Program Audits

Special Needs Plans Care
Coordination (SNPCC)
PROGRAM AUDIT PROTOCOL AND DATA
REQUEST

Program Audit Protocol and Data Request
Special Needs Plans Care Coordination (SNPCC)

Table of Contents

Program Audit Protocol ............................................................................................................................. 3
Purpose ........................................................................................................................................................ 3
Audit Elements Tested ............................................................................................................................... 3
Program Audit Data Request .................................................................................................................... 8
Audit Engagement and Universe Submission Phase ............................................................................... 8
Universe Submissions ............................................................................................................................. 8
Universe Requests ................................................................................................................................... 8
Universe Table 1: Special Needs Plans Enrollees (SNPE) Record Layout .............................................. 9
Supplemental Documentation Submissions........................................................................................ 12
Supplemental Documentation Requests ............................................................................................. 12
Audit Field Work Phase ........................................................................................................................... 12
Supporting Documentation Submissions ............................................................................................ 12
Root Cause Analysis Submissions ....................................................................................................... 13
Impact Analysis Submissions............................................................................................................... 13
Impact Analysis Requests .................................................................................................................... 13
Table 1IA: Care Coordination Impact Analysis (CC-IA) Record Layout ..............................................14
Table 2IA: HRA Timeliness Impact Analysis (HRAT-IA) Record Layout ...........................................18

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Program Audit Protocol and Data Request
Special Needs Plans Care Coordination (SNPCC)

Program Audit Protocol
Purpose
To evaluate performance in the areas outlined in this Program Audit Protocol and Data Request
related to Special Needs Plans Care Coordination (SNPCC). The Centers for Medicare and
Medicaid Services (CMS) performs its program audit activities in accordance with the SNPCC
Program Audit Data Request and applying the compliance standards outlined in this Program
Audit Protocol and the Program Audit Process Overview document. At a minimum, CMS will
evaluate cases against the criteria listed below. CMS may review factors not specifically
addressed below if it is determined that there are other related SNPCC requirements not being
met.
Audit Elements Tested
1. Care Coordination

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Program Audit Protocol and Data Request
Special Needs Plans Care Coordination (SNPCC)
Audit
Element
Not
Applicable

Compliance
Data Request
Standard
Universe
Universe
Table 1: Special
Integrity
Needs Plans Enrollees
Testing
(SNPE)

Method of Evaluation
Select 10 cases from Universe Table 1.
Prior to field work, CMS will schedule a
webinar with the Sponsoring organization to
verify accuracy of data within Table 1 for
each of the sampled cases. System data such
as enrollment dates, dates of initial HRA, etc.
will be verified.

Criteria Effective
01/01/2021
42 CFR § 422.504(e)
42 CFR § 422.504(f)

Review all cases selected for universe
integrity testing. The integrity of the universe
will be questioned if data points specific to
the sample case(s) are incomplete, do not
match, or cannot be verified by viewing the
Sponsoring organization’s systems and/or
other supporting documentation.

Care
Coordination

1.1

Universe Table 1:
Special Needs Plans
Enrollees (SNPE)
Table 2IA: HRA
Timeliness Impact
Analysis (HRAT-IA)

Sample selections will be provided to the
Sponsoring organization approximately one
hour prior to the scheduled integrity testing
webinar.
Conduct a timeliness test at the universe level
of enrollees who have been continuously
enrolled for at least 90 days, to determine
whether the Sponsoring organization
conducted initial health risk assessments
(IHRAs) within 90 days (before or after)
enrollees’ effective date of enrollment. IHRA
Timeliness assessments will be conducted
using current enrollments, from Table 1.
Assessments will be limited to individuals
enrolled with effective dates within 12 months
of the audit engagement letter.

42 CFR § 422.101(f)
42 CFR § 422.152(g)

Request an impact analysis for any enrollee
identified as not having an IHRA conducted
to quantify the outreach made by the
Sponsoring organization in an attempt to
conduct the IHRA within 90 days of
enrollment. Impact analysis review period is
limited to the 12-month period prior to date of
the engagement letter, to align with the
timeliness test.
*Outreach data points in Table 2IA are
subject to validation, as requested by CMS.

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Program Audit Protocol and Data Request
Special Needs Plans Care Coordination (SNPCC)
Audit
Element
Care
Coordination

Compliance
Standard
1.2

Data Request
Universe Table 1:
Special Needs Plans
Enrollees (SNPE)
Table 2IA: HRA
Timeliness Impact
Analysis (HRAT-IA)

Care
Coordination

1.3

Universe Table 1:
Special Needs Plans
Enrollees (SNPE)
Associated Model Of
Care (MOC)

Method of Evaluation
Conduct timeliness test at the universe level
of enrollees who have either been
continuously enrolled for 365 days or more,
or new enrollees who missed the deadline to
complete an initial HRA, to determine
whether the Sponsoring organization
conducted timely annual health re-assessment
HRAs (AHRAs).

Criteria Effective
01/01/2021
42 CFR § 422.101(f)
42 CFR § 422.152(g)

Request an impact analysis for any enrollee
identified as having an untimely AHRA to
quantify the outreach made by the
Sponsoring organization in an attempt to
conduct the AHRA within 365 days of the
prior HRA completion date, or date of
enrollment if no initial HRA was conducted.
42 CFR § 422.101(f)
Select a sample of 30 enrollees from Table 1
that reflect general composition of
membership in each of the Sponsoring
organization’s plan types or PBPs. A
minimum of 5 enrollees should be selected
from each plan type. If there are less than 5
enrollees included in the universe for that plan
type, then include them all in the sample. The
remaining number of sampled enrollees
should be from the plan type with the greatest
representation in the universe. Also consider
responses to Column IDs L and M in
Universe Table 1 when selecting samples.
Review the 30 selected samples to determine
whether the completed HRA included a
comprehensive initial assessment and
reassessment(s) of the needs of the enrollees
including, for example, the medical,
psychosocial, cognitive, functional, and
mental health needs.
Sample selections will be provided to the
Sponsoring organization the Thursday prior
to the start of audit field work.

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Program Audit Protocol and Data Request
Special Needs Plans Care Coordination (SNPCC)
Audit
Element
Care
Coordination

Compliance
Standard
1.4

Data Request
Universe Table 1:
Special Needs Plans
Enrollees (SNPE)
Associated Model Of
Care (MOC)

Method of Evaluation
Review the 30 selected samples to determine
whether the Sponsoring organization
completed an individualized care plan (ICP)
for each enrollee, designed to address needs
identified in the HRA, consistent with the
MOC.

Criteria
Effective
01/01/2021
42 CFR § 422.101(f)

Determine whether the ICP included
measurable outcomes, inclusive of a
timeframe for completion or evaluation if the
outcome was not met, in accordance with the
MOC.

Care
Coordination

Care
Coordination

1.5

1.6

Universe Table 1:
Special Needs Plans
Enrollees (SNPE)
Associated Model Of
Care (MOC)
Universe Table 1:
Special Needs Plans
Enrollees (SNPE)
Associated Model Of
Care (MOC)

Care
Coordination

1.7

Universe Table 1:
Special Needs Plans
Enrollees (SNPE)
Associated Model Of
Care (MOC)

Page 6 of 21

Consider whether the ICP includes the
following, in accordance with the MOC:
• The enrollee’s self-management goals
and objectives.
• The enrollee’s personal healthcare
preferences.
• A description of services specifically
tailored to the enrollee’s needs.
• Identification of goals (met or not met).
Review the 30 selected samples to determine
whether the enrollees’ ICPs were reviewed
and/or modified as there were changes to the
enrollees’ health care needs.

42 CFR § 422.101(f)
42 CFR § 422.152(g)

Review documentation which may include, but
is not limited to case management notes, ICT
documentation, and systems information such
as utilization management, claims data, and
prescription drug events (PDE) for each of the
30 selected samples to determine whether the
Sponsoring organization implemented the ICP.

42 CFR § 422.101(f)

Review documentation which may include,
but is not limited to ICT notes and
communications (amongst ICT members
and/or with enrollees/caregivers) pertaining to
each of the 30 selected samples to determine
how the enrollee or the
caregiver/representative was involved in the
ICP development.

42 CFR § 422.101(f)

42 CFR § 422.152(g)

42 CFR § 422.152(g)

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Program Audit Protocol and Data Request
Special Needs Plans Care Coordination (SNPCC)
Audit
Element
Care
Coordination

Compliance
Data Request
Standard
1.8
Universe Table 1:
Special Needs Plans
Enrollees (SNPE)
Associated Model Of
Care (MOC)

Care
Coordination

1.9

Universe Table 1:
Special Needs Plans
Enrollees (SNPE)
Associated Model Of
Care (MOC)

Care
Coordination

1.10

Universe Table 1:
Special Needs Plans
Enrollees (SNPE)
Associated Model Of
Care (MOC)

Care
Coordination

1.11

Universe Table 1:
Special Needs Plans
Enrollees (SNPE)
Associated Model Of
Care (MOC)

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Method of Evaluation
Review systems for documentation which
may include but is not limited to case
management notes, ICT member notes and
communications (e.g. documented phone
calls, letters to/from providers regarding
member care, etc.), and ICT meeting
agendas/minutes pertaining to each of the 30
selected samples to determine whether the
Sponsoring organization coordinated
communication amongst its personnel,
providers, and enrollees.
Review documentation for each of the 30
selected samples to determine whether each
enrollee’s:
• Care was managed by an interdisciplinary
care team (ICT) comprised of appropriate
clinical disciplines according to the SNP’s
approved MOC, as well as the inclusion of
specialists when needed.
• Primary care provider (PCP) was involved
in coordination of care and
communications (e.g., ICT meeting
attendee lists or other documentation
reflecting PCP interaction with ICT
members).
Review documentation for each of the 30
selected samples to determine whether the
Sponsoring organization developed and
implemented care transition protocols to
maintain continuity of care as defined in the
MOC.
Documentation may include, but is not
limited to:
• Case management and/or ICT notes.
• Correspondence with the enrollee’s PCP,
specialists, hospital, skilled nursing staff,
assisted living facility, etc.
• Discharge planning and/or care setting
transition discussions held with the
enrollee, the enrollee’s caregiver or
authorized representative.
Review documentation for each of the 30
selected samples to determine whether ICPs
were developed and implemented by staff
that met the professional requirements,
including credentials, described in the MOC.

Criteria Effective
01/01/2021
42 CFR § 422.101(f)

42 CFR § 422.101(f)

42 CFR § 422.101(f)

42 CFR § 422.101(f)

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Program Audit Protocol and Data Request
Special Needs Plans Care Coordination (SNPCC)
Audit
Element
Care
Coordination

Care
Coordination

Compliance
Data Request
Standard
1.12
Universe Table 1:
Special Needs Plans
Enrollees (SNPE)

1.13

Associated Model Of
Care (MOC)
Universe Table 1:
Special Needs Plans
Enrollees (SNPE)
Associated Model Of
Care (MOC)

Method of Evaluation
Review documentation for each of the 30
selected samples to determine whether each
member of the enrollee’s ICT received
training on the model of care.

Review documentation for each of the 30
selected samples to determine whether
network providers caring for each of the
enrollees received training on the model of
care. Specifically, review documentation
supporting that outreach was
conducted/training materials were provided
to network providers in accordance with the
MOC. Noting every provider’s completion
of training/certificate(s) is not necessary.

Criteria Effective
01/01/2021
42 CFR § 422.101(f)

42 CFR § 422.101(f)

Program Audit Data Request
Audit Engagement and Universe Submission Phase

Universe Submissions
Sponsoring organizations must submit each universe, comprehensive of all contracts and Plan
Benefit Packages (PBP) identified in the audit engagement letter, in either Microsoft Excel
(.xlsx) file format with a header row or Text (.txt) file format without a header row. Descriptions
and clarifications of what must be included in each submission and data field are outlined in the
individual universe record layouts below. Characters are required in all requested fields, unless
otherwise specified, and data must be limited to the request specified in each record layout.
Sponsoring organizations must provide accurate and timely universe submissions within 15
business days of the audit engagement letter date. Submissions that do not strictly adhere to the
record layout specifications will be rejected.
Universe Requests
1. Universe Table 1: Special Needs Plans Enrollees (SNPE) Record Layout
Universe
Record Layout
Table 1

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Scope of Universe Request
List of enrollees as of the date of the audit engagement letter

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Program Audit Protocol and Data Request
Special Needs Plans Care Coordination (SNPCC)
Please use the guidance below for the following record layout:
Universe Table 1: Special Needs Plans Enrollees (SNPE) Record Layout
• List all current SNP enrollees as of the date of the audit engagement letter.
• List each enrollee only once.
• Include enrollees with disenrollment effective dates at the end of month in which the audit
engagement letter is received.
• Exclude enrollments received before the date of the audit engagement letter that are not
effective until the first day of the month following the audit engagement letter.
Column ID

Field Name

A

Enrollee First
Name

B

Enrollee Last
Name

C

Enrollee ID

CHAR
11
Always
Required

D

Contract ID

E

Plan Benefit
Package (PBP)

F

Plan Type

CHAR
5
Always
Required
CHAR
3
Always
Required
CHAR
5
Always
Required

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Field
Type
CHAR
Always
Required
CHAR
Always
Required

Field
Length
50

Description

50

Enter the last name of the enrollee.

Enter the first name of the enrollee.

Enter the Medicare Beneficiary
Identifier (MBI) of the enrollee. An
MBI is the non-intelligent unique
identifier that replaced the HICN on
Medicare cards as a result of The
Medicare Access and CHIP
Reauthorization Act (MACRA) of
2015. The MBI contains uppercase
alphabetic and numeric characters
throughout the 11-digit identifier and
is unique to each Medicare enrollee.
This number must be submitted
excluding hyphens or dashes.
Enter the contract number (e.g.,
H1234) of the organization in which
the enrollee is currently part.
Enter the PBP (e.g., 001).
Enter type of SNP. Valid values are:
• D-SNP
• C-SNP
• I-SNP

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Program Audit Protocol and Data Request
Special Needs Plans Care Coordination (SNPCC)
Column ID

Field Name

G

Enrollment
Effective Date

H

Most Recent Plan
Change Effective
Date

Field
Field
Type
Length
CHAR
10
Always
Required

CHAR
10
Always
Required

Description
Enter the effective date of the most
current/continuous enrollment for the
enrollee with the Sponsoring
organization.
Submit in CCYY/MM/DD format
(e.g., 2020/01/01).
Enter the date of last plan change
within the continuous SNP
enrollment.
Submit in CCYY/MM/DD format
(e.g., 2020/01/01)
For a PBP change or consolidation
event the Sponsoring organization
must use the post-event effect date for
the enrollee.

I

Date of most
recent HRA

CHAR
10
Always
Required

Enter None if there were no PBP or
plan consolidation events.
Enter the date of the enrollee’s most
recently completed HRA.
Submit in CCYY/MM/DD format
(e.g., 2020/01/01).
Enter None if no HRA was
completed (e.g. when enrollee
refused the HRA or was unable to be
reached).
If only the Initial HRA has been
completed this date should equal the
Initial HRA date.

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Program Audit Protocol and Data Request
Special Needs Plans Care Coordination (SNPCC)
Column ID

Field Name

J

Date of previous
HRA

Field
Field
Type
Length
CHAR
10
Always
Required

Description
Enter the date of the enrollee’s
previously completed HRA.
Submit in CCYY/MM/DD format
(e.g., 2020/01/01).
This is the date of the most recently
completed HRA prior to the date
entered in Column ID I.

K

Date Initial HRA
(IHRA) was
completed

CHAR
10
Always
Required

Enter None if another HRA was
not completed (e.g. when enrollee
refused the HRA or was unable to
be reached).
Enter the date of the enrollee’s
first HRA completion (within 90
days before or after the effective
date of enrollment).
HRA completion date is the date
the HRA is returned completed to
the Sponsoring organization by
either the enrollee or the enrollee’s
representative.
Submit in CCYY/MM/DD format
(e.g., 2020/01/01).
Enter None if no HRA was completed
within 90 days before or after the
effective date of enrollment.

L

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Enrollee Risk
Stratification
Level at time of
audit engagement
letter

CHAR
15
Always
Required

Enter EXC-10 if the IHRA date is
greater than 10 years ago.
Enter the enrollee risk level at time of
the audit engagement letter.
Enter None if no risk stratification
level has been assigned.

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Program Audit Protocol and Data Request
Special Needs Plans Care Coordination (SNPCC)
Column ID

Field Name

M

Date of most
recent
Individualized
Care Plan (ICP)

N

Was an
Interdisciplinary
Care Team (ICT)
created/identified?

Field
Field
Type
Length
CHAR
10
Always
Required

Description

CHAR
1
Always
Required

Enter Y for Yes if the enrollee has
an ICT assigned.

Submit in CCYY/MM/DD format
(e.g., 2020/01/01).
Enter None if the Sponsoring
organization did not develop an ICP.
If care plan is continuous, enter the
date of the most recent update.

Enter N for No if the enrollee does
not have an assigned ICT.

Supplemental Documentation Submissions
Sponsoring organizations must submit the requested documentation identified below in either a
Microsoft Word (.docx), Microsoft Excel (.xlsx.), or Adobe Portable Document File (.pdf).
Sponsoring organizations must submit this documentation within 15 business days of the audit
engagement letter date, unless otherwise specified.
Supplemental Documentation Requests
1. Copies of selected Models of Care (MOC) and any (red-lined) updates to the original
submissions.
2. SNPCC Supplemental Questionnaire- due within 5 business days of the audit
engagement letter date.

Audit Field Work Phase

Supporting Documentation Submissions
During audit field work, CMS will review 30 enrollee samples selected from Table 1 to
determine whether the Sponsoring organization is compliant with its Part C contract
requirements. To facilitate this review, the Sponsoring organization must have access to, and the
ability to save and upload screenshots of, supporting documentation and data relevant to a
particular case, including, but not limited to:
• Completed enrollee Health Risk Assessment(s).
• Copy of the enrollee’s Individualized Care Plan (ICP).
• Care and case management documentation associated with the ICP (including claims,
encounters, and Prescription Drug Events) submitted for the enrollee since the last HRA was
completed. Specific documentation will be selected by the audit team based on the content of
the ICP.
• Membership of the ICT with evidence of appropriate credentials.
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Program Audit Protocol and Data Request
Special Needs Plans Care Coordination (SNPCC)
•
•
•
•
•
•

Information on the Sponsoring organization’s process to confirm MOC training for network
providers and ICT members and evidence of the Sponsoring organization’s confirmation.
Meeting minutes
Case files
Telephone scripts
Attendance records
Policies and procedures

Sponsoring organizations must submit supporting documentation within 2 business days of the
request.
Root Cause Analysis Submissions
Sponsoring organizations may be required to provide a root cause analysis using the Root Cause
Template provided by CMS. Sponsoring organizations have 2 business days from the date of
request to respond.
Impact Analysis Submissions
When noncompliance with contract and/or MOC requirements is identified on audit, Sponsoring
organizations must submit each requested impact analysis, comprehensive of all contracts and
Plan Benefit Packages (PBP) identified in the audit engagement letter, in either Microsoft Excel
(.xlsx) file format with a header row or Text (.txt) file format without a header row. Descriptions
and clarifications of what must be included in each submission and data field is outlined in the
individual tables below. Characters are required in all requested fields, unless otherwise
specified, and data must be limited to the request specified in each table. Sponsoring
organizations must provide accurate and timely impact analysis submissions within 10 business
days of the request. Submissions that do not strictly adhere to the record layout specifications
will be rejected.
Impact Analysis Requests
1. Table 1IA: Care Coordination Impact Analysis (CC-IA) Record Layout
2. Table 2IA: HRA Timeliness Impact Analysis (HRAT-IA) Record Layout
Impact
Analysis
Record Layout
Table 1IA
Table 2IA

Page 13 of 21

Scope of Impact Analysis Request
Submit a list of enrollees impacted by the Care Coordination issue(s) identified
during the 26-week period preceding the date of the audit engagement letter
through the date the issue was identified on audit.
Submit a list of enrollees who did not receive a timely initial and/or annual HRA
within the 12-month period prior to the date of the engagement letter. Populate
untimely cases with the appropriate outreach information for initial and/or annual
HRAs as identified during the timeliness test.
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Program Audit Protocol and Data Request
Special Needs Plans Care Coordination (SNPCC)
Please use the guidance below for the following record layout:
Table 1IA: Care Coordination Impact Analysis (CC-IA) Record Layout
• Include all enrollees impacted by the care coordination issue as specified in the request for an
impact analysis.
Column
ID
A

Field Name

B

Enrollee Last Name

C

Enrollee ID

D

Contract ID

E

Plan Benefit
Package (PBP)

F

Plan Type

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Enrollee First
Name

Field
Type
CHAR
Always
Required
CHAR
Always
Required
CHAR
Always
Required

Field
Length
50

Description

50

Enter the last name of the enrollee.

11

Enter the Medicare Beneficiary
Identifier (MBI) of the enrollee. An
MBI is the non-intelligent unique
identifier that replaced the HICN on
Medicare cards as a result of The
Medicare Access and CHIP
Reauthorization Act (MACRA) of 2015.
The MBI contains uppercase alphabetic
and numeric characters throughout the
11-digit identifier and is unique to each
Medicare enrollee. This number must be
submitted excluding hyphens or dashes.
Enter the contract number (e.g., H1234)
of the organization in which the enrollee
is currently part.
Enter the PBP (e.g., 001).

CHAR
5
Always
Required
CHAR
3
Always
Required
CHAR
5
Always
Required

Enter the first name of the enrollee.

Enter type of SNP. Valid values are:
• D-SNP
• C-SNP
• I-SNP

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Program Audit Protocol and Data Request
Special Needs Plans Care Coordination (SNPCC)
Column
ID
G

Field Name

H

If an HRA was
conducted, were
needs identified?

CHAR
2
Always
Required

I

If an ICP was
created, were the
identified needs
addressed?

CHAR
2
Always
Required

J

If an ICP was
created, was
enrollee or enrollee
representative
involved in its
development?
Initial ICP Date

CHAR
2
Always
Required

K

L

Was an HRA
conducted?

Date of Most
Recent ICP revision

Field
Field
Type
Length
CHAR
1
Always
Required

CHAR
10
Always
Required

CHAR
10
Always
Required

Description
Enter:
• Y for Yes only if the HRA was
returned completed to the
Sponsoring organization by either
the enrollee or the enrollee’s
representative.
• N for No
Enter:
• Y for Yes
• N for No
• NA if an HRA was not conducted
Enter:
• Y for Yes
• N for No
• NA if no ICP created
Enter:
• Y for Yes
• N for No
• NA if an ICP was not created
Enter the date the initial ICP was
completed.
Submit in CCYY/MM/DD format
(e.g., 2020/01/01).
Enter None if an initial ICP was not
completed.
Enter the date the ICP was most
recently revised.
Submit in CCYY/MM/DD format
(e.g., 2020/01/01).
Enter NA if the enrollee’s ICP has not
been completed or revised since the
initial ICP was completed per Column
ID K.

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Program Audit Protocol and Data Request
Special Needs Plans Care Coordination (SNPCC)
Column
ID
M

N

Field Name

Field
Field
Type
Length
16
Basis of most recent CHAR
Always
ICP
Required

Date of previous
ICP revision

CHAR
10
Always
Required

Description
Enter basis for most recent ICP revision
in Column ID L:
• Initial
• Annual, or
• Change in Status
Enter NA if the enrollee’s ICP has not
been completed or revised since the
initial ICP was completed per Column
ID K.
Enter the date the enrollee’s ICP was
previously revised compared to Column
ID L.
Submit in CCYY/MM/DD format
(e.g., 2020/01/01).
In the case of an ICP that was revised on
January 1, but then revised again on
March 1 of the same year, March is the
date of the most recent ICP revision, and
January is the date of the previous ICP
revision.

O

Basis of previous
ICP

CHAR
16
Always
Required

Enter NA if the enrollee’s ICP has not
been completed or revised since the ICP
was revised per Column ID L.
Enter basis for previous ICP revision:
• Initial
• Annual, or
• Change in Status
Enter NA if the enrollee’s ICP has not
been completed or revised since the ICP
was revised per Column ID L.

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Special Needs Plans Care Coordination (SNPCC)
Column
ID
P

Q

R

S
T

U

V

Page 17 of 21

Field Name
Did enrollee
experience a
hospitalization or
other change in
health status during
the impact analysis
request period?
If enrollee
experienced a
hospitalization or
other change in
health status during
the impact analysis
request period, was
the ICP updated?
If enrollee
experienced a
hospitalization, was
transitional care
offered to the
enrollee postdischarge?
Was an ICT
created?
If an ICT was
created, was the
ICT involved in
creating and
updating the
enrollee’s ICP?
Were ICT reviews
conducted at least
annually?

Field
Field
Type
Length
CHAR
1
Always
Required

Description

CHAR
2
Always
Required

Enter:
• Y for Yes
• N for No
• NA if the enrollee did not experience
a hospitalization or other change in
health status during the impact
analysis request period.

CHAR
2
Always
Required

Enter:
• Y for Yes
• N for No
• NA if the enrollee did not experience
a hospitalization.

CHAR
1
Always
Required
CHAR
2
Always
Required

Enter:
• Y for Yes
• N for No
Enter:
• Y for Yes
• N for No
• NA if an ICT was not created.

CHAR
1
Always
Required

Enter:
• Y for Yes
• N for No
Enter:
• Y for Yes
• N for No

CHAR
1
Is there evidence
Always
that the PCP was
invited to participate Required
on the enrollee’s
ICT?

Enter:
• Y for Yes
• N for No

OMB Approval 0938-1395 (Expires 05/31/2024)

Program Audit Protocol and Data Request
Special Needs Plans Care Coordination (SNPCC)
Column
ID
W

Field Name
Did all members
of enrollee’s ICT
receive annual
MOC training?

Field
Field
Type
Length
CHAR
1
Always
Required

ICT is specific to
each enrollee’s
individualized
needs.

Description
Enter:
• Y for Yes; use Y if the ICT
Providers received the MOC training
materials.
• N for No
If contracted providers received the
training materials within 1 year of
engagement letter, ok to answer Yes.
Enrollees and family members are not
required to receive MOC training.

Please use the guidance below for the following record layout:
Table 2IA: HRA Timeliness Impact Analysis (HRAT-IA) Record Layout
• Include all enrollees without a completed HRA or with an untimely HRA to quantify
outreach attempts, as specified in the request.
• Impact analysis review period is the 12-month period prior to date of the engagement letter.
Sponsoring organizations conducting HRA events within the 12-month period on a single
enrollee should populate the IA record layout with the most recent HRA event that occurred
during the applicable timeframe.
Column
ID
A

Field Name

B

Enrollee Last
Name

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Enrollee First
Name

Field
Type
CHAR
Always
Required
CHAR
Always
Required

Field
Length
50

Description

50

Enter the last name of the enrollee.

Enter the first name of the enrollee.

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Program Audit Protocol and Data Request
Special Needs Plans Care Coordination (SNPCC)
Column
ID
C

Field Name

D

Contract ID

E

Plan Benefit
Package (PBP)

F

Plan Type

G

Enrollment
effective date

CHAR
10
Always
Required

H

IHRA completion
date

CHAR
10
Always
Required

I

Number of IHRA
outreach attempts
required by MOC
Number of IHRA
outreaches
attempted

CHAR
2
Always
Required
CHAR
2
Always
Required

J

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Enrollee ID

Field
Field
Type
Length
CHAR
11
Always
Required

CHAR
5
Always
Required
CHAR
3
Always
Required
CHAR
5
Always
Required

Description
Enter the Medicare Beneficiary Identifier
(MBI) of the enrollee. An MBI is the nonintelligent unique identifier that replaced
the HICN on Medicare cards as a result of
The Medicare Access and CHIP
Reauthorization Act (MACRA) of 2015.
The MBI contains uppercase alphabetic
and numeric characters throughout the
11-digit identifier and is unique to each
Medicare enrollee. This number must be
submitted excluding hyphens or dashes.
Enter the contract number (e.g., H1234)
of the organization in which the enrollee
is currently part.
Enter the PBP (e.g., 001).
Enter type of SNP. Valid values are:
• D-SNP
• C-SNP
• I-SNP
Enter the effective date of the most
current/continuous enrollment for the
enrollee with the Sponsoring
organization. Submit in CCYY/MM/DD
format (e.g., 2020/01/01).
Enter the actual date the IHRA was
completed. Submit in CCYY/MM/DD
format (e.g., 2020/01/01) or enter NA
if not completed.
Enter number of required outreach
attempts per applicable MOC at time of
enrollment.
Enter number of outreach attempts in
numerical format.

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Program Audit Protocol and Data Request
Special Needs Plans Care Coordination (SNPCC)
Column
ID
K

L

Field Name
Date of first IHRA
outreach attempt

Date of last IHRA
outreach attempt

Field
Field
Type
Length
CHAR
10
Always
Required
CHAR
10
Always
Required

M

Date of enrollee
IHRA refusal

CHAR
10
Always
Required

N

Annual HRA
(AHRA) due date

CHAR
10
Always
Required

O

Was an AHRA
completed?

CHAR
2
Always
Required

P

AHRA completion
date

CHAR
10
Always
Required

Q
R

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Number of AHRA
outreach attempts
required by MOC
Number of AHRA
outreaches
attempted

CHAR
2
Always
Required
CHAR
2
Always
Required

Description
Enter the date first attempt was made to
conduct the IHRA.
Submit in CCYY/MM/DD format
(e.g., 2020/01/01).
Enter the date of the most recent
attempt was made to conduct the
IHRA.
Submit in CCYY/MM/DD format
(e.g., 2020/01/01).
Enter:
• refusal date in CCYY/MM/DD
format,
• NA if the enrollee did not refuse
IHRA completion.
Enter the date by which the AHRA
should have been completed. Submit in
CCYY/MM/DD format (e.g.,
2020/01/01).
Enter:
• Y for Yes
• N for No
• NA if AHRA was not yet due.
Enter the actual date the AHRA was
completed.
Submit in CCYY/MM/DD format
(e.g., 2020/01/01) or enter NA if the
AHRA was not completed.
Enter number of required outreach
attempts per approved MOC at time of
outreach event.
Enter number of outreach attempts made
by Sponsoring organization.

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Program Audit Protocol and Data Request
Special Needs Plans Care Coordination (SNPCC)
Column
ID
S

Date of first
AHRA outreach
attempt

Field
Field
Type
Length
CHAR
10
Always
Required

Date of last
AHRA outreach
attempt

CHAR
10
Always
Required

U

Date of enrollee
AHRA refusal

CHAR
10
Always
Required

V

Date the HRA Unable to Contact
(UTC) Letter was
sent to nonresponding
enrollee

CHAR
10
Always
Required

T

Field Name

Description
Enter the date first attempt was made to
conduct the AHRA.
Submit in CCYY/MM/DD format
(e.g., 2020/01/01) or enter NA if no
outreach attempts were made.
Enter the date the most recent attempt
was made to conduct the AHRA.
Submit in CCYY/MM/DD format
(e.g., 2020/01/01) or enter NA if no
outreach attempts were made.
Enter:
• refusal date in CCYY/MM/DD format
• NA if the enrollee did not refuse
AHRA completion.
Enter the date the UTC letter was sent.
Submit in CCYY/MM/DD format
(e.g., 2020/01/01) or enter NA, if no
letter sent.

Verification of Information Collected: CMS may conduct integrity tests to validate the
accuracy of all universes, impact analyses, and other related documentation submitted in
furtherance of the audit. If data integrity issues are noted, Sponsoring organizations may be
required to resubmit their data.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 0938-1395 (Expires 05/31/2024). This is a mandatory information collection. The time required to
complete this information collection is estimated to average 701 hours per response, including the time to review
instructions, search existing data resources, gather the data needed, and complete and review the information
collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this
form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850. ****CMS Disclosure**** Please do not send applications, claims, payments,
medical records or any documents containing sensitive information to the PRA Reports Clearance Office. Please
note that any correspondence not pertaining to the information collection burden approved under the associated
OMB control number listed on this form will not be reviewed, forwarded, or retained. If you have questions or
concerns regarding where to submit your documents, please contact [email protected].
Page 21 of 21

OMB Approval 0938-1395 (Expires 05/31/2024)