Coverage Determinations, Appeals and Grievances (CDAG) protocols help to evaluate performance in the areas outlined in the Centers for Medicare and Medicaid Services (CMS) Program Audit Protocol and Data Request related to Medicare Part D CDAG. The CMS performs its program audit activities in accordance with the CDAG Program Audit Data Request and applies compliance standards outlined in the Program Audit Protocol and the Program Audit Process Overview document. At a minimum, CMS will evaluate cases against the criteria listed below. CMS may review factors not specifically addressed below, if it is determined that there are other related CDAG requirements not being met.
Audit Elements Tested
- Timeliness
- Processing of Coverage Requests
- Classification of Requests
- Administration of Drug Management Program
Inovaare compiled these tables from information contained within the CMS website and displayed the 2022 audit protocol changes in an easy-to-follow format. The red font indicates critical areas health plans need to address and the blue font indicates the actual data required. This table is available for download through the link at the bottom of the page.
Table 1: CD
| COLUMN ID | FIELD NAME | FIELD LENGTH | DESCRIPTION |
| A | Enrollee First Name | 50 | Enter the first name of the enrollee. |
| B | Enrollee Last Name | 50 | Enter the last name of the enrollee. |
| C | Enrollee ID | 11 | Enter the Medicare Beneficiary Identifier (MBI) of the enrollee. An MBI is the non-intelligent unique identifier that replaced the HICN on Medicare cards as a result of The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The MBI contains uppercase alphabetic and numeric characters throughout the 11-digit identifier and is unique to each Medicare enrollee. This number must be submitted excluding hyphens or dashes. |
| D | Contract ID | 5 | Enter the contract number (e.g., H1234). |
| E | Plan Benefit Package (PBP) | 3 | Enter the PBP (e.g., 001). |
| F | Drug Name, Strength, and Dosage Form | 150 | Enter the drug name, strength, and dosage form requested. |
| G | NDC | 11 | Enter the 11-Digit National Drug Code using the NDC 11 format. Remove
special characters separating the labeler, product, and trade package
size. When less than 11 characters or a blank field is submitted by the pharmacy or delegate, populate the field as submitted. If the pharmacy submits a value greater than 11 characters, enter “valueXeeded” in the field. For multi-ingredient compound claims populate the field with the NDC as would be submitted on a paid claim’s PDE |
| H | Is this a protected class drug? | 1 | Enter whether it is a protected class drug: • Y for Yes • N for No |
| I | Authorization or Claim Number | 40 | Enter the associated authorization or
claim number for this request. If an
authorization or claim number is not available, provide the internal tracking or case number. Enter None if there is no authorization, claim or other tracking number available. |
| J | Date the request was received | 10 | Enter the date the request was received. Submit in CCYY/MM/DD format (e.g., 2020/01/01). |
| K | Time the request was received | 8 | Enter the time the request was received. Submit in HH:MM:SS military time format (e.g., 23:59:59). |
| L | AOR/Equivalent notice Receipt Date | 10 | Enter the date the Appointment of Representative (AOR) form or equivalent
written notice was received by the sponsoring organization. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Enter None if no AOR or equivalent written notice was received or required. |
| M | AOR/Equivalent notice Receipt Time | 8 | Enter the time the Appointment of Representative (AOR) form or equivalent
written notice was received by the sponsoring organization. Submit in
HH:MM:SS format (e.g., 23:59:59). Enter None if no AOR or equivalent written notice was received or required. |
| N | Request Determination | 18 | Enter: • Approved • Denied • IRE auto-forward • Re-opened Approved • Re-opened Denied • Dismissed |
| O | Was the request processed as Standard or Expedited? | 1 | Enter the manner by which the request was processed: • S for Standard • E for Expedited |
| P | Was the original request made under the standard timeframe and later requested to be expedited? | 4 | Enter: • Y for Yes • N for No • None if the request was made under the expedited timeframe. |
| Q | Date request was upgraded to expedited | 10 | Enter the date the request was received to upgrade the initial standard
request to expedited from the enrollee, their authorized representative,
their prescriber, or the sponsoring organization determined the request
should be expedited. Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None if the initial request was made under the expedited timeframe, if the Sponsoring organization chose not to expedite the request, or if the request was received and processed under the standard timeframe. |
| R | Time the request was upgraded to expedited | 8 | Enter the time the request was received to upgrade the initial standard
request to expedited from the enrollee, their authorized representative, or
their prescriber, or the sponsoring organization determined the request
should be expedited. Submit in HH:MM:SS military time format (e.g.,
23:59:59). Enter None if the initial request was made under the expedited timeframe, if the Sponsoring organization chose not to expedite the request, or if the request was received and processed under the standard timeframe. |
| S | Issue Description | 2,000 | Enter a description of the issue and, if applicable, why the
request was denied. For dismissed cases, provide the reason for dismissal. |
| T | Formulary UM Type | 4 | Enter the formulary UM criteria the enrollee satisfied or was
attempting to satisfy. Enter: • PA for Prior Authorization • ST for Step Therapy • SE for Safety Edit If multiple formulary UM criteria apply, enter the criteria applicable based on the approval or denial reason. Enter None if the enrollee did not satisfy or was not attempting to satisfy Prior Authorization and/or Step Therapy criteria. |
| U | Date of Determination | 10 | Enter the date of the determination. Submit in CCYY/MM/DD format (e.g., 2020/01/01). For dismissed cases, enter the date the sponsoring organization dismissed the request. |
| V | Time of Determination | 8 | Enter the time of the determination. Submit in HH:MM:SS military time
format (e.g., 23:59:59). Enter None for dismissed cases. |
| W | Date effectuated in the system | 10 | Enter the date the approved decision was effectuated in the system.
Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None for requests that were not approved. |
| X | Time effectuated in the system | 8 | Enter the time the approved decision was effectuated in the system.
Submit in HH:MM:SS military time format (e.g., 23:59:59). Enter None for requests that were not approved. |
| Y | Date oral notification provided to enrollee | 10 | Enter the date oral notification was
provided to enrollee. Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None for dismissed cases or if no oral notification was provided. |
| Z | Time oral notification provided to enrollee | 8 | Enter the time oral notification was provided to enrollee. Submit in
HH:MM:SS military time format (e.g., 23:59:59). Enter None for dismissed cases or if no oral notification was provided. |
| AA | Date written notification provided to enrollee | 10 | Enter the date written notification of determination was provided to
enrollee. Do not enter the date a letter is generated or printed. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Enter None if no written notification was provided. |
| AB | Time written notification provided to enrollee | 8 | Enter the time written notification of determination was provided to the
enrollee. Do not enter the time a letter is generated or printed. Submit in
HH:MM:SS military time format (e.g., 23:59:59). Enter None for dismissed cases or if no written notification was provided. |
| AC | Who made the request? | 2 | Enter who made the request: • E for enrollee • ER for enrollee’s representative or purported representative • P for prescribing physician or other prescriber |
| AD | Date forwarded to IRE | 10 | Enter the date the request was forwarded to the IRE. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Enter None if the request was not forwarded to the IRE. |
| AE | Time forwarded to IRE | 8 | Enter the time the request was forwarded to the IRE. Submit in HH:MM:SS
military time format (e.g., 23:59:59). Enter None if the request was not forwarded to the IRE. |
Table 2: CDER
| COLUMN ID | FIELD NAME | FIELD LENGTH | DESCRIPTION |
| A | Enrollee First Name | 50 | Enter the first name of the enrollee. |
| B | Enrollee Last Name | 50 | Enter the last name of the enrollee. |
| C | Enrollee ID | 11 | Enter the Medicare Beneficiary Identifier (MBI) of the enrollee. An MBI is the non-intelligent unique identifier that replaced the HICN on Medicare cards as a result of The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The MBI contains uppercase alphabetic and numeric characters throughout the 11-digit identifier and is unique to each Medicare enrollee. This number must be submitted excluding hyphens or dashes. |
| D | Contract ID | 5 | Enter the contract number (e.g., H1234). |
| E | Plan Benefit Package (PBP) | 3 | Enter the PBP (e.g., 001). |
| F | Drug Name, Strength, and Dosage Form | 150 | Enter the drug name, strength, and dosage form requested. |
| G | NDC | 11 | Enter the 11-Digit National Drug Code using the NDC 11 format. Remove special characters
separating the labeler, product, and trade package size. When less than 11 characters or a blank field is submitted by the pharmacy or delegate, populate the field as submitted. If the pharmacy submits a value greater than 11 characters, enter “valueXeeded” in the field. For multi-ingredient compound claims populate the field with the NDC as would be submitted on a paid claim’s PDE. |
| H | Is this a protected class drug? | 1 | Enter whether it was a protected class drug: • Y for Yes • N for No |
| I | Authorization or Claim Number | 40 | Enter the associated authorization or
claim number for this request. If an
authorization or claim number is not available, provide the internal tracking or case number. Enter None if there is no authorization, claim or other tracking number available. |
| J | Date the request was received | 10 | Enter the date the request was received. Submit in CCYY/MM/DD format (e.g., 2020/01/01). |
| K | Time the request was received | 8 | Enter the time the request was received. Submit in HH:MM:SS military time format (e.g., 23:59:59). |
| L | AOR/Equivalent notice Receipt Date | 10 | Enter the date the Appointment of Representative (AOR) form or equivalent
written notice was received by the sponsoring organization. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Enter None if no AOR or equivalent written notice was received or required. |
| M | AOR/Equivalent notice Receipt Time | 8 | Enter the time the Appointment of Representative (AOR) form or equivalent
written notice was received by the sponsoring organization. Submit in
HH:MM:SS format (e.g., 23:59:59). Enter None if no AOR or equivalent written notice was received or required. |
| N | Request Determination | 18 | Enter: • Approved • Denied • IRE auto-forward • Re-opened Approved • Re-opened Denied • Dismissed |
| O | Was the request processed as Standard or Expedited? | 1 | Enter the manner by which the request was processed: • S for Standard • E for Expedited |
| P | Was the original request made under the standard timeframe and later requested to be expedited? | 4 | Enter: • Y for Yes • N for No • None if the original request was made under the expedited timeframe. |
| Q | Date request was upgraded to expedited | 10 | Enter the date the request was received to upgrade the initial standard
request to expedited from the enrollee, their authorized representative,
their prescriber, or the sponsoring organization determined the request
should be expedited. Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None if the initial request was made under the expedited timeframe, if the Sponsoring organization chose not to expedite the request, or if the request was received and processed under the standard timeframe. |
| R | Time request was upgraded to expedited | 8 | Enter the time the request was received to upgrade the initial standard
request to expedited from the enrollee, their authorized representative, or
their prescriber, or the sponsoring organization determined the request
should be expedited. Submit in HH:MM:SS military time format (e.g.,
23:59:59). Enter None if the initial request was made under the expedited timeframe, if the Sponsoring organization chose not to expedite the request, or if the request was received and processed under the standard timeframe. |
| S | Issue Description | 2,000 | Provide a description of the issue and, if applicable, why the request was
denied. For dismissed cases, provide the reason for dismissal. |
| T | Exception Type | 25 | Enter the type of exception request: • Tiering exception • Non-formulary exception • Formulary UM exception • Hospice • Safety edit exception If multiple exception types apply, enter the exception type applicable based on the approval or denial reason. |
| U | UM Exception Type | 4 | If the case was a UM exception, indicate what criteria the
enrollee was attempting to waive. Enter: • PA for Prior Authorization • ST for Step Therapy • QL for Quantity Limit If the case was a safety edit exception enter: • SE for Safety Edit Enter None if the request was not a UM exception or safety edit exception. If multiple UM exception criteria apply, enter the criteria applicable based on the approval or denial reason. |
| V | Date prescriber supporting statement received | 10 | Enter the date the prescriber’s supporting statement was received. If the
prescriber statement was received with the initial request, enter the date
the exception request was received. Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Enter None if no prescriber supporting statement was received. |
| W | Time prescriber supporting statement received | 8 | Enter the time the prescriber’s supporting statement was received. If the
prescriber statement was received with the initial request, enter the time
the exception request was received. Submit in HH:MM:SS military time format
(e.g., 23:59:59). Enter None if no prescriber supporting statement was received. |
| X | Date of Determination | 10 | Enter the date of the determination. Submit in CCYY/MM/DD format (e.g., 2020/01/01). For dismissed cases, enter the date the sponsoring organization dismissed the request. |
| Y | Time of Determination | 8 | Enter the time of the determination. Submit in HH:MM:SS military time
format (e.g., 23:59:59). Enter None for dismissed cases. |
| Z | Date effectuated in the system | 10 | Enter the date the approved decision was effectuated in the system.
Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None if the exception was not approved. |
| AA | Time effectuated in the system | 8 | Enter the time the approved decision was effectuated in the system. Submit
in HH:MM:SS military time format (e.g., 23:59:59). Enter None if the exception was not approved. |
| AB | Expiration date of the approval | 10 | Enter the expiration date of the exception approval. Submit in CCYY/MM/DD format
(e.g., 2020/01/01). Enter None if the exception was not approved. |
| AC | Date oral notification provided to enrollee | 10 | Enter the date oral notification was provided to enrollee. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Enter None for dismissed cases or if no oral notification was provided. |
| AD | Time oral notification provided to enrollee | 8 | Enter the time oral notification was provided to enrollee. Submit in
HH:MM:SS military time format (e.g., 23:59:59). Enter None for dismissed cases or if no oral notification was provided. |
| AE | Date written notification provided to enrollee | 10 | Enter the date written notification of determination was provided to
enrollee. Do not enter the date a letter is generated or printed. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Enter None if no written notification was provided. |
| AF | Time written notification provided to enrollee | 8 | Enter the time written notification of determination was provided to the
enrollee. Do not enter the time a letter is generated or printed. Submit in
HH:MM:SS military time format (e.g., 23:59:59). Enter None for dismissed cases or if no written notification was provided. |
| AG | Who made the request? | 2 | Enter who made the request: • E for enrollee • ER for enrollee’s representative or purported representative • P for prescribing physician or other prescriber |
| AH | Date forwarded to IRE | 10 | Enter the date the request was forwarded to the IRE. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Enter None if the request was not forwarded to the IRE. |
| AI | Time forwarded to IRE | 8 | Enter the time the request was forwarded to the IRE. Submit in HH:MM:SS
military time format (e.g., 23:59:59). Enter None if the request was not forwarded to the IRE. |
Table 3: PYMT_D
| COLUMN ID | FIELD NAME | FIELD LENGTH | DESCRIPTION |
| A | Enrollee First Name | 50 | Enter the first name of the enrollee. |
| B | Enrollee Last Name | 50 | Enter the last name of the enrollee. |
| C | Enrollee ID | 11 | Enter the Medicare Beneficiary Identifier (MBI) of the enrollee. An MBI is the non-intelligent unique identifier that replaced the HICN on Medicare cards as a result of The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The MBI contains uppercase alphabetic and numeric characters throughout the 11-digit identifier and is unique to each Medicare enrollee. This number must be submitted excluding hyphens or dashes. |
| D | Contract ID | 5 | Enter the contract number (e.g., H1234). |
| E | Plan Benefit Package (PBP) | 3 | Enter the PBP (e.g., 001). |
| F | Drug Name, Strength, and Dosage Form | 150 | Enter the drug name, strength, and dosage form requested. |
| G | NDC | 11 | Enter the 11-Digit National Drug Code using the NDC 11 format. Remove special characters
separating the labeler, product, and trade package size. When less than 11 characters or a blank field is submitted by the pharmacy or delegate, populate the field as submitted. If the pharmacy submits a value greater than 11 characters, enter “valueXeeded” in the field. For multi-ingredient compound claims populate the field with the NDC as would be submitted on a paid claim’s PDE. |
| H | Is this a protected class drug? | 1 | Enter whether it was a protected class drug: · Y for Yes · N for No |
| I | Authorization or Claim Number | 40 | Enter the associated authorization or
claim number for this request. If an
authorization or claim number is not available, provide the internal tracking or case number. Enter None if there is no authorization, claim or other tracking number available. |
| J | Date the request was received | 10 | Enter the date the request was received. If the sponsoring organization obtained information establishing good cause after the 60-day filing timeframe, enter the date the sponsoring organization received the information establishing good cause. Submit in CCYY/MM/DD format (e.g., 2020/01/01). |
| K | AOR/Equivalent notice Receipt Date | 10 | Enter the date the Appointment of Representative (AOR) form or equivalent
written notice was received by the sponsoring organization. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Enter None if no AOR or equivalent written notice was received or required. |
| L | Type of Request | 30 | Enter: · payment coverage determination · payment redetermination |
| M | Request Determination | 18 | Enter: · Approved · Denied · IRE auto-forward · Re-opened Approved · Re-opened Denied · Dismissed |
| N | Was the request processed as an exception request? | 1 | Enter: · Y for Yes · N for No |
| O | Issue Description | 2,000 | Enter a description of the issue and, if applicable, why the request was denied. For dismissed cases, provide the reason for dismissal. |
| P | Exception Type | 25 | Enter the type of exception request: • Tiering exception • Non-formulary exception • Formulary UM exception • Hospice • Safety edit exception If multiple exception types apply, enter the exception type applicable based on the approval or denial reason. Enter None if the request was not an exception request. |
| Q | UM Exception Type | 4 | If the case was a UM exception, indicate what criteria the
enrollee was attempting to waive. Enter: • PA for Prior Authorization • ST for Step Therapy • QL for Quantity Limit If the case was a safety edit exception enter: • SE for Safety Edit Enter None if the request was not a UM exception or safety edit exceUption. If multiple UM exception criteria apply, enter the criteria applicable based on the approval or denial reason. |
| R | Date prescriber supporting statement received | 10 | Enter the date the prescriber’s supporting statement was received. If the
prescriber statement was received with the initial request, enter the date
the exception request was received. Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Enter None if no prescriber supporting statement was received. |
| S | Was the coverage determination request denied for lack of medical necessity? | 4 | Enter: · Y for Yes · N for No · None if the request was not denied (i.e., approved, auto- forwarded, dismissed). |
| T | Date of Determination | 10 | Enter the date of the determination. Submit in CCYY/MM/DD format (e.g., 2020/01/01). For dismissed cases, enter the date the sponsoring organization dismissed the request. |
| U | Date effectuated in the system | 10 | Enter the date the approved decision was effectuated in the system. Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None if the payment request was not approved. |
| V | Expiration date of the approval | 10 | Enter the expiration date of the exception approval. Submit in CCYY/MM/DD format
(e.g., 2020/01/01). Enter None if the exception was not approved or if the request was not an exception request. |
| W | Date written notification provided to enrollee | 10 | Enter the date written notification of determination was provided to
enrollee. Do not enter the date a letter is generated or printed. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Enter None if no written notification was provided. |
| X | Who made the request? | 2 | Enter who made the request: • E for enrollee • ER for enrollee’s representative or purported representative • P for prescribing physician or other prescriber |
| Y | Date reimbursement provided | 10 | Enter the date the check or reimbursement was provided to the enrollee.
Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter NRD if the request was approved but no reimbursement was due to the enrollee. Enter NP if the payment has not been issued at the time of the universe submission. Enter None if the request was not approved. |
| Z | Date forwarded to IRE | 10 | Enter the date the request was forwarded to the IRE. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Enter None if the request was not forwarded to the IRE. |
Table 4: RD
| COLUMN ID | FIELD NAME | FIELD LENGTH | DESCRIPTION |
| A | Enrollee First Name | 50 CHAR | Enter the first name of the enrollee. |
| B | Enrollee Last Name | 50 CHAR | Enter the last name of the enrollee. |
| C | Enrollee ID | 11 CHAR | Enter the Medicare Beneficiary Identifier (MBI) of the enrollee. An MBI is the non-intelligent unique identifier that replaced the HICN on Medicare cards as a result of The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The MBI contains uppercase alphabetic and numeric characters throughout the 11-digit identifier and is unique to each Medicare enrollee. This number must be submitted excluding hyphens or dashes. |
| D | Contract ID | 5 CHAR | Enter the contract number (e.g., H1234). |
| E | Plan Benefit Package (PBP) | 3 CHAR | Enter the PBP (e.g., 001). |
| F | Drug Name, Strength, and Dosage Form | 150 CHAR | Enter the drug name, strength, and dosage form requested. |
| G | NDC | 11 CHAR | Enter the 11-Digit National Drug Code using the NDC 11 format. Remove special characters
separating the labeler, product, and trade package size. When less than 11 characters or a blank field is submitted by the pharmacy or delegate, or NDC is not applicable (e.g., for at-risk redeterminations), populate the field as submitted. If the pharmacy submits a value greater than 11 characters, enter “valueXeeded” in the field. For multi-ingredient compound claims populate the field with the NDC as would be submitted on a paid claim’s PDE. |
| H | Is this a protected class drug? | 4 CHAR | Enter whether it is a protected class drug: • Y for Yes • N for No • None if not applicable |
| I | Authorization or Claim Number | 40 CHAR | Enter the associated authorization or
claim number for this request. If an
authorization or claim number is not available, provide the internal tracking or case number. Enter None if there is no authorization, claim or other tracking number available. |
| J | Date the request was received | 10 CHAR | Enter the date the request was received. If the sponsoring organization obtained information establishing good cause after the 60-day filing timeframe, enter the date the sponsoring organization received the information establishing good cause. Submit in CCYY/MM/DD format (e.g., 2020/01/01). |
| K | Time the request was received | 8 CHAR | Enter the time the request was received. If
the sponsoring organization obtained information establishing good cause
after the 60-day filing timeframe, enter the time the sponsoring organization
received the information establishing good cause. Submit in HH:MM:SS military time format (e.g.,
23:59:59). Enter None for standard cases. |
| L | AOR/Equivalent notice Receipt Date | 10 CHAR | Enter the date the Appointment of Representative (AOR) form or equivalent
written notice was received by the sponsoring organization. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Enter None if no AOR or equivalent written notice was received or required. |
| M | AOR/Equivalent notice Receipt Time | 8 CHAR | Enter the time the Appointment of Representative (AOR) form or
equivalent written notice was received by the sponsoring organization. Submit
in HH:MM:SS format (e.g., 23:59:59). Enter None for standard cases or if no AOR or equivalent written notice was received or required. |
| N | Is this an appeal of an at-risk determination? | 1 CHAR | Enter whether it was an appeal of an at-risk determination (e.g.
request for a change in pharmacy and/or prescriber limitations, request for a
change in the enrollee’s at-risk determination status): • Y for Yes • N for No |
| O | Request Determination | 18 CHAR | Enter: • Approved • Denied • IRE auto-forward • Re-opened Approved • Re-opened Denied • Dismissed |
| P | Was the request processed as Standard or Expedited? | 1 CHAR | Enter the manner by which the request was processed: • S for Standard • E for Expedited |
| Q | Was the original request made under the standard timeframe and later requested to be expedited? | 4 CHAR | Enter: • Y for Yes • N for No • None if the request was made under the expedited timeframe |
| R | Date request was upgraded to expedited | 10 CHAR | Enter the date the request was received to upgrade the initial standard
request to expedited from the enrollee, their authorized representative,
their prescriber, or the sponsoring organization determined the request
should be expedited. Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None if the initial request was made under the expedited timeframe, if the Sponsoring organization chose not to expedite the request, or if the request was received and processed under the standard timeframe. |
| S | Time request was upgraded to expedited | 8 CHAR | Enter the time the request was received to upgrade the initial standard
request to expedited from the enrollee, their authorized representative, or
their prescriber, or the sponsoring organization determined the request
should be expedited. Submit in HH:MM:SS military time format (e.g., 23:59:59). Enter None if the initial request was made under the expedited timeframe, if the sponsoring organization chose not to expedite the request, or if the request was received and processed under the standard timeframe. |
| T | Issue Description | 2000 CHAR | Enter a description of the redetermination issue and, if applicable, why the request was denied. For dismissed cases, provide the reason for dismissal. |
| U | Exception Type | 25 CHAR | Enter the type of exception request: • Tiering exception • Non-formulary exception • Formulary UM exception • Hospice • Safety edit exception If multiple exception types apply, enter the exception type applicable based on the approval or denial reason. Enter None if the request was not an exception request. |
| V | UM Exception Type | 4 CHAR | If the case was a UM exception, indicate what criteria the
enrollee was attempting to waive. Enter: • PA for Prior Authorization • ST for Step Therapy • QL for Quantity Limit If the case was a safety edit exception enter: • SE for Safety Edit Enter None if the request was not a UM exception or safety edit exception. If multiple UM exception criteria apply, enter the criteria applicable based on the approval or denial reason. |
| W | Was the coverage determination request denied for lack of medical necessity? | 4 CHAR | Enter: • Y for Yes • N for No • None if the request was auto-forwarded |
| X | Date of Determination | 10 CHAR | Enter the date of the determination. Submit in CCYY/MM/DD format (e.g.,
2020/01/01). For dismissed cases, enter the
date the sponsoring organization dismissed the request. |
| Y | Time of Determination | 8 CHAR | Enter the time of the determination. Submit in HH:MM:SS military time
format (e.g., 23:59:59). Enter None for standard cases and dismissed cases. |
| Z | Date effectuated in the system | 10 CHAR | Enter the date the approved decision was effectuated in the system.
Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None for requests that were not approved. |
| AA | Time effectuated in the system | 8 CHAR | Enter the time the approved decision was effectuated in the system.
Submit in HH:MM:SS military time format (e.g., 23:59:59). Enter None for standard cases and requests that were not approved |
| AB | Expiration date of the approval | 10 CHAR | Enter the expiration date of the exception approval. Submit in CCYY/MM/DD format
(e.g., 2020/01/01). Enter None if the exception was not approved or if it is not an exception request. |
| AC | Date oral notification provided to enrollee | 10 CHAR | Enter the date oral notification was provided to enrollee. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Enter None for standard cases, dismissed cases or if no oral notification was provided. |
| AD | Time oral notification provided to enrollee | 8 CHAR | Enter the time oral notification was provided to enrollee. Submit in
HH:MM:SS military time format (e.g., 23:59:59). Enter None for standard cases, dismissed cases or if no oral notification was provided. |
| AE | Date written notification provided to enrollee | 10 CHAR | Enter the date written notification of determination was provided to
enrollee. Do not enter the date a letter is generated or printed. Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None if no written notification was provided. |
| AF | Time written notification provided to enrollee | 8 CHAR | Enter the time written notification of determination was provided to the
enrollee. Do not enter the time a letter is generated or printed. Submit in
HH:MM:SS military time format (e.g., 23:59:59). Enter None for standard cases, dismissed cases or if no written notification was provided. |
| AG | Who made the request? | 2 CHAR | Enter who made the request: • E for enrollee • ER for enrollee’s representative • P for prescribing physician or other prescriber |
| AH | Date forwarded to IRE | 10 CHAR | Enter the date the redetermination request was forwarded to the IRE.
Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None if the request was not forwarded to the IRE. |
| AI | Time forwarded to IRE | 8 CHAR | Enter the time the redetermination request was forwarded to the IRE.
Submit in HH:MM:SS military time format (e.g., 23:59:59). Enter None if the request was not forwarded to the IRE. |
Table 5: EFF_D
| COLUMN I | FIELD NAME | FIELD LEN | DESCRIPTION |
| A | Enrollee First Name | 50 CHAR | Enter the first name of the enrollee. |
| B | Enrollee Last Name | 50 CHAR | Enter the last name of the enrollee. |
| C | Enrollee ID | 11 CHAR | Enter the Medicare Beneficiary Identifier (MBI) of the enrollee. An MBI is the non-intelligent unique identifier that replaced the HICN on Medicare cards as a result of The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The MBI contains uppercase alphabetic and numeric characters throughout the 11-digit identifier and is unique to each Medicare enrollee. This number must be submitted excluding hyphens or dashes. |
| D | Contract ID | 5 CHAR | Enter the contract number (e.g., H1234). |
| E | Plan Benefit Package (PBP) | 3 CHAR | Enter the PBP (e.g., 001). |
| F | Drug Name, Strength, and Dosage Form | 150 CHAR | Enter the drug name, strength, and
dosage form requested. Enter None if not applicable. |
| G | NDC | 11 CHAR | Enter the 11-Digit National Drug Code using the NDC 11 format. Remove special characters
separating the labeler, product, and trade package size. When less than 11 characters or a blank field is submitted by the pharmacy or delegate, or NDC is not applicable (e.g., for at-risk redeterminations), populate the field as submitted. If the pharmacy submits a value greater than 11 characters, enter “valueXeeded” in the field. For multi-ingredient compound claims populate the field with the NDC as would be submitted on a paid claim’s PDE. |
| H | Is this a protected class drug? | 1 CHAR | Enter whether it is a protected class drug: • Y for Yes • N for No • None if not applicable |
| I | Authorization or Claim Number | 40 CHAR | Enter the associated authorization or
claim number for this request. If an
authorization or claim number is not available, provide the internal tracking or case number. Enter None if there is no authorization, claim or other tracking number available. |
| J | Date the overturn decision was received | 10 CHAR | Enter the date the overturn decision was received. Submit in CCYY/MM/DD format (e.g., 2020/01/01). |
| K | Time the overturn decision was received | 8 CHAR | Enter the time the overturn decision was received. Submit in HH:MM SS military time format (e.g., 23:59:59). |
| L | Type of Request reversed by review entity | 43 CHAR | Enter the type of request: • Standard request for benefits • Standard request for payment • Standard request for at-risk determination • Expedited request for benefits • Expedited request for at- risk determination |
| M | Date the overturn decision was effectuated in the system | 10 CHAR | Enter the date the benefit was provided, payment was authorized or the
change to the at-risk determination was implemented. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Enter None if the overturn decision was not effectuated or if no effectuation was required. |
| N | Time the overturn decision was effectuated in the system | 8 CHAR | Enter the time the benefit was provided, payment was authorized or the
change to the at-risk determination was implemented. Submit in HH:MM:SS
military time format (e.g., 23:59:59). Enter None if the overturn decision was not effectuated or if no effectuation was required. |
| O | Date reimbursement provided | 10 CHAR | Enter the date the check or reimbursement was provided to the enrollee.
Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter NRD if the request was approved but no reimbursement was due to the enrollee. Enter NP if the payment has not been issued at the time of the universe submission. Enter None if it was not a post-service (payment) request. |
| P | Expiration date of the approval | 10 CHAR | Enter the expiration date of the exception approval. Submit in CCYY/MM/DD format
(e.g., 2020/01/01). Enter None if it was not an exception request. |
Table 6: GRV_D
| COLUMN I | FIELD NAME | FIELD LEN | DESCRIPTION |
| A | Enrollee First Name | 50 | Enter the first name of the enrollee. |
| B | Enrollee Last Name | 50 | Enter the last name of the enrollee. |
| C | Enrollee ID | 11 | Enter the Medicare Beneficiary Identifier (MBI) of the enrollee. An MBI is the non-intelligent unique identifier that replaced the HICN on Medicare cards as a result of The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The MBI contains uppercase alphabetic and numeric characters throughout the 11-digit identifier and is unique to each Medicare enrollee. This number must be submitted excluding hyphens or dashes. |
| D | Contract ID | 5 | Enter the contract number (e.g., H1234). |
| E | Plan Benefit Package (PBP) | 3 | Enter the PBP (e.g., 001). |
| F | Date the grievance was received | 10 | Enter the date the grievance was received. Submit in CCYY/MM/DD format (e.g., 2020/01/01). |
| G | Time the grievance was received | 8 | Enter the time the grievance was received. Submit in HH:MM:SS military
time format (e.g., 23:59:59). Enter None for standard cases. |
| H | AOR/Equivalent notice Receipt Date | 10 | Enter the date the Appointment of Representative (AOR) form or equivalent
written notice was received by the sponsoring organization. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Enter None if no AOR or equivalent written notice was received or required. |
| I | AOR/Equivalent notice Receipt Time | 8 | Enter the time the Appointment of Representative (AOR) form or
equivalent written notice was received by the sponsoring organization. Submit
in HH:MM:SS format (e.g., 23:59:59). Enter None for standard cases or if no AOR or equivalent written notice was received or required. |
| J | How was the grievance received? | 7 | Enter: • Oral • Written |
| K | Was the grievance processed as Standard, or Expedited? | 1 | Enter: • S for Standard • E for Expedited |
| L | Category of the issue | 50 | Enter the category of the grievance as assigned by the Sponsoring organization. Enter based on the Sponsoring organization’s internal labeling system. |
| M | Grievance Description | 1800 | Enter the description of the grievance. |
| N | Was this processed as a quality of care grievance? | 1 | Enter: • Y for Yes • N for No |
| O | Was a timeframe extension taken | 1 | Enter: • Y for Yes • N for No |
| P | Date oral notification provided to enrollee | 10 | Enter the date oral notification was provided to enrollee. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Enter None if no oral notification was provided. |
| Q | Time oral notification provided to enrollee | 8 | Enter the time oral notification was provided to enrollee. Submit in
HH:MM:SS military time format (e.g., 23:59:59). Enter None for standard cases or if no oral notification was provided. |
| R | Date written notification provided to enrollee | 10 | Enter the date written notification was provided to enrollee. Do not
enter the date a letter is generated or printed. Submit in CCYY/MM/DD format
(e.g., 2020/01/01). Enter None if no written notification was provided. |
| S | Time written notification provided to enrollee | 8 | Enter the time written notification was provided to enrollee. Submit in
HH:MM:SS military time format (e.g., 23:59:59). Enter None for standard cases or if no written notification was provided. |
| T | Who made the request? | 2 | Enter who made the request: • E for enrollee • ER for enrollee’s representative or purported representative |
Table 7: AR
| COLUMN ID | FIELD NAME | FIELD LENGTH | DESCRIPTION |
| A | Enrollee First Name | 50 | Enter the first name of the enrollee. |
| B | Enrollee Last Name | 50 | Enter the last name of the enrollee. |
| C | Enrollee ID | 11 | Enter the Medicare Beneficiary Identifier (MBI) of the enrollee. An MBI is the non- intelligent unique identifier that replaced the HICN on Medicare cards as a result of The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015. The MBI contains uppercase alphabetic and numeric characters throughout the 11- digit identifier and is unique to each Medicare enrollee. This number must be submitted excluding hyphens or dashes. |
| D | Contract ID | 5 | Enter the contract number (e.g., H1234). |
| E | Plan Benefit Package (PBP) | 3 | Enter the PBP (e.g., 001). |
| F | Drug Name, Strength, and Dosage Form | 150 | Enter the drug name, strength, and
dosage form applicable
to the specific limitation the sponsoring organization intends to place on
the beneficiary’s access to coverage for frequently abused drugs under the
program. Enter Multiple if the intended limitation applies to more than one drug (e.g. beneficiary level edit blocking all opioid access, beneficiary level edit allowing a defined cumulative MME dosage). Enter None if the intended limitation is not related to a specific drug (e.g. pharmacy lock- in, prescriber lock-in). |
| G | Date the Initial Written Notification of potential at-risk status was provided to enrollee | 10 | Enter the date the initial notification was provided to the enrollee
that identified them as potentially at-risk. Submit in CCYY/MM/DD format
(e.g., 2020/01/01). Enter None if no written notification was provided. |
| H | Date Second Written Notification of At-Risk Determination Provided to Enrollee | 10 | Enter the date the second written notification or alternate
second written notification was provided to enrollee. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Enter None if no written notification was provided. |
| I | Date the At- Risk Determination was made | 10 | Enter the date the at-risk or not at-risk determination was made. Submit in CCYY/MM/DD format (e.g., 2020/01/01). |
| J | Request Determination | 11 | Enter the determination: • At-Risk • Not At-Risk |
| K | Type of At-Risk Limitation | 54 | Enter the type of at-risk limitation imposed upon the
enrollee: • Point of Sale Edit • Pharmacy Lock-In • Provider Lock-In If there are multiple limitations, enter all limitations that apply (e.g., POS edit, pharmacy lock-in and prescriber lock- in). Enter None if an at-risk determination was not imposed on the enrollee. |
| L | Confirmation of Agreement to Place Limitation upon Enrollee | 4 | Identify if agreement to place limitation was confirmed by
either the pharmacy, provider or both. Enter: • YPR for Yes from Provider • YPH for Yes from Pharmacy • YBO for Yes from Both Enter None if no confirmation of agreement was received. |
| M | If an enrollee edit was used, date the edit was effectuated in the system | 10 | Enter the date the enrollee edit/limitation was effectuated in
the system. Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None if no limitations were entered into the system. |
| N | Expiration date of the at-risk restriction/lock-in | 10 | Enter the expiration date of the at-risk restriction/lock-in.
Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None if there was not a restriction/lock-in placed on enrollee. |
- Yellow: Audit Review Period
- Blue: valid values
Disclaimer: The data included in these tables are transposed directly from the CMS website and have not been edited for grammar and format consistency. Inovaare distilled the content for your convenience and educational purposes; it should not be used as a substitute for health plan compliance team authorization. Due to the unique needs of health plans, the reader should consult her or his compliance officer to determine the appropriateness of the information contained herein.