Data Validation Audit Changes – Grievances: What to Expect in the 2017 Reporting Year Audit

By Jason Hoyme
Thu, Sep, 07, 2017

CMS continues to make changes to the data validation audit specifications. For this year, CMS has added new elements, suspended a section, and provided clarifications to help plans with their reporting. Here is information about the Grievances changes along with guidance Burchfield received from CMS.


  • CMS added a new element called “Dismissals.” Generally, a dismissal would occur if the procedural requirements for a valid grievance are not met and the plan cannot correct the defects. For example, a plan receives a grievance from a purported representative of the enrollee, but the plan doesn’t receive documentation that the individual is authorized within a reasonable time. In Burchfield’s experience, this is the most common dismissal type.
    • Another common scenario is when a plan dismisses a grievance received more than 60 days after the grievance incident (CMS does not require plans to consider a grievance filed after the 60-day deadline). But not all plans dismiss grievances received more than 60 days after the incident and nothing in the regulations prevents plans from doing so on a case-by-case basis. A plan that accepts non-timely grievances is responsible for developing criteria for evaluating such requests.
    • An enrollee who files a quality of care grievance with a QIO is not required to file the grievance within a specific time frame. Therefore, quality of care grievances filed with a QIO may be filed and investigated beyond 60 days.
    • Any complaint that a member requests to withdraw prior to the plan making their decision should be excluded from Data Validation and should not be counted as a dismissal.
  • CMS is directing plans to generate the Grievances reporting at the end of each quarter and then hold the counts for annual submission.
    • Burchfield has found that many of our clients already generate their reporting on a quarterly basis. Plans can then monitor the reports for any trending differences and help investigate any root causes of complaints. As was true last year, Grievances will have an early due data for uploading counts in HPMS – February 5th. By starting early, plans won’t be as rushed to complete the uploads and will have more time to review the counts.
  • CMS clarified how to handle grievances when enrollees change contracts: “If the enrollee files a grievance with a previous contract, but enrolls in a new contract before the grievance is resolved, the previous contract is still responsible for investigating, resolving and reporting the grievance.”
  • CMS also added to the Part D specifications only clarification for complaints received when the individual is not enrolled: “Grievances filed by non-enrollees (including prospective members) should not be reported to CMS.”
    • This Part D update seems to contradict the guidance in the Part C specifications – “Report grievances if the member is ineligible on the date of the call to the plan but was eligible previously.” Burchfield recommends creating separate and distinct reporting for each section when the specifications are not consistent.

Burchfield has observed that our highest scoring clients develop an understanding of the technical specifications as early as possible. This provides more time to operationally capture all data needed for the reporting year.

Here is a link to the updated specifications CMS Technical Specifications. Please make sure to check regularly for any updates. For this blog post, Burchfield reviewed the technical specification changes as of July 2017.