Crosswalk (60day-30day)

60-day Package	Revised/New in 30-day Package	Reason for Change
There were two reporting sections with no subsections- Initial Determinations and Appeals	There are now two subsections for each reporting section - Initial Determinations (coverage decisions), Initial Determinations (payment), Reconsiderations (coverage decisions), Reconsiderations (payment)	Previously, there were elements that only applied to either a coverage request or a payment request and this could have been confusing to report. This change was also in response to comments related to whether the reporting applies to both pre-service and payment requests. By separating each section this clarifies the expectation for reporting of both pre-service/coverage and payment requests.
Reporting Elements for all Initial Determination Requests: OD Number Contract number and PBP Parent organization Provider NPI Enrollee MBI Requested service codes (CPT/HCPCS) Name of service associated with CPT/HCPCS Submitted diagnosis codes (e.g., ICD-10, HIPPS codes) Processing priority (standard or expedited) Service location (Zip) Date of service Provider status (contracted or non-contracted) Approved or denied Date request received Date of decision Decision rationale Were internal plan criteria applied? Was PA requested? If element R is yes, provide OD number for PA (claims only) If element R is yes, was PA request required? If element R is yes, was a voluntary pre-service request received? Place of service, if applicable https://www.cms.gov/medicare/coding-billing/place-of-service-codes/code-sets	Revised Reporting Elements for Initial Determinations (coverage decisions): Organization Determination Number Contract Number Plan Benefit Package (PBP) Enrollee MBI Requesting Party Provider NPI Item/Service/Part B Drug Code Item/Service/Part B Drug Description Diagnosis Codes Was prior authorization required? Was this a concurrent review decision? Processing Priority Was expedited processing requested? Date Request Received Date of Decision Notification Disposition Dismissal Rationale (if applicable) Decision Rationale Reviewer Qualifications Were internal plan coverage criteria applied? Did a third-party vendor participate, in any capacity, in the determination’s review or decision-making?	Based on comments and upon further review, there have been several revisions to the elements.  We have reworded/rephrased some elements to improve clarity and the addition of new elements in each reporting section will allow CMS to broaden the scope of review for each case. Many commenters requested clarification around what is a "voluntary pre-service request".  As a result, we revised this element to avoid confusion and will gather the information needed by asking if prior-authorization was required. We have also added "reviewer qualification" at the initial determination level based on several comments received.
	Revised Reporting Elements for Initial Determinations (payment): Organization Determination Number Contract Number Plan Benefit Package (PBP) Enrollee MBI Requesting Party Item/Service/Part B Drug Code Item/Service/Part B Drug Description Diagnosis Codes Service Location Place of Service Date of Service Provider NPI Date Claim Received Date of Decision Date Claim was Paid Was it a clean claim? Disposition Dismissal Rationale (if applicable) Decision Rationale Reviewer Qualifications Were internal plan coverage criteria applied? Was prior approval (e.g., a prior authorization or voluntary pre-service request) requested? If element V is yes, provide the organization determination number for associated prior approval request If element V is yes, was prior authorization a required condition for coverage? Did a third-party vendor participate, in any capacity, in the determination’s review or decision-making?
Reporting Elements for Reconsiderations: Applicable initial determination number (to link to initial decision) Approved/denied Date request received Date of decision Processing priority (standard or expedited) Decision rationale Reviewer qualifications	Revised Elements for Reconsiderations (coverage decisions): Associated Organization Determination Number Appeal Number Contract Number Plan Benefit Package (PBP) Enrollee MBI Date Request Received Date of Decision Notification Processing Priority Was expedited processing requested? Is this an appeal of an organization determination dismissal? Disposition Dismissal Rationale (if applicable) Decision Rationale Was the initial organization determination request denied for lack of medical necessity? Was the reconsideration request reviewed by a physician? Did a third-party vendor participate, in any capacity, in the determination’s review or decision-making?
	Revised Elements for Reconsiderations (payment): Associated Organization Determination Number Appeal Number Contract Number Plan Benefit Package (PBP) Enrollee MBI Date Request Received Date of Decision Notification Date Claim was Paid Is this an appeal of an organization determination dismissal? Disposition Dismissal Rationale (if applicable) Decision Rationale Was the initial organization determination request denied for lack of medical necessity? Was the reconsideration request reviewed by a physician? Did a third-party vendor participate, in any capacity, in the determination’s review or decision-making?
Background read: "The Part C Reporting Requirements, as set forth in § 422.516(a), provide CMS with the ability to collect more granular data related to all plan activities regarding adjudicating requests for coverage and plan procedures related to making service utilization decisions. This includes collecting more timely data with greater frequency or closer in real-time. Pursuant to that authority, each MAO must have an effective procedure to develop, compile, evaluate, and report information to CMS in the time and manner that CMS requires."	Revised to read: "The Part C Reporting Requirements, as set forth in 42 CFR § 422.516(a), provide CMS with the ability to collect data on plan procedures related to, and utilization of, its items and services. This includes collecting service-level data related to plan coverage and appeal decisions that are processed in accordance with the requirements of part 422, subpart M. Pursuant to that authority, each MAO must have an effective procedure to develop, compile, evaluate, and report information to CMS in the time and manner that CMS requires."	The revised language is more clear and concise as it relates to the intent and general expectation of the data collection.
	Included due dates for each quarterly submission	To ensure plans are aware of CMS' expectation for timely submission of the data.