Organization Determinations, Appeals and Grievances (ODAG) 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 C ODAG. The CMS performs its program audit activities in accordance with the ODAG 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 ODAG requirements not being met.
Audit Elements Tested
- Timeliness
- Processing of Coverage Requests
- Classification of Requests
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: OD
| 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 | First Tier, Downstream, and Related Entity | 70 | Enter the name of the First Tier, Downstream, and Related Entity (which
is any party that enters into a written arrangement, acceptable to CMS, with
the sponsoring organization to provide administrative or health care services
to an enrollee under the Part C or D program) that processed the
request. Enter None if the sponsoring organization processed the request. |
| G | Authorization or Claim Number | 40 | Enter the associated authorization or
claim number for this request. If an
authorization or claim number is not available, enter the internal tracking or case number. Enter None if there is no authorization, claim or other tracking number available. |
| H | Date the request was received | 10 | Enter the date the request was received. Submit in CCYY/MM/DD format
(e.g., 2020/01/01). If a standard request was upgraded to expedited, enter the date the request was upgraded. |
| I | Time the request was received | 8 | For all expedited requests and standard Part B drug requests,
enter the time the
request was received. Submit in HH:MM:SS military time format (e.g.,
23:59:59). If a standard request was upgraded to expedited, enter the time the request was upgraded. Enter None for standard service requests and dismissed requests. |
| J | Part B Drug Request? | 1 | Enter: • Y for Yes • N for No |
| 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 | AOR/Equivalent notice Receipt Time | 8 | For all expedited requests and standard Part B drug requests,
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 service requests or if no AOR or equivalent written notice was received or required. |
| M | Request Determination | 9 | Enter: • Approved • Denied • Dismissed |
| N | Was the request processed as Standard or Expedited? | 1 | Enter the manner by which the request was processed: • S for Standard • E for Expedited |
| O | Was a timeframe extension taken? | 1 | Enter: • Y for Yes • N for No |
| P | Date of Determination | 10 | Enter the date of the determination. Submit in CCYY/MM/DD format (e.g., 2020/01/01). For dismissed requests, enter the date the Sponsoring organization dismissed the request. |
| Q | Time of Determination | 8 | For all expedited requests and standard Part B drug requests,
enter the time of the
determination. Submit in HH:MM:SS military time format (e.g.,
23:59:59). Enter None for standard service requests and dismissed requests. |
| R | 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. |
| S | Time oral notification provided to enrollee | 8 | For all expedited requests and standard Part B drug requests,
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 service requests, dismissed requests, or if no oral notification was provided. |
| T | 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. |
| U | Time written notification provided to enrollee | 8 | For all expedited requests and standard Part B drug requests,
enter the time written
notification of determination was provided to enrollee. Do not enter the time
a letter was generated or printed. Submit in HH:MM:SS military time format (e.g., 23:59:59). Enter None for standard service requests, dismissed requests, or if no written notification was provided. |
| V | Who made the request? | 3 | Enter who made the request: • E for enrollee • ER for enrollee’s representative or purported representative • CP for requests by a contract provider/facility • NCP for requests by a non- contract provider/facility |
| W | Issue description and type of service | 2,000 | Provide a description of the service or item requested and why it was requested
(if known). For denials, also provide an explanation of why the pre-service
request was denied. For dismissed requests, provide the reason for dismissal. |
| X | Was an expedited request made but processed as standard? | 4 | Enter: • Y for Yes if an expedited request was received but downgraded to standard • None for all other requests (e.g. the request was received as expedited and processed as expedited, the request was received as standard) |
| Y | Was the request denied for lack of medical necessity? | 4 | Enter: • Y for Yes • N for No • None if the request was approved or dismissed. |
Table 2: RECON
| 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 | First Tier, Downstream, and Related Entity | 70 | Enter the name of the First Tier, Downstream, and Related Entity (which is
any party that enters into a written arrangement, acceptable to CMS, with the
sponsoring organization to provide administrative or health care services to
an enrollee under the Part C or D program) that processed the request. Enter None if the sponsoring organization processed the request. |
| G | Authorization or Claim Number | 40 | Enter the associated authorization or
claim number for this request. If an
authorization or claim number is not available, enter the internal tracking
or case number. Enter None if there is no authorization, claim or other tracking number available. |
| H | Date the request was received | 10 | Enter the date the reconsideration request was received. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). If a standard request was upgraded to expedited, enter the date the request was upgraded. 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. |
| I | Time the request was received | 8 | For all expedited requests, enter the
time the reconsideration request was received.
Submit in HH:MM:SS military time format (e.g., 23:59:59). If a standard request was upgraded to expedited, enter the time the request was upgraded. 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. Enter None for standard and dismissed requests. |
| J | Part B Drug Request? | 1 | Enter: • Y for Yes • N for No |
| 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 | AOR/Equivalent Notice Receipt Time | 8 | For all expedited requests, 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 requests or if no AOR or equivalent written notice was received or required. |
| M | Request Determination | 9 | Enter: • Approved • Denied • Dismissed |
| N | Was the request processed as Standard or Expedited? | 1 | Enter the manner by which the request was processed: • S for Standard • E for Expedited |
| O | Was a timeframe extension taken? | 1 | Enter: • Y for Yes • N for No |
| P | Date of Determination | 10 | Enter the date of the determination. Submit in CCYY/MM/DD format (e.g.,
2020/01/01). For dismissed requests, enter the date the Sponsor dismissed the request. |
| Q | Time of Determination | 8 | For all expedited requests, enter the time of the
determination. Submit in HH:MM:SS military time format (e.g.,
23:59:59). Enter None for standard and dismissed requests. |
| R | 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 requests or if no oral notification was provided. |
| S | Time oral notification provided to enrollee | 8 | For all expedited requests, , 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 requests, dismissed requests, or if no oral notification was provided. |
| T | 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. |
| U | Time written notification provided to enrollee | 8 | For all expedited requests, enter the time written notification was provided to 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 requests, dismissed requests, or if no written notification was provided. |
| V | Date reconsidered determination effectuated in the system | 10 | Enter the date the reconsidered determination was effectuated in the
system. Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None if the determination was denied or dismissed |
| W | Time reconsidered determination effectuated in the system | 8 | For all expedited requests, enter the time the reconsidered determination was effectuated in the
system. Submit in HH:MM:SS military time format (e.g., 23:59:59). Enter None for standard cases, dismissed cases, or if the request was denied. |
| X | 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 enrollee was notified of the approved reconsideration or if the request was not forwarded to the IRE. |
| Y | Time forwarded to IRE | 8 | For all expedited requests, 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 enrollee was notified of the approved reconsideration, if the request was not forwarded to the IRE, or for standard requests. |
| Z | Who made the request? | 3 | Enter the person who made the request: • E for enrollee • ER for enrollee’s representative or purported representative • CP for requests by a contract provider/facility • NCP for requests by a non- contract provider/facility |
| AA | Issue description and type of service | 2,000 | Provide a description of the service or item requested and why it was requested
(if known). For denials, also provide an
explanation of why the pre-service request was denied. For dismissed requests, provide the reason for dismissal. |
| AB | Was an expedited request made but processed as standard? | 4 | Enter: • Y for Yes if an expedited request was received but downgraded to standard • None for all other cases (e.g. the request was received as expedited and processed as expedited, the request was received as standard, or the request was dismissed). |
| AC | Was the initial organization determination request denied for lack of medical necessity? | 1 | Enter: • Y for Yes • N for No |
Table 3: PYMT_C
| 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 | First Tier, Downstream, and Related Entity | 70 | Enter the name of the First Tier, Downstream, and Related Entity (which
is any party that enters into a written arrangement, acceptable to CMS, with
the sponsoring organization to provide administrative or health care services
to an enrollee under the Part C or D program) that processed the
request. Enter None if the sponsoring organization processed the request. |
| G | Authorization or Claim Number | 40 | Enter the associated authorization or
claim number for this request. If an
authorization or claim number is not available, enter the internal tracking
or case number. Enter None if there is no authorization, claim or other tracking number available. |
| H | Date the request was received | 10 | Enter the date the payment 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). |
| I | 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 for dismissed requests or if no AOR or equivalent written notice was received or required |
| J | Waiver of Liability (WOL) Receipt Date | 10 | Enter the date the WOL form was received for non- contracted provider
payment appeals. Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None for ODs, enrollee submitted requests, or if a WOL was never received. |
| K | Was it a clean claim? | 4 | Enter: • Y for clean claim • N for unclean claim • None for payment reconsiderations |
| L | Was the request processed as an OD or Recon? | 5 | Enter the manner by which the request was processed: • OD • Recon |
| M | Request Determination | 9 | Enter: • Approved • Denied • Dismissed |
| N | Date of Determination | 10 | Enter the date of the determination. Submit in CCYY/MM/DD format (e.g.,
2020/01/01). This is the date the determination was entered in the system and
may be the same as the date claim was paid. For dismissed requests, enter the date the Sponsoring organization dismissed the request. |
| O | Date claim/reconsideration was paid | 10 | Enter the date the claim/reconsideration was paid. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Enter None if payment was not provided, if the request was denied, or if the request was dismissed. |
| P | Date written notification provided to enrollee | 10 | Enter the date 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. |
| Q | Date written notification provided to provider | 10 | Enter the date written notification
was provided to provider. 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 or if the enrollee submitted the request. |
| R | Date forwarded to IRE | 10 | Enter the date the reconsideration request was forwarded to the IRE.
Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None for organization determination requests, or if the reconsideration request was approved, dismissed, or not forwarded to the IRE. |
| S | Who made the request? | 3 | Enter who made the request: • E for enrollee • ER for enrollee’s representative or purported representative • NCP for requests by a non- contract provider/pharmacy |
| T | Issue description and type of service | 2,000 | Provide a description of the service or item requested and why it was requested
(if known). For denials, also provide an
explanation of why the payment organization determination or payment
reconsideration request was denied. For dismissed requests, please provide the reason for dismissal. |
| U | Was the initial organization determination request denied for lack of medical necessity? | 4 | Enter: • Y for Yes • N for No • None if the request was approved or dismissed. |
Table 4: EFF_C
| 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 | First Tier, Downstream, and Related Entity | 70 | Enter the name of the First Tier, Downstream, and Related Entity (which
is any party that enters into a written arrangement, acceptable to CMS, with
the sponsoring organization to provide administrative or health care services
to an enrollee under the Part C or D program) that processed the
request. Enter None if the sponsoring organization processed the request. |
| G | Authorization or Claim Number | 40 | Enter the associated authorization or
claim number for this request. If an
authorization or claim number is not available, enter the internal tracking or case number. Enter None if there is no authorization, claim or other tracking number available. |
| H | Type of reconsideration case | 9 | Enter the type of reconsideration case submitted to
IRE/ALJ/MAC: • Standard • Expedited • Payment For pre-service cases, enter Standard or Expedited. For post-service cases, enter Payment. |
| I | Review Entity | 3 | Enter the entity that overturned the decision: • IRE • ALJ • MAC |
| J | Date the overturned decision was received |
10 | Enter the date the overturned decision was received. Submit in CCYY/MM/DD format (e.g., 2020/01/01). |
| K | Time the overturned decision was received | 8 | For expedited requests and Part B drug requests, enter the time the overturned
decision was received. Submit in HH:MM:SS military time format (e.g.,
23:59:59). Enter None for Standard (pre- service) and Payment reconsideration cases. |
| L | Part B Drug Request? | 1 | Enter: • Y for Yes • N for No |
| M | Date overturned decision or payment effectuated in the system | 10 | Enter the date overturned decision effectuated in the system. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Enter None if the overturned decision was not effectuated. |
| N | Time overturned decision or payment effectuated in the system | 8 | For expedited requests and Part B drug requests, enter the time the overturned
decision was effectuated in the system. Submit in HH:MM:SS military time
format (e.g., 23:59:59). Enter None for standard service requests and payment reconsideration cases, or if the overturned decision was not effectuated. |
Table 5: GRV_C
| 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 | First Tier, Downstream, and Related Entity | 70 | Enter the name of the First Tier, Downstream, and Related Entity (which
is any party that enters into a written arrangement, acceptable to CMS, with
the sponsoring organization to provide administrative or health care services
to an enrollee under the Part C or D program) that processed the
grievance. Enter None if the sponsoring organization processed the grievance. |
| G | Date the grievance was received | 10 | Enter the date the grievance was received. Submit in CCYY/MM/DD format
(e.g., 2020/01/01). |
| H | 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. |
| I | 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. |
| J | AOR/Equivalent notice Receipt Time | 8 | For expedited grievances, 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 grievances or if an AOR or equivalent written notice was not received or required. |
| K | How was the grievance received? | 7 | Enter the method of receipt of the grievance: • Oral • Written |
| L | Was the grievance processed as Standard or Expedited? | 1 | Enter how the grievance was processed: • S for Standard • E for Expedited |
| M | 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. |
| N | Grievance Description | 1,800 | Enter a description of the grievance. |
| O | Was this processed as a quality of care grievance? | 1 | Enter: • Y for Yes • N for No |
| P | Was a timeframe extension taken? | 1 | Enter: • Y for Yes • N for No |
| Q | Date oral notification provided to enrollee | 10 | Enter the date oral notification was provided to the enrollee. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Enter None if no oral notification was provided. |
| R | Time oral notification provided to enrollee | 8 | Enter the time oral notification was provided to the enrollee. Submit in
HH:MM:SS military time format (e.g., 23:59:59). Enter None for standard grievances, or if no oral notification was provided. |
| S | 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 a written notification was not provided. |
| T | 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 written notification was not provided. |
| U | Who made the request? | 2 | Enter who made the request: • E for enrollee • ER for enrollee’s representative or purported representative |
Table 6: AIP
| 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 | First Tier, Downstream, and Related Entity | 70 | Enter the name of the First Tier, Downstream, and Related Entity (which
is any party that enters into a written arrangement, acceptable to CMS, with
the sponsoring organization to provide administrative or health care services
to an enrollee under the Part C or D program) that processed the
request. Enter None if the sponsoring organization processed the request. |
| G | Authorization or Claim Number | 40 | Enter the associated authorization or
claim number for this request. If an
authorization or claim number is not available, enter the internal tracking or case number. Enter None if there is no authorization, claim or other tracking number available. |
| H | Date DSNP-AIP notified enrollee of its decision to reduce, suspend or terminate services | 10 | Enter the date the DSNP-AIP notified the enrollee of the reduction, suspension, or termination. Submit in CCYY/MM/DD format (e.g., 2020/01/01). |
| I | Effective date of reduction, suspension, or termination of services |
10 | Indicate the intended date of action (that is, the date on which reduction, suspension, or termination became effective). Submit in CCYY/MM/DD format (e.g., 2020/01/01). |
| J | Was the decision appealed? | 1 | Enter: • Y for Yes • N for No If ‘N’ is entered, populate all remaining fields with None. |
| K | Who made the request? | 4 | Enter who made the plan level appeal: • E for enrollee • ER for enrollee’s representative or purported representative • CP for requests by a contract provider/facility • NCP for requests by a non-contract provider/facility Enter None if the decision was not appealed as indicated by N in column ID J. |
| L | Date the appeal was received | 10 | Enter the date the request was received. Submit in CCYY/MM/DD format
(e.g., 2020/01/01). Enter None if the decision was not appealed as indicated by N in column ID J. |
| M | 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 for dismissed requests, if no AOR or equivalent written notice was received or required, or if the decision was not appealed as indicated by N in column ID J. |
| N | Was the appeal processed as Standard or Expedited? | 4 | Enter the manner by which the appeal was processed: • S for Standard • E for Expedited Enter None if the decision was not appealed as indicated by N in column ID J. |
| O | Was appeal made under the expedited timeframe but processed by the plan under the standard timeframe? | 4 | Yes(Y) / No(N) indicator
of whether the request was received as expedited but was downgraded and
processed under the standard timeframe (e.g., based on the DSNP-AIP deciding
that the expedited plan level appeal was unnecessary). Enter None if the request was received as a standard request or if the decision was not appealed as indicated by N in column ID J. |
| P | Was a timeframe extension taken? | 4 | Yes(Y) / No(N) indicator
of whether the DSNP-AIP extended the timeframe to make the appeal
decision. Enter None if the decision was not appealed as indicated by N in column ID J |
| Q | Did the enrollee request continuation of benefits? | 4 | Yes(Y) / No(N) indicator
of whether the enrollee requested continuation of benefits. Enter None if someone other than the enrollee requested continuation of benefits or if the decision was not appealed as indicated by N in column ID J. |
| R | Were the benefits under appeal provided to the enrollee during the plan level appeal process? | 4 | Yes(Y) / No(N) indicator
of whether the benefits under appeal were provided to the enrollee during the
reconsideration process. Enter None if no request for continuation of benefits was made or if the decision was not appealed as indicated by N in column ID J. |
| S | Request Disposition | 9 | Enter: • Approved • Denied • Dismissed Enter None if the decision was not appealed as indicated by N in column ID J. |
| T | Date of DSNP- AIP decision | 10 | Date of
the DSNP-AIP decision. Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None if the decision was not appealed as indicated by N in column ID J. |
| U | Date oral notification provided to enrollee | 10 | Date
oral notification provided to enrollee. Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Enter None if no oral notification provided or if the decision was not appealed as indicated by N in column ID J. |
| V | Date written notification provided to enrollee/provider | 10 | Date written
notification provided to enrollee, or if applicable the non-contract
provider. Do not enter the date when a letter is generated or printed within
the DSNP-AIP’s organization. Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Enter None if no written notification was provided or if the decision was not appealed as indicated by N in column ID J. |
| W | Date reconsidered determination effectuated in the DSNP-AIP system | 10 | Date reconsidered
determination effectuated in the DSNP-AIP ‘s system. Submit in CCYY/MM/DD
format (e.g., 2020/01/01). Enter None for denials and or if the decision was not appealed as indicated by N in column ID J. |
| X | Date forwarded to IRE if denied or untimely | 10 | Date
the AIP forwarded request to the IRE if request for Medicare service was
denied or processed untimely. Submit in CCYY/MM/DD format (e.g.,
2020/01/01). Enter None if approved or not forwarded to IRE or if the decision was not appealed as indicated by N in column ID J. |
| Y | If request denied, date services were terminated, reduced, suspended | 10 | Enter the date the services were terminated, reduced, suspended. Submit
in CCYY/MM/DD format (e.g., 2020/01/01). Enter None if the reconsideration was approved or if the decision was not appealed as indicated by N in column ID J. |
Table 7: TERM
| COLUMN ID | FIELD NAME | FIELD TYPE | FIELD LENGTH | DESCRIPTION |
| A | Enrollee First Name | CHAR Always Required | 50 | Enter the first name of the enrollee. |
| B | Enrollee Last Name | CHAR Always Required | 50 | Enter the last name of the enrollee. |
| C | Enrollee ID | CHAR Always Required | 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 due to 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 | CHAR Always Required | 5 | Enter the contract number (e.g., H1234). |
| E | Plan Benefit Package (PBP) | CHAR Always Required | 3 | Enter the PBP (e.g., 001). |
| F | First Tier, Downstream, and Related Entity (FDR) | CHAR Always Required | 70 | Enter the name of the FDR (that is, any party that enters into a written arrangement, acceptable to CMS, with the Sponsoring organization to provide administrative or health care services to an enrollee under the Part C or D program) that processed the request. Enter None if the Sponsoring organization processed the request. |
| G | Authorization or Claim Number | CHAR Always Required | 40 | Enter the associated authorization or
claim number for this request. If an authorization or claim number is not available, enter the internal tracking or case number. Enter None if there is no authorization, claim or other tracking number available. |
| H | Date of notification by the QIO of enrollee fast-track appeal | CHAR Always Required | 10 | Enter the date QIO notified the Sponsoring organization the enrollee filed a request for a fast-track appeal. Submit in CCYY/MM/DD format (e.g., 2024/01/01). |
| I | Date the Detailed Explanation of Non-Coverage (DENC) was provided to enrollee | CHAR Always Required | 10 | Enter the date the DENC was provided to enrollee. Submit in CCYY/MM/DD format (e.g., 2024/01/01). Enter None if no written notification was provided. |
| J | Explanation of Non-Coverage | CHAR Always Required | 2,000 | Provide the explanation of why services are either no longer reasonable and necessary or are no longer covered. If possible, include the applicable coverage rule, instruction, or policy upon which the termination was based. |
- 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.