Form CMS-10913 Medicare PartC_UM_Annual Data Submission

Medicare Part C Utilization Management (UM)

Annual Data Submission

Contents

Annual Data Submission 3

Purpose 3

Universe Submissions 3

Utilization Management Annual Submission (UMAS) Record Layout 4

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Annual Data Submission

Purpose

To collect and analyze data related to Medicare Part C utilization management (UM) requirements. The Centers for Medicare and Medicaid Services (CMS) will collect and analyze the information in this data submission on an annual basis from all Medicare Advantage (MA) organizations (MAO) that offer the Medicare Part C benefit. In addition to analyzing the information across all MAOs, CMS will utilize the submitted data to select a number of MAOs each year for a UM audit.

Universe Submissions

MAOs must submit the following universe (Table 1) in Microsoft Excel (.xlsx) file format with a header row. The universe must be comprehensive of all contracts and Plan Benefit Packages (PBP).

Descriptions and guidance for what must be included in each data field are outlined in the universe record layout below. Characters are required in all requested fields, unless otherwise specified, and data must be limited to the request specified in each field MAOs must provide accurate and timely universe submissions by January 31st of each calendar year. Submissions that do not strictly adhere to the record layout specifications will be rejected.

CMS may validate universe submissions and request resubmissions if errors are noted.

Please use the guidance below for the following record layout:

Utilization Management Annual Submission (UMAS) Record Layout

• Enter all internal coverage criteria approved and applicable for the calendar year by the MAO, including internal coverage criteria used by any first tier, downstream, and related entity (FDR), for the purposes of rendering coverage or payment medical necessity decisions.

• Identify all internal coverage criteria for all Medicare services.

  • “Service” is defined at 42 C.F.R. 400.202 as “medical care or services and items, such as medical diagnosis and treatment, drugs and biologicals, supplies, appliances, and equipment, medical social services, and use of hospital, CAH, or SNF facilities.”

  • Therefore, for the purposes of the following record layout, the term “service” encompasses all applicable services and items covered under Medicare Part C that may have applicable internal coverage criteria, including but not limited to diagnostic tests, admissions to hospitals and/or other facilities (e.g., SNFs, LTACHs, IRFs, etc.), behavioral health services, home health services, therapies, durable medical equipment, and Part B drugs.

  • Any internal coverage criteria related to Part B drugs (other than step therapy policies) should be identified and included in this list.

  • If an MAO utilizes different internal coverage criteria for a service depending on the service area, then each unique internal coverage criteria policy would be entered in a new row.

• Enter information in each field (i.e., no blank fields).

• Enter information in the specific formatting requested (when applicable).

• Enter NA if a column or field does not apply.

• For all fields with multiple responses/entries (e.g., multiple states, jurisdictions, contracts, FDRs, etc.) use commas to separate each entry (e.g., FDR1, FDR2, FDR3, etc.).

• Do NOT use commas as part of criteria, service, FDR, organization, or vendor names.

• Reference the Utilization Management Annual Submission (UMAS) Record Layout with Examples document for more examples of how to populate the UMAS Record Layout.

Column ID	Field Name	Description
A	Criteria Name or Identifier	Enter the unique name, number, or other identifier for each policy or document containing internal coverage criteria for all Medicare services. Each unique criteria name or identifier must be entered into a separate row.
B	Service Name	Enter the name of each Medicare service associated with the applicable internal coverage criteria policy or document. If the internal coverage criteria policy or document covers multiple services, include all applicable services using a comma-separated list.
C	Date of Most Recent Approval	Enter the date the internal coverage criteria policy or document was most recently reviewed and approved by the UM committee. Enter date in CCYY/MM/DD format.
D	Medicare Administrative Contractor (MAC) Jurisdictions	Enter all MAC jurisdictions where the internal coverage criteria policy or document is applicable. When entering the jurisdiction, enter “J-” and the jurisdiction code. For example, J-5. MAC jurisdiction codes are available at: https://www.cms.gov/medicare/coding-billing/medicare- administrative-contractors-macs/who-are-macs If the internal coverage criteria policy or document is applicable in multiple MAC jurisdictions, enter all applicable jurisdictions using a comma-separated list. Enter ALL if this specific internal coverage criteria policy or document applies in all MAC jurisdictions in which the MAO operates.

Column ID	Field Name	Description
E	States	Enter all US states and territories using the two-digit abbreviation from the United States Postal Service (USPS) where this specific internal coverage criteria policy or document is applicable. If the internal coverage criteria policy or document is applicable in multiple states and/or territories, enter all applicable state and territory two-digit abbreviations using a comma-separated list. Enter ALL if this specific internal coverage criteria policy or document applies in all US states and territories in which the MAO operates.
F	Contracts	Enter all contract numbers that utilize this specific internal coverage criteria policy or document for medical necessity determinations. If the internal coverage criteria policy or document is utilized by multiple contracts, enter all applicable contract numbers using a comma-separated list. Enter ALL if all contracts utilize this specific internal coverage criteria policy or document.

Column ID	Field Name	Description
G	FDR	Identify all entities (including your organization and any applicable FDRs) that utilize this specific internal coverage criteria policy or document. If multiple entities utilize the internal coverage criteria policy or document, enter all applicable entities using a comma- separated list. Enter ALL if all FDRs utilize this specific internal coverage criteria policy or document.
H	Organization or Vendor	Enter the name(s) of any entity (your organization, entity and/or any vendors) that developed, assisted with developing, or is/are responsible for updating this specific internal coverage criteria policy or document. Use a comma-separated list for multiple entries (e.g., MCG).
I	Website Link	Provide a direct link to the organization website where this specific internal coverage criteria policy or document can be found. At a minimum, the link provided must allow CMS to easily navigate to the identified criteria.

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 OMB 0938-New. This information collection will allow CMS to conduct a comprehensive review of Sponsoring organizations’ compliance with Medicare Part C utilization management (UM) requirements. The time required to complete this information collection is estimated at 410 hours per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is mandatory per CMS’s authority under Section 1857(d) of the Social Security Act and implementing regulations at 42 CFR § 422.503 and § 422.504, which state that CMS must oversee a Medicare Advantage (MA) organization’s continued compliance with the requirements for a MA organization. Additionally, per § 422.516(a), MA organizations are required to compile and report to CMS information related to the utilization of services, and other matters as CMS may require. If you have comments concerning the accuracy of the time estimate 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.

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