results:

Organization meets deadline for reporting annual data to CMS by 2/27/2023.
[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.]
2.d

RSC - 4

Terms used are properly defined per CMS regulations, guidance, Reporting
Requirements, and Technical Specifications.
Organization properly defines the term Health Risk Assessment (HRA) as
defined in 42 CFR § 422.101 (f). This includes applying all relevant guidance
properly when performing its HRA.

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 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:

2.e

RSC - 5 a

No data

Review Results:

2.e

RSC - 5b

RSC-5: Organization accurately calculates the number of new members who are No data
eligible for an initial health risk assessment (HRA), including the following
criteria:

Data Element A

Data Sources:

b: Includes members who have an effective enrollment date that falls within
the measurement year, are continuously enrolled for fewer than 90 days, and
complete an initial HRA. (Data Element A)
2.e

RSC - 5b

No data

Data Element A

Review Results:

*

*

Standard/Sub-standard ID

Reporting
Section Criteria
ID

2.e

RSC 5.c

Standard/Sub-standard Description

Data Element

RSC-5: Organization accurately calculates the number of new members who are No data
eligible for an initial health risk assessment (HRA), including the following
criteria:

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

Enter

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

c: Includes members who have an effective enrollment date that falls in the
previous measurement year, but a 90-day deadline for initial HRA completion
that falls in this measurement year, if no initial HRA was completed in the
previous measurement year. (Data Element A)
2.e

RSC 5.c

No data

2.e

RSC 5.d

RSC-5: Organization accurately calculates the number of new members who are No data
eligible for an initial health risk assessment (HRA), including the following
criteria:

Data Element A

Review Results:

Data Sources:

*

d: Includes members who have enrolled in the plan after dis- enrolling from
another plan (different sponsor or organization). (Data Element A)
2.e

RSC 5.d

No data

2.e

RSC 5. e

RSC-5: Organization accurately calculates the number of new members who are No data
eligible for an initial health risk assessment (HRA), including the following
criteria:

Data Element A

Review Results:

Data Sources:

*

e: Includes members who dis-enrolled from and re-enrolled into the same plan
if an initial HRA was not performed prior to dis-enrollment and calculates the
member’s eligibility date starting from the date of re- enrollment. (Data
Element A)
2.e

RSC 5. e

No data

2.e

RSC 5.f

RSC-5: Organization accurately calculates the number of new members who are No data
eligible for an initial health risk assessment (HRA), including the following
criteria:

Data Element A

Review Results:

Data Sources:

*

f: Excludes continuously enrolled members with a documented initial HRA that
occurred under the plan during the previous year. These members, and their
HRAs, should be counted as new in the previous year. (Data Element A)
2.e

RSC 5.f

No data

2.e

RSC 5.g

RSC-5: Organization accurately calculates the number of new members who are No data
eligible for an initial health risk assessment (HRA), including the following
criteria:

Data Element A

Review Results:

Data Sources:

*

g: Excludes members who received an initial HRA but were subsequently
deemed ineligible because they were never enrolled in the plan. (Data Element
A)
2.e

RSC 5.g

No data

2.e

RSC 5.h

RSC-5: Organization accurately calculates the number of new members who are No data
eligible for an initial health risk assessment (HRA), including the following
criteria:
h: Excludes members who disenroll from the plan prior to the effective
enrollment date or within the first 90 days after the effective enrollment date, if
an initial HRA was not completed prior to disenrolling.

Data Element A

Review Results:

Data Sources:

*

Standard/Sub-standard ID

Reporting
Section Criteria
ID

2.e

RSC 5.h

No data

2.e

RSC 5.i

RSC-5: Organization accurately calculates the number of new members who are No data
eligible for an initial health risk assessment (HRA), including the following
criteria:

Standard/Sub-standard Description

Data Element
Data Element A

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

Enter

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

Review Results:

Data Sources:

*

i: Excludes enrollees who receive an initial or reassessment HRA and remain
continuously enrolled under a MAO whose contract was part of a consolidation
of merger under the same legal entity during the member’s continuous
enrollment, where the consolidated SNP is still under the same Model of Care
(MOC) as the enrollee’s previous SNP. (Data Element A)
2.e

RSC 5.i

No data

Data Element A

Review Results:

2.e

RSC-6.a

RSC-6: Organization accurately reports data by applying data integrity checks
listed below and uploads it into HPMS.

No data

Data Sources:

*

a: The number of initial HRAs performed on new enrollees (Data Element C)
does not exceed the number of new enrollees (Data Element A).

2.e

RSC-6.a

No data

Data Element C

Review Results:

2.e

RSC-6.b

RSC-6: Organization accurately reports data by applying data integrity checks
listed below and uploads it into HPMS.

No data

Data Sources:

*

b: The number of annual re-assessments performed (Data Element F) does not
exceed number of enrollees eligible for annual HRA (Data Element B).

2.e

RSC-6.b

No data

Data Element F

Review Results:

2.e

RSC-6.c

RSC-6: Organization accurately reports data by applying data integrity checks
listed below and uploads it into HPMS.

No data

Data Sources:

*

c: Number of initial HRAs refusals (Data Element D) does not exceed number of
new enrollees (Data Element A).

2.e

RSC-6.c

No data

Data Element D

Review Results:

2.e

RSC-6.d

RSC-6: Organization accurately reports data by applying data integrity checks
listed below and uploads it into HPMS.

No data

Data Sources:

Data Element G

Review Results:

d: Number of annual reassessment refusals (Data Element G) does not exceed
the number of enrollees eligible for an annual reassessment HRA (Data Element
B).
2.e

RSC-6.d

No data

*

Standard/Sub-standard ID

Reporting
Section Criteria
ID

2.e

RSC-6.e

Standard/Sub-standard Description
RSC-6: Organization accurately reports data by applying data integrity checks
listed below and uploads it into HPMS.

Data Element

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

No data

Data Sources:

Enter

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

e: Number of initial HRAs where SNP is unable to reach enrollees (Data Element
E) does not exceed number of new enrollees (Data Element A).

2.e

RSC-6.e

No data

Data Element E

Review Results:

2.e

RSC-6.f

RSC-6: Organization accurately reports data by applying data integrity checks
listed below and uploads it into HPMS.

No data

Data Sources:

*

f: Number of annual reassessments where SNP is unable to reach enrollee
(Data Element H) does not exceed number of enrollees eligible for annual HRA
(Data Element B).
2.e

RSC-6.f

No data

Data Element H

Review Results:

2.e

RSC-6.g

RSC-6: Organization accurately reports data by applying data integrity checks
listed below and uploads it into HPMS.

No data

Data Sources:

*

g: If the organization received a CMS outlier/data integrity notice, validate
whether or not an internal procedure change was warranted or resubmission
through HPMS. (Data Element A-H)
2.e

RSC-6.g

No data

Data Elements A-H

Review Results:

2.e

RSC-7.a

RSC-7: Organization accurately calculates the number of members eligible for
an annual health risk reassessment during the reporting period, including the
following criteria:

No data

Data Sources:

*

a: Includes members who remained continuously enrolled in the same plan for
365 days, starting from the initial day of enrollment if no initial HRA had been
performed, or from the date of their previous HRA.
2.e

RSC-7.a

No data

Data Element B

Review Results:

2.e

RSC-7.b

RSC-7: Organization accurately calculates the number of members eligible for
an annual health risk reassessment during the reporting period, including the
following criteria:

No data

Data Sources:

*

b: Includes members who received a reassessment during the measurement
year within 365 days after their last HRA.
2.e

RSC-7.b

No data

Data Element B

Review Results:

2.e

RSC-7.c

RSC-7: Organization accurately calculates the number of members eligible for
an annual health risk reassessment during the reporting period, including the
following criteria:

No data

Data Sources:

Data Element B

Review Results:

c: Includes new enrollees who missed both the deadline to complete an initial
HRA and the deadline to complete a reassessment HRA, and are enrolled for all
365 days of the measurement year.
2.e

RSC-7.c

No data

*

Standard/Sub-standard ID

Reporting
Section Criteria
ID

2.e

RSC-7.d

Standard/Sub-standard Description
RSC-7: Organization accurately calculates the number of members eligible for
an annual health risk reassessment during the reporting period, including the
following criteria:

Data Element

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

No data

Data Sources:

Enter

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

d: Includes new enrollees who missed an initial HRA, but completed a
reassessment HRA by the 365-day deadline (even if the enrollee was covered
for fewer than 365 days).
2.e

RSC-7.d

No data

Data Element B

Review Results:

2.e

RSC-7.e

RSC-7: Organization accurately calculates the number of members eligible for
an annual health risk reassessment during the reporting period, including the
following criteria:

No data

Data Sources:

2.e

RSC-7.e

2.e

RSC-7.f

e: Includes members who dis-enrolled from and re-enrolled into the same plan
if an initial HRA was performed within 90 days of re-enrollment and the
member has continuously enrolled in the same plan for up to 365 days since
the initial HRA.
No data
Data Element B

RSC-7: Organization accurately calculates the number of members eligible for
an annual health risk reassessment during the reporting period, including the
following criteria:

*

Review Results:

No data

Data Sources:

*

f: Includes members who dis-enrolled from and re-enrolled into the same plan
if an initial HRA or reassessment was not performed within 90 days of reenrollment. The enrollee becomes eligible for a reassessment HRA the day after
the 90-day initial period expires.
2.e

RSC-7.f

No data

Data Element B

Review Results:

2.e

RSC-7.g

RSC-7: Organization accurately calculates the number of members eligible for
an annual health risk reassessment during the reporting period, including the
following criteria:

No data

Data Sources:

*

g: Excludes enrollees for whom the initial HRA was completed within the
current measurement year.
2.e

RSC-7.g

No data

Data Element B

Review Results:

2.e

RSC-7.h

RSC-7: Organization accurately calculates the number of members eligible for
an annual health risk reassessment during the reporting period, including the
following criteria:

No data

Data Sources:

*

h: Excludes new enrollees who miss the deadline to complete an initial HRA,
and have not yet completed their reassessment HRA, but whose 365-day
reassessment deadline is not until the following calendar year.
2.e

RSC-7.h

No data

Data Element B

Review Results:

2.e

RSC-7.i

RSC-7: Organization accurately calculates the number of members eligible for
an annual health risk reassessment during the reporting period, including the
following criteria:

No data

Data Sources:

i. Excludes members who received a reassessment but were subsequently
deemed ineligible because they were never enrolled in the plan.

*

Standard/Sub-standard ID

Reporting
Section Criteria
ID

2.e

RSC-7.i

No data

Data Element B

Review Results:

2.e

RSC-7.j

RSC-7: Organization accurately calculates the number of members eligible for
an annual health risk reassessment during the reporting period, including the
following criteria:

No data

Data Sources:

Standard/Sub-standard Description

Data Element

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

Enter

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

*

j: Excludes members who were not continuously enrolled in their same health
plan for 365 days after their last HRA and did not receive a reassessment HRA.
2.e

RSC-7.j

No data

Data Element B

Review Results:

2.e

RSC-8.a

RSC-8: Organization accurately calculates the number of initial health risk
assessments performed on new members, including the following criteria:

No data

Data Sources:

*

[Note to reviewer: CMS has not identified a standard tool that SNPs must use to
complete initial and annual health risk assessments. The information will not be
captured by designated CPT or ICD-10 Procedure codes. Reviewer should
confirm that the SNP maintained documentation for each reported
assessment.]
2.e

RSC-8.a

No data

Data Element C

Review Results:

2.e

RSC-8.b

RSC-8: Organization accurately calculates the number of initial health risk
assessments performed on new members, including the following criteria:

No data

Data Sources:

*

b: The initial HRA is counted in the year that the effective date of enrollment
occurred. For members who dis-enrolled from and re-enrolled into the same
plan, excludes any HRAs (initial or reassessment) performed during their
previous enrollment unless the re-enrollment occurred the day after the
disenrollment.
2.e

RSC-8.b

No data

Data Element C

Review Results:

2.e

RSC-8.c

RSC-8: Organization accurately calculates the number of initial health risk
assessments performed on new members, including the following criteria:

No data

Data Sources:

*

c: For members who dis-enrolled from and re-enrolled into the same plan,
includes HRAs (initial or reassessment) performed during their previous
enrollment if the HRAs are not more than 365 days old.
2.e

RSC-8.c

No data

Data Element C

Review Results:

2.e

RSC-8.d

RSC-8: Organization accurately calculates the number of initial health risk
assessments performed on new members, including the following criteria:

No data

Data Sources:

Data Element C

Review Results:

d: Counts only one HRA for members who have multiple HRAs within 90 days
before or after the effective date of enrollment.

2.e

RSC-8.d

No data

*

Standard/Sub-standard ID

Reporting
Section Criteria
ID

2.e

RSC-8.e

Standard/Sub-standard Description
RSC-8: Organization accurately calculates the number of initial health risk
assessments performed on new members, including the following criteria:

Data Element

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

No data

Data Sources:

Enter

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

e: Excludes HRAs completed for members who were subsequently deemed
ineligible because they were never enrolled in the plan.

2.e

RSC-8.e

No data

Data Element C

Review Results:

2.e

RSC-9.a

RSC-9 Organization accurately calculates the number of initial health risk
assessments refusals, including the following criteria:

No data

Data Sources:

*

a: Includes only initial HRAs that were not performed within 90 days before or
after the effective date of enrollment/re-enrollment due to enrollee refusal.

2.e

RSC-9.a

No data

Data Element D

Review Results:

2.e

RSC-9.b

RSC-9 Organization accurately calculates the number of initial health risk
assessments refusals, including the following criteria:

No data

Data Sources:

*

b: Includes only initial HRA refusals for which the SNP has documentation of
enrollee refusal.

2.e

RSC-9.b

No data

Data Element D

Review Results:

2.e

RSC-10.a

RSC-10: Organization accurately calculates the number of initial health risk
assessments not performed due to SNP not being able to reach the enrollee,
including the following criteria:

No data

Data Sources:

*

a: Includes only initial HRAs not performed for which the SNP has
documentation showing that enrollee did not respond to the SNP’s attempts to
reach him/her. Documentation must show that the SNP made at least 3 phone
calls and sent a follow-up letter in its attempts to reach the enrollee.
2.e

RSC-10.a

No data

Data Element E

Review Results:

2.e

RSC-10.b

RSC-10 Organization accurately calculates the number of initial health risk
assessments not performed due to SNP not being able to reach the enrollee,
including the following criteria:

No data

Data Sources:

Data Element E

Review Results:

No data

Data Sources:

2.e

RSC-10.b

2.e

RSC-11.a

b: Includes only those initial HRAs not performed where the SNP made an
attempt to reach the enrollee at least within 90 days after the effective
enrollment date.
No data

RSC-11: Organization accurately calculates the number of annual health risk
reassessments performed on members eligible for a reassessment, including
the following criteria:
[Note to reviewer: CMS has not identified a standard tool that SNPs must use to
complete initial and annual health risk assessments. The information will not be
captured by designated CPT or ICD-10 Procedure codes. Reviewer should
confirm that the SNP maintained documentation for each reported
assessment.]

*

*

Standard/Sub-standard ID

Reporting
Section Criteria
ID

2.e

RSC-11.a

No data

Data Element F

Review Results:

2.e

RSC-11.b

RSC-11: Organization accurately calculates the number of annual health risk
reassessments performed on members eligible for a reassessment, including
the following criteria:

No data

Data Sources:

Standard/Sub-standard Description

Data Element

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

Enter

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

*

b: Includes annual HRA reassessments within 365 days of the member's initial
date of enrollment if the member did not receive an initial HRA within 90 days
before or after the effective date of enrollment.
2.e

RSC-11.b

No data

Data Element F

Review Results:

2.e

RSC-11.c

RSC-11: Organization accurately calculates the number of annual health risk
reassessments performed on members eligible for a reassessment, including
the following criteria:

No data

Data Sources:

*

c: Includes only HRAs that were performed between 1/1 and 12/31 of the
measurement year.
2.e

RSC-11.c

No data

Data Element F

Review Results:

2.e

RSC-11.d

RSC-11: Organization accurately calculates the number of annual health risk
reassessments performed on members eligible for a reassessment, including
the following criteria:

No data

Data Sources:

*

d: Counts only one HRA for members who have multiple reassessments within
365 days of becoming eligible for a reassessment.
2.e

RSC-11.d

No data

Data Element F

Review Results:

2.e

RSC-11.e

RSC-11: Organization accurately calculates the number of annual health risk
reassessments performed on members eligible for a reassessment, including
the following criteria:

No data

Data Sources:

*

e: Excludes HRAs completed for members who were subsequently deemed
ineligible because they were never enrolled in the plan.
2.e

RSC-11.e

No data

Data Element F

Review Results:

2.e

RSC-12.a

RSC-12: Organization accurately calculates the number of annual health risk
reassessments not performed on members eligible for a reassessment due to
enrollee refusal.

No data

Data Sources:

*

a: Only includes annual reassessments not performed due to enrollee refusal.

2.e

RSC-12.a

No data

Data Element G

Review Results:

2.e

RSC-12.b

RSC-12: Organization accurately calculates the number of annual health risk
reassessments not performed on members eligible for a reassessment due to
enrollee refusal.

No data

Data Sources:

Data Element G

Review Results:

b: Includes only annual reassessments refusals for which the SNP has
documentation of enrollee refusal.
2.e

RSC-12.b

No data

*

Standard/Sub-standard ID

Reporting
Section Criteria
ID

2.e

RSC-13.a

Standard/Sub-standard Description

Data Element

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

No data

Data Sources:

No data

Data Element H

Review Results:

RSC-13: Organization accurately calculates the number of annual health risk
reassessments not performed on members eligible for a reassessment due to
SNP not being able to reach enrollee.

Enter

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

a: Only includes annual reassessments not performed for which the SNP has
documentation showing that the enrollee did not respond to the plan’s
attempts to reach him/her. Documentation must show that the SNP made at
least 3 phone calls and sent a follow-up letter in its attempts to reach the
enrollee.
2.e

RSC-13.a

3

No data

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

No data

Data Sources:

3.a

No data

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

Data Element A

Review Results:

3.a

No data

No data

Data Element B

Review Results:

3.a

No data

No data

Data Element C

Review Results:

3.a

No data

No data

Data Element D

Review Results:

3.a

No data

No data

Data Element E

Review Results:

3.a

No data

No data

Data Element F

Review Results:

3.a

No data

No data

Data Element G

Review Results:

3.a

No data

No data

Data Element H

Review Results:

3.b

No data

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

No data

Review Results:

4

No data

Organization implements policies and procedures for periodic data system
updates (e.g., changes in enrollment, provider/pharmacy status, 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
another entity: Organization regularly monitors the quality and timeliness of
the data collected and/or reported by the delegated entity or first tier/
downstream contractor.

No data

Review Results:

*