Medicare Parts C and D Program Audit Protocols and Data Requests (CMS-10191)

42 CFR 422.502 describes CMS' regulatory authority to evaluate, through inspection or other means, Medicare Advantage Part C organizations. These records include books, contracts, medical records, patient care documentation and other records that pertain to any aspect of services performed, reconciliation of benefit liabilities, and determination of amounts payable. 42 CFR 423.503 states that CMS must oversee a Part D plan sponsor's continued compliance with the requirements for a Part D plan sponsor. 423.514 states that the Part D plan sponsor must have an effective procedure to develop, compile, evaluate, and report to CMS, to its enrollees, and to the general public, at the times and in the manner that CMS requires, statistics regarding areas such as cost of operations, patterns of utilization availability, accessibility, and acceptability of services. CMS developed a strategy to address our oversight and audit responsibilities within the context of limited audit/oversight resources. We intend to combine all Part C and Part D guides into one universal guide as it will promote efficiency and effectiveness and reduce financial and time burdens for both CMS and Medicare-contracting entities.

The latest form for Medicare Parts C and D Program Audit Protocols and Data Requests (CMS-10191) expires 2023-06-30 and can be found here.