Form CMS-10913 CMS List of Targeted Services

CMS List of Targeted Services

Instructions: Medicare Advantage organizations (MAOs) must utilize the following list of services to populate the requested universe in the Part C UM Audit Protocol and Data Request document. 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.” This includes but is 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, Part B drugs, and durable medical equipment. Therefore, for the purposes of the CMS List of Targeted Services, “service” is meant to include all services, items and Part B drugs.

This list may contain up to 50 unique services. MAOs do NOT need to submit copies of internal coverage criteria or other information for these services, only the requested universe of information in the Part C UM Audit Protocol and Data Request. CMS will provide this list to the MAO with the audit engagement letter.

Applicable Calendar Year: {CMS will enter applicable calendar year.}

Targeted Services: {CMS will identify all targeted services in the table below.}

Number	Name of Service	Brief Description of Service (if applicable)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26

Number	Name of Service	Brief Description of Service (if applicable)
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50

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.