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Final MAPDProgram AuditProtocol TrainingPart C Organization Determinations, Appeals, and Grievances(ODAG)August 17, 2021Matthew GuerandDivision of Audit Operations, Medicare Parts C & D Oversight & Enforcement Group, CMSFor Official Federal Government use Only. This pre-decisional, privileged, and confidential information is for internal government use only, and must not be disseminated, distributed, or copied to personsnot authorized to receive the information. Unauthorized disclosure may result in prosecution to the full extent of the law.
2Polling Question 1Let us know who is listening:A. Medicare Advantage/Prescription Drug PlanB. Independent AuditorC. Pharmacy Benefit ManagerD. CMS Central/Regional OfficeE. Other
3ODAG Program Audit ProtocolOverview Program Audit Protocol– Audit Elements Tested– Method of Evaluation New Measures Program Audit Data Request– Review Technical Specifications
4ODAG Program Audit Protocol Specifications and tools are forauditing/monitoring activities, notinterpreting policy Not all data points are used to determinecompliance
5ODAG Audit Elements Tested Timeliness Processing of Coverage Requests Classification of Requests
6Universe Integrity Testing 60 cases– 10 cases from each universe, Tables 1 – 6* Verify accuracy of data within universe submissions Confirm effectuation of approved requests*Organizations offering DSNP who have not beenidentified as an AIP do not complete Table 6: AIP
7Timeliness Audit Element (1 of 8)Pre-service Organization Determination NotificationPart C Service(Standard) 14 days 28 days withextensionPart C Service(Expedited) 72 hours 17 days withextensionPart B Drug(Standard) 72 hoursPart B Drug(Expedited) 24 hours
8Timeliness Audit Element (2 of 8)Pre-service Reconsideration NotificationPart C (Standard/Expedited) ApprovalsProvided to Enrollee/Representative30 or 44 days with extension/72 hours or 17 dayswith extensionDenialsForwarded to IREWithin 24 hours of affirmation of decision18 days/96 hours if timeframe missedPart B Drug(Standard/Expedited)Approvals Provided to Enrollee/Representative 7 days/72 hoursDenials Forwarded to IRE Within 24 hours of affirmation of decision 96 hours if timeframe missed
9Timeliness Audit Element (3 of 8) Payment Organization Determinations– Member submitted claims– Non-Contract Provider submitted claims– Paid or Denied within 60 days– Notification of denial was provided to the provideror the enrollee
10Timeliness Audit Element (4 of 8)Payment ReconsiderationsMA 60 days Overturned claim paid toprovider or enrollee Upheld decision forwarded toIREDSNP-AIP 30 days Overturned claim paid toprovider or enrollee Upheld decisions forwardedto IRE
11Timeliness Audit Element (5 of 8)Independent Review Entity (IRE) Overturn EffectuationsPart CService/Item(Standard) 14 daysPart CService/Item(Expedited) 72 hoursPart B Drug(Standard) 72 hours All post service (payment) overturns: 30 daysPart B Drug(Expedited) 24 hours
12Timeliness Audit Element (6 of 8)Administrative Law Judge (ALJ) andMedicare Administrative Contractor (MAC) Overturn EffectuationsPart C Service/Item(Standard & Expedited) Pre-service – 60 days Post-service – 60 daysPart B Drug Standard – 72 hours Expedited – 24 hours
13Timeliness Audit Element (7 of 8)GrievancesStandard 30 days 44 days with extensionExpedited 24 hours
14Timeliness Audit Element (8 of 8)Dual Eligible Special Needs Plan – Applicable Integrated PlanAdverse nsiderations(Standard) Provided notice 10 days 30 daysprior to effective 44 days with extensiondecision dateIntegratedReconsiderations(Expedited) 72 hours 17 days with extension*Decision to terminate, suspend, or reduce previously approved service
15Processing of Coverage Requests(1 of 5) 30 Denied Samples– DSNP-AIPs: 5 additional samples from Table 6 (AIP)– Represents various medical services– Provided 1 hour prior to start of review If enrollee identified a representative: determine if notificationwas sent to enrollee’s representative If provider requested: review to ensure theenrollee was notified, as well as theprovider, of determination
16Processing of Coverage Requests(2 of 5) Ensure physician or other appropriate health care professionalreviewed determination For reconsiderations, ensure person(s) not involved in makingthe determination conducts reconsideration Review clinical decisions– National Coverage Determinations (NCD)– Local Coverage Determinations (LCD)– Follow internal coverage policies Ensure Sponsor has adequate process tomake appropriate clinical decisions
17Processing of Coverage Requests(3 of 5) Integrated Denial Notice (IDN) Review– Notice sent to appropriate party/parties– Identifies service or drug requested– Explain why medical services/items or Part B drugdenied– Include appeal rights (standard/expedited)– Include any other notice requirements specified byCMS Ensure extensions were appropriate
18Processing of Coverage Requests(4 of 5) If Sponsor denies request for expedited determination, CMSreviews determination and the following:– Provide enrollee prompt oral notice of denial– Within 3 calendar days, deliver a written letter that: Explains MA organization will process the request using the 14-day/30-daytimeframe for standard determinations/reconsiderations Informs enrollee of right to file an expedited grievance if he or she disagreeswith the MA organization's decision not to expedite Provides instructions about the grievance process and its timeframes
19Processing of Coverage Requests(5 of 5) Part B Drug Step Therapy– 365-day look back period DSNP-AIPs– 5 samples will be reviewed to ensure: Continuation of Benefits Appropriate decision not to provide continuation benefits Appropriate duration of continued or reinstated benefits
20Classification ofRequests – Dismissed Select up to 10 Cases– Review to determine if request: Was appropriately dismissed Should have been treated as a coveragerequest or grievance
21Classification ofRequests – Grievances Select up to 20 Cases – verbal and written– Targeting quality of care, involve multiple issues, do not appear inorganization determination and reconsideration universes,misclassified requests– Determine if proper notification provided– If Sponsor extended deadline, review for documentation stating howdelay is in the interest of enrollee Review for written notification to enrollee of delay reason(s)– Representative requested: determine if notification was sent toenrollee’s representative
22Program Audit Data Request
23Program Audit Data Request Submit universe tables 1 – 5 Dual Eligible Special Needs Plans - Applicable IntegratedPlan (DSNP-AIP) submit universe table 6 Descriptions/clarifications for each submission and data field areoutlined in the individual universe record layouts Characters required in all requested fields, unless otherwise specifiedand data must be limited to request specified in each record layout Submissions due within 15 business days of audit engagement letter Submissions that do not strictly adhere to the record layoutspecifications will be rejected
24Scope of Universe RequestMA/MAPD Enrollment 50,000Submit 12-week periodpreceding auditengagement letter date 50,000 but 250,000Submit 8-week periodpreceding auditengagement letter date 250,000 but 500,000Submit 4-week periodpreceding auditengagement letterdate 500,000Submit 2-weekperiod precedingaudit engagementletter date
25Record LayoutsRecord LayoutsUniverse Table 1Standard and Expedited Pre-service Organization Determinations (OD)Universe Table 2Standard and Expedited Pre-service Reconsiderations (RECON)Universe Table 3Payment Organization Determinations and Reconsiderations (PYMT C)Universe Table 4Part C Effectuations of Overturned Decisions by IRE, ALJ, or MAC (EFF C)Universe Table 5Part C Standard and Expedited Grievances (GRV C)Universe Table 6Dual Eligible Special Needs Plan – Applicable Integrated Plan Reductions,Suspensions, and Terminations (AIP)
26Record Layout Instructions All time fields – same time zonePopulate fields depending on how plan processed requestRequest for services/items/drugs that do not require prior-authorizationDismissed requests– Included in OD, RECON, PYMT C, GRV C, and AIP record layouts– Exclude dismissed requests that were withdrawn Exclude Reopened casesExclude Value Added Items and ServicesRetrospective ReviewsInclude all requests for Part B drugs
27Field Descriptions – Enrollee IDENROLLEE ID Medicare Beneficiary IdentifierAUTHORIZATION OR CLAIMNUMBERDATE THE REQUEST WASRECEIVEDTIME THE REQUEST WASRECEIVEDPART B DRUG REQUEST? Enter Y if Part B drug is primary Enter Time request received Expedited requests, Part B drugrequests For reconsideration and Standard and dismissed: enter If authorization or claim numbernonepayment requests, if information For reconsideration requests, ifis unavailable, enter the internalestablishing good cause wastracking or case numberobtained after 60-dayinformation establishing goodcause was obtained after 60timeframe, enter date No authorization, claim, otherday timeframe, enter timeinformation received byinformation received bytracking number available: enterorganizationorganizationnone Enter the associatedauthorization or claim numberfor this request Date standard or expeditedrequest received
28Field Descriptions – Authorizationor Claim NumberENROLLEE ID Medicare Beneficiary IdentifierAUTHORIZATION OR CLAIMNUMBERDATE THE REQUEST WASRECEIVEDTIME THE REQUEST WASRECEIVEDPART B DRUG REQUEST? Enter Y if Part B drug is primary Enter Time request received Expedited requests, Part B drugrequests For reconsideration and Standard and dismissed: enter If authorization or claim numbernonepayment requests, if information For reconsideration requests, ifis unavailable, enter the internalestablishing good cause wastracking or case numberobtained after 60-dayinformation establishing goodcause was obtained after 60timeframe, enter date No authorization, claim, otherday timeframe, enter timeinformation received byinformation received bytracking number available: enterorganizationorganizationnone Enter the associatedauthorization or claim numberfor this request Date standard or expeditedrequest received
29Field Descriptions – Date theRequest was ReceivedENROLLEE ID Medicare Beneficiary IdentifierAUTHORIZATION OR CLAIMNUMBERDATE THE REQUEST WASRECEIVEDTIME THE REQUEST WASRECEIVEDPART B DRUG REQUEST? Enter Y if Part B drug is primary Enter Time request received Expedited requests, Part B drugrequests Standard and dismissed: enter For reconsideration and If authorization or claim numbernonepayment requests, if information For reconsideration requests, ifis unavailable, enter the internalestablishing good cause wastracking or case numberinformation establishing goodobtained after 60-daycause was obtained after 60timeframe, enter date No authorization, claim, otherday timeframe, enter timeinformation received byinformation received bytracking number available: enterorganizationorganizationnone Enter the associatedauthorization or claim numberfor this request Date standard or expeditedrequest received
30Field Descriptions – Time theRequest was ReceivedENROLLEE ID Medicare Beneficiary IdentifierAUTHORIZATION OR CLAIMNUMBERDATE THE REQUEST WASRECEIVEDTIME THE REQUEST WASRECEIVEDPART B DRUG REQUEST? Enter Y if Part B drug is primary Enter Time request received Expedited requests, Part B drugrequests For reconsideration and Standard and dismissed: enter If authorization or claim numbernonepayment requests, if information For reconsideration requests, ifis unavailable, enter the internalestablishing good cause wastracking or case numberobtained after 60-dayinformation establishing goodcause was obtained after 60timeframe, enter date No authorization, claim, otherday timeframe, enter timeinformation received byinformation received bytracking number available: enterorganizationorganizationnone Enter the associatedauthorization or claim numberfor this request Date standard or expeditedrequest received
31Field Descriptions – Part B DrugRequestENROLLEE ID Medicare Beneficiary IdentifierAUTHORIZATION OR CLAIMNUMBERDATE THE REQUEST WASRECEIVEDTIME THE REQUEST WASRECEIVEDPART B DRUG REQUEST? Enter Y if Part B drug is primary Enter Time request received Expedited requests, Part B drugrequests For reconsideration and Standard and dismissed: enter If authorization or claim numbernonepayment requests, if information For reconsideration requests, ifis unavailable, enter the internalestablishing good cause wastracking or case numberobtained after 60-dayinformation establishing goodcause was obtained after 60timeframe, enter date No authorization, claim, otherday timeframe, enter timeinformation received byinformation received bytracking number available: enterorganizationorganizationnone Enter the associatedauthorization or claim numberfor this request Date standard or expeditedrequest received
32Field Descriptions – AOR/EquivalentNotice Receipt DateAOR/EQUIVALENT NOTICERECEIPT DATEAOR/EQUIVALENT NOTICERECEIPT TIME Enter the date the Appointment Time of Appointment ofof Representative (AOR) form orRepresentative (AOR)equivalent written notice wasform/written notice receipt byreceived by the SponsoringSponsoring organizationorganization. May precede date of request Enter None if no AOR or No AOR or written noticeequivalent written notice wasreceived/required: enter nonereceived or required. Standard and dismissedrequests: enter noneREQUEST DETERMINATION Approved Denied DismissedDATE OF DETERMINATION Enter the date of thedetermination. For dismissed requests, enterthe date the Sponsoringorganization dismissed therequestTIME OF DETERMINATION Enter the time of determinationo All expedited requestso Standard Part B OrganizationDetermination requests Enter None for standard servicerequests and standard Part Breconsiderations
33Field Descriptions – AOR/EquivalentNotice Receipt TimeAOR/EQUIVALENT NOTICERECEIPT DATEAOR/EQUIVALENT NOTICERECEIPT TIME Enter the date the Appointment Time of Appointment ofof Representative (AOR) form orRepresentative (AOR)equivalent written notice wasform/written notice receipt byreceived by the SponsoringSponsoring organizationorganization. May precede date of request Enter None if no AOR or No AOR or written noticeequivalent written notice wasreceived/required: enter nonereceived or required. Standard and dismissedrequests: enter noneREQUEST DETERMINATION Approved Denied DismissedDATE OF DETERMINATION Enter the date of thedetermination. For dismissed requests, enterthe date the Sponsoringorganization dismissed therequestTIME OF DETERMINATION Enter the time of determinationo All expedited requestso Standard Part B OrganizationDetermination requests Enter None for standard servicerequests and standard Part Breconsiderations
34Field Descriptions – RequestDeterminationAOR/EQUIVALENT NOTICERECEIPT DATEAOR/EQUIVALENT NOTICERECEIPT TIME Enter the date the Appointment Time of Appointment ofof Representative (AOR) form orRepresentative (AOR)equivalent written notice wasform/written notice receipt byreceived by the SponsoringSponsoring organizationorganization. May precede date of request Enter None if no AOR or No AOR or written noticeequivalent written notice wasreceived/required: enter nonereceived or required. Standard and dismissedrequests: enter noneREQUEST DETERMINATION Approved Denied DismissedDATE OF DETERMINATION Enter the date of thedetermination. For dismissed requests, enterthe date the Sponsoringorganization dismissed therequestTIME OF DETERMINATION Enter the time of determinationo All expedited requestso Standard Part B OrganizationDetermination requests Enter None for standard servicerequests and standard Part Breconsiderations
35Field Descriptions – Date ofDeterminationAOR/EQUIVALENT NOTICERECEIPT DATEAOR/EQUIVALENT NOTICERECEIPT TIME Enter the date the Appointment Time of Appointment ofof Representative (AOR) form orRepresentative (AOR)equivalent written notice wasform/written notice receipt byreceived by the SponsoringSponsoring organizationorganization. May precede date of request Enter None if no AOR or No AOR or written noticeequivalent written notice wasreceived/required: enter nonereceived or required. Standard and dismissedrequests: enter noneREQUEST DETERMINATION Approved Denied DismissedDATE OF DETERMINATION Enter the date of thedetermination. For dismissed requests, enterthe date the Sponsoringorganization dismissed therequestTIME OF DETERMINATION Enter the time of determinationo All expedited requestso Standard Part B OrganizationDetermination requests Enter None for standard servicerequests and standard Part Breconsiderations
36Field Descriptions – Time ofDeterminationAOR/EQUIVALENT NOTICERECEIPT DATEAOR/EQUIVALENT NOTICERECEIPT TIME Enter the date the Appointment Time of Appointment ofof Representative (AOR) form orRepresentative (AOR)equivalent written notice wasform/written notice receipt byreceived by the SponsoringSponsoring organizationorganization. May proceed date of request Enter None if no AOR or No AOR or written noticeequivalent written notice wasreceived/required: enter nonereceived or required. Standard and dismissedrequests: enter noneREQUEST DETERMINATION Approved Denied DismissedDATE OF DETERMINATION Enter the date of thedetermination. For dismissed requests, enterthe date the Sponsoringorganization dismissed therequestTIME OF DETERMINATION Enter the time of determinationo All expedited requestso Standard Part B OrganizationDetermination requests Enter None for standard servicerequests and standard Part Breconsiderations
37Field Descriptions – Date OralNotification Provided to EnrolleeDATE ORAL NOTIFICATIONPROVIDED TO ENROLLEE Enter date oral notificationprovided to enrollee Enter None if no oral notificationwas provided.TIME ORAL NOTIFICATION PROVIDED TO DATE WRITTEN NOTIFICATION PROVIDEDENROLLEETO ENROLLEE Enter the time oral notification wasprovided to enrolleeo All expedited requestso Standard Part B OrganizationDetermination requests Enter None if no oral notification wasprovided Enter date written notification provided toenrollee Enter None if no written notification wasprovided. Dismissed caseso Date written notification of dismissalprovided to enrollee Do not enter a date a letter is generated orprintedTIME WRITTEN NOTIFICATIONPROVIDED TO ENROLLEE Enter time written notification provided toenrolleeo All expedited requestso Standard Part B OrganizationDetermination requests Enter None if no written notification wasprovided and for dismissed requests
38Field Descriptions – Time OralNotification Provided to EnrolleeDATE ORAL NOTIFICATIONPROVIDED TO ENROLLEE Enter date oral notificationprovided to enrollee Enter None if no oral notificationwas provided.TIME ORAL NOTIFICATION PROVIDED TO DATE WRITTEN NOTIFICATION PROVIDEDENROLLEETO ENROLLEE Enter the time oral notification wasprovided to enrolleeo All expedited requestso Standard Part B OrganizationDetermination requests Enter None if no oral notification wasprovided Enter date written notification provided toenrollee Enter None if no written notification wasprovided. Dismissed caseso Date written notification of dismissalprovided to enrollee Do not enter a date a letter is generated orprintedTIME WRITTEN NOTIFICATIONPROVIDED TO ENROLLEE Enter time written notification provided toenrolleeo All expedited requestso Standard Part B OrganizationDetermination requests Enter None if no written notification wasprovided and for dismissed requests
39Field Descriptions – Date WrittenNotification Provided to EnrolleeDATE ORAL NOTIFICATIONPROVIDED TO ENROLLEE Enter date oral notificationprovided to enrollee Enter None if no oral notificationwas provided.TIME ORAL NOTIFICATION PROVIDED TO DATE WRITTEN NOTIFICATION PROVIDEDENROLLEETO ENROLLEE Enter the time oral notification wasprovided to enrolleeo All expedited requestso Standard Part B OrganizationDetermination requests Enter None if no oral notification wasprovided Enter date written notification provided toenrollee Enter None if no written notification wasprovided. Dismissed caseso Date written notification of dismissalprovided to enrollee Do not enter a date a letter is generated orprintedTIME WRITTEN NOTIFICATIONPROVIDED TO ENROLLEE Enter time written notification provided toenrolleeo All expedited requestso Standard Part B OrganizationDetermination requests Enter None if no written notification wasprovided and for dismissed requests
40Field Descriptions – Time WrittenNotification Provided to EnrolleeDATE ORAL NOTIFICATIONPROVIDED TO ENROLLEE Enter date oral notificationprovided to enrollee Enter None if no oral notificationwas provided.TIME ORAL NOTIFICATION PROVIDED TO DATE WRITTEN NOTIFICATION PROVIDEDENROLLEETO ENROLLEE Enter the time oral notification wasprovided to enrolleeo All expedited requestso Standard Part B OrganizationDetermination requests Enter None if no oral notification wasprovided Enter date written notification provided toenrollee Enter None if no written notification wasprovided. Dismissed caseso Date written notification of dismissalprovided to enrollee Do not enter a date a letter is generated orprintedTIME WRITTEN NOTIFICATIONPROVIDED TO ENROLLEE Enter time written notification provided toenrolleeo All expedited requestso Standard Part B OrganizationDetermination requests Enter None if no written notification wasprovided and for dismissed requests
41Field Descriptions – Date ReconsideredDetermination Effectuated in SystemDATE RECONSIDEREDDETERMINATIONEFFECTUATED IN SYSTEMTIME RECONSIDEREDDETERMINATIONEFFECTUATED IN SYSTEM Enter date reconsidered Enter time reconsidereddetermination effectuated in thedetermination was effectuatedsystemin the system Enter None if the determinationwas denied or dismissedo All expedited requests Enter None for standard cases,dismissed cases, or if therequest was deniedDATE FORWARDED TO IRE Enter date request wasforwarded to the IRE Enrollee notified of approvedreconsideration: enter none Request was not forwarded tothe IRE: enter noneTIME FORWARDED TO IRE Enter time request wasforwarded to the IREo All expedited requests Enter None if:o Enrollee notified of approvedreconsiderationo Not forwarded to IREISSUE DESCRIPTION ANDTYPE OF SERVICE Brief description of service/itemrequested Why service/item wasrequested (if known) Denialso Why the pre-service requestwas denied Dismissed requestso Reason for dismissal
42Field Descriptions – Time ReconsideredDetermination Effectuated in SystemDATE RECONSIDEREDDETERMINATIONEFFECTUATED IN SYSTEMTIME RECONSIDEREDDETERMINATIONEFFECTUATED IN SYSTEM Enter date reconsidered Enter time reconsidereddetermination effectuated in thedetermination was effectuatedsystemin the system Enter None if the determinationwas denied or dismissedo All expedited requests Enter None for standard cases,dismissed cases, or if therequest was deniedDATE FORWARDED TO IRE Enter date request wasforwarded to the IRE Enrollee notified of approvedreconsideration: enter none Request was not forwarded tothe IRE: enter noneTIME FORWARDED TO IRE Enter time request wasforwarded to the IREo All expedited requests Enter None if:o Enrollee notified of approvedreconsiderationo Not forwarded to IREISSUE DESCRIPTION ANDTYPE OF SERVICE Brief description of service/itemrequested Why service/item wasrequested (if known) Denialso Why the pre-service requestwas denied Dismissed requestso Reason for dismissal
43Field Descriptions – DateForwarded to IREDATE RECONSIDEREDDETERMINATIONEFFECTUATED IN SYSTEMTIME RECONSIDEREDDETERMINATIONEFFECTUATED IN SYSTEM Enter date reconsidered Enter time reconsidereddetermination effectuated in thedetermination was effectuatedsystemin the system Enter None if the determinationwas denied or dismissedo All expedited requests Enter None for standard cases,dismissed cases, or if therequest was deniedDATE FORWARDED TO IRE Enter date request wasforwarded to the IRE Enrollee notified of approvedreconsideration: enter none Request was not forwarded tothe IRE: enter noneTIME FORWARDED TO IRE Enter time request wasforwarded to the IREo All expedited requests Enter None if:o Enrollee notified of approvedreconsiderationo Not forwarded to IREISSUE DESCRIPTION ANDTYPE OF SERVICE Brief description of service/itemrequested Why service/item wasrequested (if known) Denialso Why the pre-service requestwas denied Dismissed requestso Reason for dismissal
44Field Descriptions – TimeForwarded to IREDATE RECONSIDEREDDETERMINATIONEFFECTUATED IN SYSTEMTIME RECONSIDEREDDETERMINATIONEFFECTUATED IN SYSTEM Enter date reconsidered Enter time reconsidereddetermination effectuated in thedetermination was effectuatedsystemin the system Enter None if the determinationwas denied or dismissedo All expedited requests Enter None for standard cases,dismissed cases, or if therequest was deniedDATE FORWARDED TO IRE Enter date request wasforwarded to the IRE Enrollee notified of approvedreconsideration: enter none Request was not forwarded tothe IRE: enter noneTIME FORWARDED TO IRE Enter time request wasforwarded to the IREo All expedited requests Enter None if:o Enrollee notified of approvedreconsiderationo Not forwarded to IREISSUE DESCRIPTION ANDTYPE OF SERVICE Brief description of service/itemrequested Why service/item wasrequested (if known) Denialso Why the pre-service requestwas denied Dismissed requestso Reason for dismissal
45Field Descriptions – IssueDescription and Type of ServiceDATE RECONSIDEREDDETERMINATIONEFFECTUATED IN SYSTEMTIME RECONSIDEREDDETERMINATIONEFFECTUATED IN SYSTEM Date reconsidered Enter time reconsidereddetermination was effectuateddetermination effectuated in thein the systemsystem Decision upheld: enter noneo All expedited requests Enter None for standard cases,dismissed cases, or if therequest was deniedDATE FORWARDED TO IRE Enter date request wasforwarded to the IRE Enrollee notified of approvedreconsideration: enter none Request was not forwarded tothe IRE: enter noneTIME FORWARDED TO IRE Enter time request wasforwarded to the IREo All expedited requests Enter None if:o Enrollee notified of approvedreconsiderationo Not forwarded to IREISSUE DESCRIPTION ANDTYPE OF SERVICE Brief description of service/itemrequested Why service/item wasrequested (if known) Denialso Why the pre-service requestwas denied Dismissed requestso Reason for dismissal
46Field Descriptions – Was an expeditedrequest made but processed asstandard?WAS AN EXPEDITED REQUESTMADE BUT PROCESSED ASSTANDARD? Requests made under expeditedtimeframe but transferred tostandard timeframe; enter Y All other requests: enter noneWAS THE REQUEST DENIED FOR LACKOF MEDICAL NECESSITY? Request denied for lack of medicalnecessity: enter Y Approved or Dismissed: enter noneWAS THE INITIAL ORGANIZATIONDATE CLAIM/RECONSIDERATION WASDETERMINATION REQUEST DENIED FORPAIDLACK OF MEDICAL NECESSITY? Aligned with CDAG protocol PYMT C RL only Initial organization determination requestdenied for lack of medical necessity: enter Y Date/claim/reconsideration was paid For Universe Table 3, if request wasprocessed as Recon (per column L): enter Y Request was denied: enter none Request processed as OD: enter N Payment not provided: enter none Request was dismissed: enter none
47Field Descriptions – Was the requestdenied for lack of medical necessity?WAS AN EXPEDITED REQUESTMADE BUT PROCESSED ASSTANDARD? Requests made under expeditedtimeframe but transferred tostandard timeframe; enter Y All other requests: enter noneWAS THE REQUEST DENIED FOR LACKOF MEDICAL NECESSITY? Request denied for lack of medicalnecessity: enter Y Approved or Dismissed: enter noneWAS THE INITIAL ORGANIZATIONDATE CLAIM/RECONSIDERATION WASDETERMINATION REQUEST DENIED FORPAIDLACK OF MEDICAL NECESSITY? Aligned with CDAG protocol PYMT C RL only Initial organization determination requestdenied for lack of medical necessity: enter Y Date/claim/reconsideration was paid For Universe Table 3, if request wasprocessed as Recon (per column L): enter Y Request was denied: enter none Request processed as OD: enter N Payment not provided: enter none Request was dismissed: enter none
48Field Descriptions – Was the initialorganization determination requestdenied for lack of medical necessity?WAS AN EXPEDITED REQUESTMADE BUT PROCESSED ASSTANDARD? Requests made under expeditedtimeframe but transferred tostandard timeframe; enter Y All other requests: enter noneWAS THE REQUEST DENIED FOR LACKOF MEDICAL NECESSITY? Request denied for lack of medicalnecessity: enter Y Approved or Dismissed: enter noneWAS THE INITIAL ORGANIZATIONDATE CLAIM/RECONSIDERATION WASDETERMINATION REQUEST DENIED FORPAIDLACK OF MEDICAL NECESSITY? Aligned with CDAG protocol PYMT C RL only Initial organization determination requestdenied for lack of medical necessity: enter Y Date/claim/reconsideration was paid For Universe Table 3, if request wasprocessed as Recon (per column L): enter Y Request was denied: enter none Request processed as OD: enter N Payment not provided: enter none Request was dismissed: enter none
49Field Descriptions – DateClaim/Reconsideration was PaidWAS AN EXPEDITED REQUESTMADE BUT PROCESSED ASSTANDARD? Requests made under expeditedtimeframe but transferred tostandard timeframe; enter Y All other requests: enter noneWAS THE REQUEST DENIED FOR LACKOF MEDICAL NECESSITY? Request denied for lack of medicalnecessity: enter Y Approved or Dismissed: enter noneWAS THE INITIAL
Payment Organization Determinations and Reconsiderations (PYMT_C) Universe Table 4. Part C Effectuations of Overturned Decisions by IRE, ALJ, or MAC (EFF_C) Universe Table 5. Part C Standard and Expedited Grievances (GRV_C) Universe Table 6. Dual Eligible Special Needs Plan -Applicable Integrated Plan Reductions, Suspensions, and Terminations .
