Data Validation Part C and D Audit Changes – What to Expect in the 2019 Reporting Year Audit

By Jason Hoyme
Thu, Aug, 29, 2019

After a relatively quiet 2018 data validation season, CMS has enacted some major changes for the 2019 reporting requirements. This guide will detail the key 2019 Part C and Part D changes you need to be aware of. We haven’t seen this many changes in at least two years, so make sure your team is ready! CMS added some wording to the technical specifications document for “Contracts and/or Plan Benefit Packages (PBPs) that terminate prior to July 1st of the following Contract Year are to be excluded from these reporting requirements.” Make sure to note this exclusion for the 2019 reporting.

Data Validation Part C Audit Changes:

CMS is looking to create more uniformity between the Part C and Part D sections. Beginning in 2019, CMS will use two separate documents for Part C reporting, matching the Part D section. The Part C Reporting Requirements provide a description of the elements for each section and the Part C Technical Specifications provide additional detail to help define the data elements.

If you are a Medicare/Medicaid Plan (MMP) your job was made easier by CMS. You no longer need to complete the Part C Reporting (including Organization Determinations and Grievances). Keep in mind that this only applies to Part C. MMPs will still need to report on the Part D sections.

CMS has made some significant changes to the Part C Grievances section. Plans will no longer report the separate categories (Marketing, Other, CMS Issues, etc.) and will only need to report these five elements: Total Grievances, Total Timely Grievances, Total Expedited Grievances, Total Timely Expedited Grievances, and Dismissals. CMS has added emphasis that Dismissals are not to be counted in the Total elements, while expedited grievances should be counted in the Total elements.

The Organization Determinations section has also gone through some big changes. The entire section has been restructured and now looks like this:

5 sub-sections (re-organized from single list of all elements)

Subsection # 1 – Organization Determinations

Subsection # 2 – Disposition – All Organization Determinations

Subsection # 3 – Reconsiderations

Subsection # 4 – Disposition – All Reconsiderations

Subsection # 5 – Reopenings

  • The timeliness elements are removed and will no longer need to be calculated
  • Plans will now need to report all ODR counts by requestor (either by or on the behalf of the Enrollee/Representative or Non-Contract Provider).
  • Plans should no longer report claims or appeals submitted by contracted providers
  • Make sure to review the reporting of Part B drugs as this guidance from CMS has been enhanced
  • CMS has added additional explanation for when to exclude Medicaid benefits
  • The ODR section is now uploaded instead of being entered directly into HPMS

The SNP section has also been through some updates. This section is often the most complicated and we recommend reading through the guidance closely as your SNP score can impact Star Ratings. While the elements stayed the same, they are now letters A-G instead of numerical 13.1-13.8.

CMS added emphasis that HRAs must be completed within 365 days of a prior HRA or the member’s enrollment date. Clarification was also added that new enrollees without an HRA need to be in 13.2/B only if the member is enrolled 365 or more days (1/1/2019). CMS also specified that members cannot be counted more than once in the same data element for the same plan.

Data Validation Part D Audit Changes:

CMS has made some significant changes to the Part D Grievances section. Plans will no longer report the separate categories (Marketing, Other, CMS Issues, etc.) and will only need to report these five elements: Total Grievances, Total Timely Grievances, Total Expedited Grievances, Total Timely Expedited Grievances, and Dismissals. CMS has added emphasis that Dismissals are not to be counted in the Total elements, while expedited grievances should be counted in the Total elements.

The Coverage Determination section has also gone through some big changes. CMS has removed the old Section 1 – Rejected pharmacy transaction transactions. This section included elements A-G and was normally reported by your PBM. CMS also removed all timeliness elements from the CDR reporting.

CMS also updated how to count the Withdrawals and Dismissals in HPMS. These elements are now excluded from the Total element. Only count the Withdrawals and Dismissals in their own element.

CMS also made some updates to the MTM elements.

New Elements:

H. Beneficiary in a long term care facility at the time of the first CMR offer or delivery of CMR? (Y (yes), N (no), or U (unknown))

O. If offered a CMR, recipient of (initial) offer (Beneficiary, Beneficiary’s prescriber; Caregiver; or Other authorized individual).

R. Date CMR written summary in CMS standardized format was provided or sent. (If more than 1 CMR was performed, report the date the initial CMR written summary was provided or sent.)

W. Date the first TMR was performed

 

Removed Element:

D. Beneficiary Middle Initial

 

CMS made some substantial changes to the Improving Drug Utilization Review Controls section. The section is now split into three:

1. Opioid Care Coordination Safety Edit at 90 MME

2. Hard MME Safety Edit

3. Opioid Naïve Days Supply Safety Edit

Many of elements within these sub-sections are also different from last year’s version.

Hopefully the Part C and Part D data validation guides have been helpful as you move into the Data Validation pre-audit period. Remember to keep checking the CMS.gov website and make sure to use the most up-to-date guidance for your reporting. If you need any help or have questions, please let us know. Burchfield works with clients as a pre-audit reviewer and during the audit season as a Data Validation auditor.

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