Medicare-Medicaid Plan Service Authorization Requests, Appeals, and Grievances (MMP-SARAG) protocols help to evaluate performance in the Centers for Medicare and Medicaid Services (CMS) Program Audit Protocol and Data Request related to MMP-SARAG service authorization requests, provider payment requests, appeals and grievances for medical, behavioral health, substance use disorder, and long-term services and supports (LTSS) services. The CMS performs its program audit activities in accordance with the MMP-SARAG Program Audit Protocol and 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 three-way contract 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.
1 M_SAR
| 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 MMP to provide administrative or health care services to an enrollee
under the MMP program) that processed the request. Enter None if the MMP 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 MMP. 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 MMP. Submit in HH:MM:SS format (e.g., 23:59:59). Enter None for standard service requests, dismissed 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 MMP 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 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 | 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. |
| 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). If describing behavioral health
services, long-term services and supports (LTSS), or substance use disorder
services, include the terms behavioral health, LTSS, and substance use
disorder service in the description, as applicable. 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. |
2 M_PLA
| 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 MMP to provide administrative or health care services to an enrollee
under the MMP program) that processed the request. Enter None if the MMP 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. If the MMP obtained information establishing good cause after the 60-day filing timeframe, enter the date the MMP received the information establishing good cause. |
| I | Time the request was received | 8 | For all expedited 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. If the MMP obtained information establishing good cause after the 60-day filing timeframe, enter the time the MMP 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 MMP. 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 MMP. 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 MMP 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 appeal effectuated in the system | 10 | Enter the date the appeal was effectuated in the system. Submit in CCYY/MM/DD format (e.g., 2020/01/01). Enter None if the appeal was not effectuated. |
| W | Time appeal effectuated in the system | 8 | For all expedited requests, enter the
time the appeal was effectuated in the
system. Submit in HH:MM:SS military time format (e.g., 23:59:59). Enter None for standard appeals, or if the request was not effectuated. |
| X | Date forwarded to IRE/IAHO | 10 | Enter the date the request was forwarded to the IRE/IAHO. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Enter None if the enrollee was notified of the approved appeal, or if the request was not forwarded to the IRE/IAHO. |
| Y | Time forwarded to IRE/IAHO | 8 | For all expedited requests, enter the
time the request was forwarded to the
IRE/IAHO. Submit in HH:MM:SS military time format (e.g., 23:59:59). Enter None if the enrollee was notified of the approved appeal, if the request was not forwarded to the IRE/IAHO, or for standard requests. |
| Z | 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 |
| 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). If describing behavioral health
services, long-term services and supports (LTSS), or substance use disorder
services, include the terms behavioral health, LTSS, and substance use
disorder service in the description, as applicable. 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 service authorization request denied for lack of medical necessity? | 2 | Enter: • Y for Yes • N for No • NA for Not Applicable |
| AD | Did the enrollee request to continue services pending an appeal resolution for a previously approved service that was being terminated or modified? | 1 | Enter: • Y for Yes • N for No |
| AE | Were the services under appeal provided to the enrollee during the plan level appeal process? | 2 | Enter: • Y for Yes • N for No • NA for Not Applicable. If the service under appeal was not a previously approved service that was being appealed due to the termination or modification of the service. |
| AF | Is the requested service a Medicaid-only service? | 1 | Enter: • Y for Yes • N for No |
3 M_PYMT
| 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 MMP to provide administrative or health care services to an enrollee
under the MMP program) that processed the request. Enter None if the MMP 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 MMP obtained information establishing good cause
after the 60-day filing timeframe, enter the date the MMP received the
information establishing good cause. Submit in CCYY/MM/DD format (e.g., 2020/01/01). |
| I | 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 claims, or if a WOL was never received. |
| J | Was it a clean claim? | 4 | Enter: • Y for clean claim • N for unclean claim • None for payment appeals |
| K | Was the request processed as a claim or an appeal? | 6 | Enter the manner by which the request was processed: • Claim • Appeal |
| L | Request Determination | 9 | Enter: • Approved • Denied • Dismissed |
| M | 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 MMP dismissed the request. |
| N | Date claim/ payment appeal was paid | 10 | Enter the date the claim 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. |
| O | 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. |
| P | 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. |
| Q | Date forwarded to IRE | 10 | Enter the date the payment appeal was forwarded to the IRE. Submit in
CCYY/MM/DD format (e.g., 2020/01/01). Enter None for claims, or if the payment appeal was approved, dismissed, or not forwarded to the IRE. |
| R | Issue description and type of service | 2,000 | Provide a description of the service or item requested and why it was requested
(if known). If describing behavioral health
services, long-term services and supports (LTSS), or substance use disorder
services, include the terms behavioral health, LTSS, and substance use
disorder service in the description, as applicable. For denials, also provide
an explanation of why the claim or payment appeal was denied. For dismissed requests, please provide the reason for dismissal. |
| S | Was the initial claim denied for lack of medical necessity? | 4 | Enter: • Y for Yes • N for No • None if the request was approved or dismissed. |
| T | Is the requested service a Medicaid-only service? | 1 | Enter: • Y for Yes • N for No |
4 M_EFF
| 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 MMP to provide administrative or health care services to an enrollee
under the MMP program) that processed the request. Enter None if the MMP 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 appeal case | 9 | Enter the type of appeal case submitted to
IRE/SFH/ALJ/MAC: • Standard • Expedited • Payment For pre-service cases, enter Standard or Expedited. Default to Standard for pre- service cases if the three- way contract has one effectuation timeframe for the applicable external appeals entity’s overturns. For post-service cases, enter Payment. |
| I | Review Entity | 3 | Enter the entity that overturned the decision: • IRE • SFH (including the IAHO) • 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 if not an expedited or Part B drug request. |
| 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 pre- service requests and payment appeals, or if the overturned decision was not effectuated. |
| O | Did the enrollee request to continue services pending an appeal resolution for a previously approved service that was being terminated or modified? | 1 | Enter: • Y for Yes • N for No |
| P | Were the services under appeal provided to the enrollee during the external appeal process? | 2 | Enter: • Y for Yes • N for No • NA for Not Applicable If the service under appeal was not a previously approved service that was being appealed due to the termination or modification of the service. |
5 M_GRV
| 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 MMP to provide administrative or health care services to an enrollee
under the MMP program) that processed the grievance. Enter None if the MMP 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 MMP. 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 MMP. 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 MMP. Enter based on the MMP’s internal labeling system. |
| N | Grievance Description | 2,000 | 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 |
- 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.