Medicare Part C and Part D Data Validation (42 C.F.R. 422.516g and 423.514g) - (CMS-10305)

Medicare Part C and Part D Measure
Instructions for Findings Data Collection Form for Data Validation
Contractors
August 26, 2010
DRAFT

Prepared by:
Centers for Medicare & Medicaid Services
Center for Drug and Health Plan Choice

DRAFT – Meets Section 508 Compliance Standards

TABLE OF CONTENTS
1.0 INTRODUCTION ............................................................................................................1
1.1
1.2
1.3

Overview of Findings Data Collection Form and Evaluation Process .........................1
Recording Findings at the Measure Level or the Measure’s Data Element
Level .........................................................................................................................1
Structure of Findings Data Collection Form ...............................................................2

2.0 APPENDIX: DATA ELEMENTS FOR PART C AND PART D MEASURES ...........3
2.1
2.2

Part C Measure Data Elements ...................................................................................3
Part D Measure Data Elements................................................................................. 12

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1.0

INTRODUCTION

1.1 Overview of Findings Data Collection Form and Evaluation Process
The Findings Data Collection Form is a tool for reviewers to record their validation findings for each
contract included in the scope of the review. The form mirrors the content of the Data Validation
Standards document, but allows the reviewer to record notes, data sources referenced, and findings for
the different standards and criteria specified for a given measure.
Using the Findings Data Collection Form, the reviewers will conduct the review and record measure-level,
and in some cases data element-level, findings for each measure’s standards. Once the findings have
been finalized, the reviewer will share the findings with the organization and then submit the completed
Findings Data Collection Form to CMS, who will evaluate the measure- or data element-level findings for
each measure’s standards to derive an overall “Pass” or “Not Pass” determination. An overview of this
process is depicted in Figure 1 below.
Figure 1: Overview of Findings Data Collection Process and Pass/Not Pass Determination

1.2 Recording Findings at the Measure Level or the Measure’s Data Element Level
While most data validation standards and criteria are assessed at the measure-level (e.g., Standard 1, a
review of source documents indicating that all source documents accurately capture required data fields
and are properly documented), some are assessed at the data element-level (e.g., Standard 2e examines
each data element for compliance with measure-specific criteria). Depending on the level of assessment
for each standard and criteria, reviewers will record results in the Findings Data Collection Form at the
measure-level or at the measure’s data element-level.
The standards and criteria that involve data element-level reviews are Standards 2.e and 3.a, specifically,
as they assess the accuracy of reported results that may vary across data elements reported by the
organization. When assessing data at the element-level for Standards 2.e and 3.a, reviewers should
always refer to the measure-specific criteria for these standards in their evaluation. Standard 3.b applies
only to the data measures or data elements that are reported to CMS via data file upload (i.e., not manual
data entry into HPMS). For example, Standard 3.b is applicable to data elements B1 and B2 from the
Part D “Retail, Home Infusion, and Long-Term Care Pharmacy Access” measure because these elements
are reported as a data file upload; Standard 3.b is not applicable to any of the data elements for the Part
C and Part D “Plan Oversight of Agents” measure because this measure requires manual, direct data
entry into HPMS.

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The remaining data validation standards and criteria (i.e., Standards 1, 4, 5, 6, 7) will involve measurelevel reviews only, as they assess organization processes that are not likely to vary at the data elementlevel. For example, Standard 4 assesses policies and procedures for periodic data system updates; an
organization will most likely have these policies and procedures in place for an entire measure, as
opposed to having them in place for only certain data elements. As a result, recording findings at the
measure-level for Standard 4 is sufficient.

1.3 Structure of Findings Data Collection Form
Each Part C and Part D measure’s Findings Data Collection Form is included in a corresponding file. The
content in each measure’s form mirrors the Data Validation Standards, and includes space for the
reviewer to record data sources, review results, and findings for a given standard. Reviewers should only
complete areas displayed in white for data sources, review results and findings. Areas displayed in grey
are not applicable and should not be completed. In the "Data Sources and Review Results:" column, the
reviewer will enter the review results and/or data sources used for each standard or sub-standard. Next
to this column, in the "Findings" column, select "Y" if the requirements for the standard or sub-standard
have been completely met. If any requirement for the standard or sub-standard has not been met, select
"N". The reviewers can also quickly reference the appropriate data element details provided in Section
4.0.

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2.0

APPENDIX: DATA ELEMENTS FOR PART C AND PART D MEASURES

2.1 Part C Measure Data Elements
2.1.1

Benefit Utilization
Table 1: Data Elements for Benefit Utilization

Element
Number
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12
1.13
1.14
1.15
1.16
1.17
1.18
1.19
1.20
1.21
1.22
1.23
1.24
1.25
1.26
1.27

Data Elements for Benefit Utilization Measure
CMS issued contract number
Plan Benefit Package (PBP) ID
Number of member months for enrollees who had access to the Inpatient Facility service under their plan benefit package during the reporting period
Unique number of plan enrollees who used the Inpatient Facility service
Appropriate code to identify how you capture utilization data for Inpatient Facility services
Total number of Inpatient Facility services used by plan enrollees during the period
Reimbursement amount from the plan to providers for Inpatient Facility services used during the period
Total cost sharing paid by members directly to providers for Inpatient Facility services used during the period
Total payments made to providers for Inpatient Facility services covered under original Medicare
Cost sharing that would be required for covered Inpatient Facility services using original Medicare requirements
Number of member months for enrollees who had access to the Skilled Nursing Facility service under their plan benefit package during the reporting period
Unique number of plan enrollees who used the Skilled Nursing Facility service
Appropriate code to identify how you capture utilization data for Skilled Nursing Facility services
Total number of Skilled Nursing Facility services used by plan enrollees during the period
Reimbursement amount from the plan to providers for Skilled Nursing Facility services used during the period
Total cost sharing paid by members directly to providers for Skilled Nursing Facility services used during the period
Total payments made to providers for Skilled Nursing Facility services covered under original Medicare
Cost sharing that would be required for covered Skilled Nursing Facility services using original Medicare requirements
Number of member months for enrollees who had access to the Home Health service under their plan benefit package during the reporting period
Unique number of plan enrollees who used the Home Health service
Code to identify how you capture utilization data for Home Health services
Total number of Home Health services used by plan enrollees during the period
Reimbursement amount from the plan to providers for Home Health services used during the period
Total cost sharing paid by members directly to providers for Home Health services used during the period
Total payments made to providers for Home Health services covered under original Medicare
Cost sharing that would be required for covered Home Health services using original Medicare requirements
Number of member months for enrollees who had access to the Ambulance service under their plan benefit package during the reporting period
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Element
Number
1.28
1.29
1.30
1.31
1.32
1.33
1.34
1.35
1.36
1.37
1.38
1.39
1.40
1.41
1.42
1.43
1.44
1.45
1.46
1.47
1.48
1.49
1.50
1.51
1.52
1.53
1.54
1.55
1.56
1.57
1.58
1.59
1.60
1.61
1.62

Data Elements for Benefit Utilization Measure
Unique number of plan enrollees who used the Ambulance service
Code to identify how you capture utilization data for Ambulance services
Total number of Ambulance services used by plan enrollees during the period
Reimbursement amount from the plan to providers for Ambulance services used during the period
Total cost sharing paid by members directly to providers for Ambulance services used during the period
Total payments made to providers for Ambulance services covered under original Medicare
Cost sharing that would be required for covered Ambulance services using original Medicare requirements
Number of member months for enrollees who had access to the DME/Prosthetics/Supplies service under their plan benefit package during the reporting period
Unique number of plan enrollees who used the DME/Prosthetics/Supplies service
Appropriate code to identify how you capture utilization data for DME/Prosthetics/Supplies services
Total number of DME/Prosthetics/Supplies services used by plan enrollees during the period
Reimbursement amount from the plan to providers for DME/Prosthetics/Supplies services used during the period
Total cost sharing paid by members directly to providers for DME/Prosthetics/Supplies services used during the period
Total payments made to providers for DME/Prosthetics/Supplies services covered under original Medicare
Cost sharing that would be required for covered DME/Prosthetics/Supplies services using original Medicare requirements
Number of member months for enrollees who had access to the OP Facility – Emergency service under their plan benefit package during the reporting period
Unique number of plan enrollees who used the OP Facility – Emergency service
Appropriate code to identify how you capture utilization data for OP Facility – Emergency services
Total number of OP Facility – Emergency services used by plan enrollees during the period
Reimbursement amount from the plan to providers for OP Facility – Emergency services used during the period
Total cost sharing paid by members directly to providers for OP Facility – Emergency services used during the period
Total payments made to providers for OP Facility – Emergency services covered under original Medicare
Cost sharing that would be required for covered OP Facility – Emergency services using original Medicare requirements
Number of member months for enrollees who had access to the OP Facility – Surgery service under their plan benefit package during the
Unique number of plan enrollees who used the OP Facility – Surgery service
Appropriate code to identify how you capture utilization data for OP Facility – Surgery services
Total number of OP Facility – Surgery services used by plan enrollees during the period
Reimbursement amount from the plan to providers for OP Facility – Surgery services used during the period
Total cost sharing paid by members directly to providers for OP Facility – Surgery services used during the period
Total payments made to providers for OP Facility – Surgery services covered under original Medicare
Cost sharing that would be required for covered OP Facility – Surgery services using original Medicare requirements
Number of member months for enrollees who had access to the OP Facility – Other service under their plan benefit package during the reporting period
Unique number of plan enrollees who used the OP Facility – Other service
Code to identify how you capture utilization data for OP Facility – Other services
Total number of OP Facility – Other services used by plan enrollees during the period
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Element
Number
1.63
1.64
1.65
1.66
1.67
1.68
1.69
1.70
1.71
1.72
1.73
1.74
1.75
1.76
1.77
1.78
1.79
1.80
1.81
1.82
1.83
1.84
1.85
1.86
1.87
1.88
1.89
1.90
1.91
1.92
1.93
1.94
1.95
1.96
1.97

Data Elements for Benefit Utilization Measure
Reimbursement amount from the plan to providers for OP Facility – Other services used during the period
Total cost sharing paid by members directly to providers for OP Facility – Other services used during the period
Total payments made to providers for OP Facility – Other services covered under original Medicare
Cost sharing that would be required for covered OP Facility – Other services using original Medicare requirements
Number of member months for enrollees who had access to the Professional service under their plan benefit package during the reporting period
Unique number of plan enrollees who used the Professional service
Code to identify how you capture utilization data for Professional services
Total number of Professional services used by plan enrollees during the period
Reimbursement amount from the plan to providers for Professional services used during the period
Total cost sharing paid by members directly to providers for Professional services used during the period
Total payments made to providers for Professional services covered under original Medicare
Cost sharing that would be required for covered Professional services using original Medicare requirements
Number of member months for enrollees who had access to the Part B Rx service under their plan benefit package during the reporting period
Unique number of plan enrollees who used the Part B Rx service
Code to identify how you capture utilization data for Part B Rx services
Total number of Part B Rx services used by plan enrollees during the period
Reimbursement amount from the plan to providers for Part B Rx services used during the period
Total cost sharing paid by members directly to providers for Part B Rx services used during the period
Total payments made to providers for Part B Rx services covered under original Medicare
Cost sharing that would be required for covered Part B Rx services using original Medicare requirements
Number of member months for enrollees who had access to the Other Medicare Part B service under their plan benefit package during the reporting period
Unique number of plan enrollees who used the Other Medicare Part B service
Code to identify how you capture utilization data for Other Medicare Part B services
Total number of Other Medicare Part B services used by plan enrollees during the period
Reimbursement amount from the plan to providers for Other Medicare Part B services used during the period
Total cost sharing paid by members directly to providers for Other Medicare Part B services used during the period
Total payments made to providers for Other Medicare Part B services covered under original Medicare
Cost sharing that would be required for covered Other Medicare Part B services using original Medicare requirements
Number of member months for enrollees who had access to the Transportation service under their plan benefit package during the reporting period
Unique number of plan enrollees who used the Transportation service
Code to identify how you capture utilization data for Transportation services
Total number of Transportation services used by plan enrollees during the period
Reimbursement amount from the plan to providers for Transportation services used during the period
Total cost sharing paid by members directly to providers for Transportation services used during the period
Number of member months for enrollees who had access to the Dental service under their plan benefit package during the reporting period
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Element
Number
1.98
1.99
1.100
1.101
1.102
1.103
1.104
1.105
1.106
1.107
1.108
1.109
1.110
1.111
1.112
1.113
1.114
1.115
1.116
1.117
1.118
1.119
1.120
1.121
1.122
1.123
1.124
1.125
1.126
1.127
1.128
1.129
1.130
1.131
1.132

Data Elements for Benefit Utilization Measure
Unique number of plan enrollees who used the Dental service
Code to identify how you capture utilization data for Dental services
Total number of Dental services used by plan enrollees during the period
Reimbursement amount from the plan to providers for Dental services used during the period
Total cost sharing paid by members directly to providers for Dental services used during the period
Number of member months for enrollees who had access to the Vision service under their plan benefit package during the reporting period
Unique number of plan enrollees who used the Vision service
Code to identify how you capture utilization data for Vision services
Total number of Vision services used by plan enrollees during the period
Reimbursement amount from the plan to providers for Vision services used during the period
Total cost sharing paid by members directly to providers for Vision services used during the period
Number of member months for enrollees who had access to the Hearing service under their plan benefit package
Unique number of plan enrollees who used the Hearing service
Code to identify how you capture utilization data for Hearing services
Total number of Hearing services used by plan enrollees during the period
Reimbursement amount from the plan to providers for Hearing services used during the period
Total cost sharing paid by members directly to providers for Hearing services used during the period
Number of member months for enrollees who had access to the Health & Education service under their plan benefit package during the reporting period
Unique number of plan enrollees who used the Health & Education service
Code to identify how you capture utilization data for Health & Education services
Total number of Health & Education services used by plan enrollees during the period
Reimbursement amount from the plan to providers for Health & Education services used during the period
Total cost sharing paid by members directly to providers for Health & Education services used during the period
Number of member months for enrollees who had access to the Other (Non-Covered) service under their plan benefit package during the reporting period
Unique number of plan enrollees who used the Other (Non-Covered) service
Code to identify how you capture utilization data for Other (Non-Covered) services
Total number of Other (Non-Covered) services used by plan enrollees during the period
Reimbursement amount from the plan to providers for Other (Non-Covered) services used during the period
Total cost sharing paid by members directly to providers for Other (Non-Covered) services used during the period
Number of member months for enrollees who had access to the Medical services under their plan benefit package during the reporting period
Unique number of plan enrollees who used the Medical services
Reimbursement amount from the plan to providers for Medical services used during the period
Total cost sharing paid by members directly to providers for Medical services used during the period
Total payments made to providers for Medical services covered under original Medicare
Cost sharing that would be required for covered Medical services using original Medicare requirements
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Element
Number
1.133
1.134
1.135
1.136
1.137
1.138
2.1.2

Data Elements for Benefit Utilization Measure
Total number of enrollees under the plan during the reporting period
Number of member months during the reporting period
Dollar figure representing premiums collected over the course of the entire reporting period for this plan
Dollar figure representing CMS revenue collected under the plan over the course of the entire reporting period inclusive of rebates applied to A/B services
Dollar figure representing CMS rebates for A and B Services under the plan over the course of the entire reporting period
Dollar figure representing reserves for outstanding claims from the reporting period

Procedure Frequency
Table 2: Procedure Frequency

Element
Number
2.1*
2.2
2.3
2.4
2.5
2.6
2.7*
2.8*
2.9
2.10
2.11
2.12
2.13
2.14
2.15
2.16
2.17*
2.18
2.19
2.20*
2.21*
2.22*

Data Elements for Procedure Frequency Measure
Number of Enrollees receiving Cardiac Catheterization
Number of Enrollees receiving Open Coronary Angioplasty
Number of Enrollees receiving PTCA or Coronary Atherectomy with CABG
Number of Enrollees receiving PTCA or Coronary Atherectomy with insertion of drug-eluting coronary artery stent(s)
Number of Enrollees receiving PTCA or Coronary Atherectomy with insertion of non-drug-eluting coronary artery stent(s)
Number of Enrollees receiving PTCA or Coronary Atherectomy without insertion of coronary artery stent
Number of Enrollees receiving Total Hip Replacement
Number of Enrollees receiving Total Knee Replacement
Number of Enrollees receiving Bone Marrow Transplant
Number of Enrollees receiving Heart Transplant
Number of Enrollees receiving Heart/Lung Transplant
Number of Enrollees receiving Kidney Transplant
Number of Enrollees receiving Liver Transplant
Number of Enrollees receiving Lung Transplant
Number of Enrollees receiving Pancreas Transplant
Number of Enrollees receiving Pancreas/Kidney Transplant
Number of Enrollees receiving CABG
Number of Enrollees receiving Gastric Bypass
Number of Enrollees receiving Excision or Destruction of Lesion or Tissue of Lung (with cancer diagnosis as specified)
Number of Enrollees receiving Excision of Large Intestine (with cancer diagnosis as specified)
Number of Enrollees receiving Mastectomy (with cancer diagnosis as specified)
Number of Enrollees receiving Lumpectomy (with cancer diagnosis as specified)
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Element
Number
2.23*

Data Elements for Procedure Frequency Measure
Number of Enrollees receiving Prostatectomy (with cancer diagnosis as specified)

* For organizations that report these data elements in HEDIS, then it is appropriate for the contract to report "0" for these data
elements, and data validation for these elements is not required.
2.1.3

Serious Reportable Adverse Events (SRAEs)
Table 3: Serious Reportable Adverse Events (SRAEs)

Element
Number
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
3.10
3.11
3.12
3.13
3.14
3.15
3.16
3.17
3.18
3.19
3.20
3.21

Data Elements for Serious Reportable Adverse Events (SRAEs) Measure
(includes SRAEs and HACs)
Number of total surgeries
Number of surgeries on wrong body part
Number of surgeries on wrong patient
Number of wrong surgical procedures on a patient
Number of surgeries with post-operative death in normal health patient
Number of surgeries with foreign object left in patient after surgery
Number of Air Embolism events
Number of Blood Incompatibility events
Number of Stage III & IV Pressure Ulcers
Number of fractures
Number of dislocations
Number of intracranial injuries
Number of crushing injuries
Number of burns
Number of Vascular Catheter-Associated Infections
Number of Catheter-Associated UTIs
Number of Manifestations of Poor Glycemic Control
Number of SSI (Mediastinitis) after CABG
Number of SSI after certain Orthopedic Procedures
Number of SSI following Bariatric Surgery for Obesity
Number of DVT and pulmonary embolism following certain orthopedic procedures

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2.1.4

Provider Network Adequacy
Table 4: Provider Network Adequacy

Element
Number
4.1 – 4.6
4.7 – 4.12
4.13 – 4.18
4.19 – 4.24
4.25 – 4.30
4.31 – 4.36
4.37 – 4.46
4.47 – 4.56
4.57 – 4.66
4.67 – 4.76
4.77 – 4.86
4.87 – 4.96

Data Elements for Provider Network Adequacy Measure
Number of PCPs in network on first day of reporting period by PCP type - General Medicine (4.1), Family Medicine (4.2), Internal Medicine (4.3), Obstetricians (4.4), Pediatricians
(4.5), State Licensed Nurse Practitioners (4.6)
Number of PCPs in network continuously through reporting period by PCP type - General Medicine (4.7), Family Medicine (4.8), Internal Medicine (4.9), Obstetricians (4.10),
Pediatricians (4.11), State Licensed Nurse Practitioners (4.12)
Number of PCPs added to network during reporting period by PCP type - General Medicine (4.13), Family Medicine (4.14), Internal Medicine (4.15), Obstetricians (4.16),
Pediatricians (4.17), State Licensed Nurse Practitioners (4.18)
Number of PCPs accepting new patients at start of reporting period by PCP type - General Medicine (4.19), Family Medicine (4.20), Internal Medicine (4.21), Obstetricians (4.22),
Pediatricians (4.23), State Licensed Nurse Practitioners (4.24)
Number of PCPs accepting new patients at end of reporting period by PCP type - General Medicine (4.25), Family Medicine (4.26), Internal Medicine (4.27), Obstetricians (4.28),
Pediatricians (4.29), State Licensed Nurse Practitioners (4.30)
Number of PCPs in network on last day of reporting period by PCP type - General Medicine (4.31), Family Medicine (4.32), Internal Medicine (4.33), Obstetricians (4.34),
Pediatricians (4.35), State Licensed Nurse Practitioners (4.36)
Number of specialists/facilities in network on first day of reporting period by specialist/facility type - Hospitals (4.37), Home Health Agencies (4.38), Cardiologist (4.39), Oncologist
(4.40), Pulmonologist (4.41), Endocrinologist (4.42), Skilled Nursing Facilities (4.43), Rheumatologist (4.44), Ophthalmologist (4.45), Urologist (4.46)
Number of specialists in network continuously through reporting period by specialist/facility type - Hospitals (4.47), Home Health Agencies (4.48), Cardiologist (4.49), Oncologist
(4.50), Pulmonologist (4.51), Endocrinologist (4.52), Skilled Nursing Facilities (4.53), Rheumatologist (4.54), Ophthalmologist (4.55), Urologist (4.56)
Number of specialists added during reporting period by specialist/facility type - Hospitals (4.57), Home Health Agencies (4.58), Cardiologist (4.59), Oncologist (4.60), Pulmonologist
(4.61), Endocrinologist (4.62), Skilled Nursing Facilities (4.63), Rheumatologist (4.64), Ophthalmologist (4.65), Urologist (4.66)
Number of specialists accepting new patients at start of reporting period by specialist/facility type - Hospitals (4.67), Home Health Agencies (4.68), Cardiologist (4.69), Oncologist
(4.70), Pulmonologist (4.71), Endocrinologist (4.72), Skilled Nursing Facilities (4.73), Rheumatologist (4.74), Ophthalmologist (4.75), Urologist (4.76)
Number of specialists accepting new patients at end of reporting period by specialist/facility type - Hospitals (4.77), Home Health Agencies (4.78), Cardiologist (4.79), Oncologist
(4.80), Pulmonologist (4.81), Endocrinologist (4.82), Skilled Nursing Facilities (4.83), Rheumatologist (4.84), Ophthalmologist (4.85), Urologist (4.86)
Number of specialists in network on last day of reporting period by specialist/facility type - Hospitals (4.87), Home Health Agencies (4.88), Cardiologist (4.89), Oncologist (4.90),
Pulmonologist (4.91), Endocrinologist (4.92), Skilled Nursing Facilities (4.93), Rheumatologist (4.94), Ophthalmologist (4.95), Urologist (4.96)

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2.1.5

Grievances (Part C)
Table 5: Grievances

Element
Number
5.1
5.2
5.3
5.4
5.5
5.6
5.7
2.1.6

Data Elements for Grievances (Part C) Measure
Number of Grievances for Fraud and Abuse
Number of Grievances for Enrollment/Disenrollment Access/Benefit package
Number of Grievances for Marketing
Number of Grievances for Confidentiality/Privacy
Number of Grievances for Quality of Care
Number of Expedited Grievances
Number of Grievances for Other

Organization Determinations/Reconsiderations
Table 6: Organization Determinations/Reconsiderations

Element
Number
6.1
6.2
6.3
6.4
6.5
6.6
2.1.7

Data Elements for Organization Determinations/ Reconsiderations Measure
Number of Organization Determinations – Fully Favorable
Number of Organization Determinations – Partially Favorable
Number of Organization Determinations – Adverse
Number of Reconsiderations – Fully Favorable
Number of Reconsiderations – Partially Favorable
Number of Reconsiderations – Adverse

Employer Group Plan Sponsors (Part C)
Table 7: Employer Group Plan Sponsors (Part C)

Element
Number
7.1
7.2
7.3
7.4
7.5

Data Elements for Employer Group Plan Sponsors (Part C) Measure
Employer Legal Name
Employer DBA Name
Employer Federal Tax ID
Employer Address
Type of Group Sponsor (employer, union, trustees of a fund)
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Element
Number
7.6
7.7
7.8
7.9
2.1.8

Data Elements for Employer Group Plan Sponsors (Part C) Measure
Organization Type (State Government, Local Government, Publicly Traded Organization, Privately Held Corporation, Non-Profit, Church Group, Other)
Type of Contract (insured, ASO, other)
Employer Plan Year Start Date
Current Enrollment

Plan Oversight of Agents (Part C)
Table 8: Plan Oversight of Agents

Element
Number
12.1
12.2
12.3
12.4
12.5
12.6
2.1.9

Data Elements for Plan Oversight of Agents (Part C) Measure
Total number of agents
Number of agents investigated based on complaints
Number of agents receiving disciplinary actions based on complaints
Number of complaints reported to State by MAO or Cost contractor
Number of agents whose selling privileges were revoked by the plan based on conduct or discipline
Number of agent-assisted enrollments

Special Needs Plans (SNPs) Care Management
Table 9: Special Needs Plans (SNPs) Care Management

Element
Number
13.1
13.2
13.3
13.4

Data Elements for Special Needs Plans (SNPs) Care Management Measure
Number of new enrollees
Number of enrollees eligible for an annual reassessment
Number of initial assessments performed on new enrollees during reporting period
Number of annual reassessments performed on enrollees eligible for a reassessment

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2.2 Part D Measure Data Elements
2.2.1

Retail, Home Infusion, and Long Term Care Pharmacy Access
Table 10: Retail, Home Infusion, and Long Term Care Pharmacy Access

Element
Number
A1
A2
A3
A4
B1
B2
C1
C2
D1
D2
2.2.2

Data Elements for Retail, Home Infusion, and Long Term Care Pharmacy Access Measure
Percentage of Medicare beneficiaries living within 2 miles of a retail network pharmacy in urban areas of a Contract’s service area (by State for PDPs and regional PPOs, and by
service area for local MA-PD plans) as of the last day of the reporting period specified above
Percentage of Medicare beneficiaries living within 5 miles of a retail network pharmacy in suburban areas (by State for PDPs and regional PPOs, and by service area for local MAPD plans) as of the last day of the reporting period specified above
Percentage of Medicare beneficiaries living within 15 miles of a retail network pharmacy in rural areas (by State for PDPs and regional PPOs, and by service area for local MA-PD
plans) as of the last day of the reporting period specified above
The number of contracted retail pharmacies in a Contract’s service area (by State for PDPs and regional PPOs, and by service area for local MA-PD plans) as of the last day of the
reporting period specified above
A list of contracted HI network pharmacies into HPMS as of the last day of the reporting period specified above
A list of contracted LTC network pharmacies into HPMS as of the last day of the reporting period specified above
Number of prescriptions provided by all pharmacies owned and operated by the plan
Number of prescriptions provided at all pharmacies contracted by the plan
Number of prescriptions provided by retail pharmacies owned and operated by the plan
Number of prescriptions provided at all retail pharmacies contracted by the plan

Medication Therapy Management Programs
Table 11: Medication Therapy Management Programs

Element
Number
A
B
C
D
E

Data Elements for Medication Therapy Management Programs Measure
The total number of beneficiaries identified to be eligible for, and automatically enrolled in, the MTMP during the specified time period above
The total number of beneficiaries who opted-out of enrollment in the MTMP during the time period specified above. This should be a longitudinally cumulative total, and be a subset of
the number of beneficiaries identified to be eligible for, and were automatically enrolled in, the MTMP in the specified time period.
The number of beneficiaries who opted-out of enrollment in the MTMP due to death at any time during the specified time period above. This should be a subset of the total number of
beneficiaries who opted-out of enrollment in the MTMP in the specified time period.
The number of beneficiaries who opted-out of enrollment in the MTMP due to disenrollment from the Plan at any time during the specified time period above. This should be a subset
of the total number of beneficiaries who opted-out of enrollment in the MTMP in the specified time period.
The number of beneficiaries who opted-out of enrollment in the MTMP at their request at any time during the specified time period above. This should be a subset of the total number
of beneficiaries who opted-out of enrollment in the MTMP in the specified time period.
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Element
Number
F
G
H
I
J
II (a)
II (b)
II (c)
II (d)
II (e)
II (f)
II (g)
II (h)
II (i)
II (j)
II (k)
II (l)
II (m)
II (n)
II (o)
2.2.3

Data Elements for Medication Therapy Management Programs Measure
The number of beneficiaries who opted-out of enrollment in the MTMP for a reason not specified in data elements C-E during the specified time period above. This should be a subset
of the total number of beneficiaries who opted-out of enrollment in the MTMP in the specified time period.
For beneficiaries enrolled in the MTMP at any time during the specified time period above, provide the prescription cost of all covered* Part D medications on a per MTMP beneficiary
per month basis.
For beneficiaries enrolled in the MTMP at any time during the specified time period above, provide the number of covered* Part D 30-day equivalent prescriptions on a per MTMP
beneficiary per month basis. This should be a numeric field.
For beneficiaries enrolled in the MTMP at any time during the specified time period above, the number of beneficiaries offered a comprehensive medication review
For beneficiaries enrolled in the MTMP at any time during the specified time period above, the number of beneficiaries who received a comprehensive medication review
Contract Number
HICN or RRB Number
Beneficiary first name
Beneficiary middle initial
Beneficiary last name
Beneficiary date of birth
LTC Enrollment
Date of MTMP enrollment
Date of MTMP opt-out, if applicable
Reason participant opted-out of MTMP (Death; Disenrollment from Plan; Request by beneficiary; or Other). Required if Date of MTMP opt-out is applicable.
Received annual comprehensive medication review
Date of annual comprehensive medication review, if applicable
Number of targeted medication reviews
Number of prescriber interventions
Number of changes to drug therapy made as a result of MTM interventions. Changes include dosage changes, therapeutic or generic substitutions, and discontinuation of therapy.

Grievances (Part D)
Table 12: Grievances

Element
Number
A
B
C1
C2
C3

Data Elements for Grievances (Part D) Measure
Number of LIS beneficiaries who filed grievances
Number of non-LIS beneficiaries who filed grievances
Number of grievances filed by LIS beneficiaries
Number of grievances filed by LIS beneficiaries which the Sponsor provided timely notification of its decision
Number of grievances filed by non-LIS beneficiaries
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Element
Number
C4
D1
D2
D3
D4
D5
D6
D7
D8
2.2.4

Data Elements for Grievances (Part D) Measure
Number of grievances filed by non-LIS beneficiaries which the Sponsor provided timely notification of its decision
Number of Enrollment, Plan Benefits, or Pharmacy Access Grievances
Number of Enrollment, Plan Benefits, or Pharmacy Access Grievances which the Sponsor provided timely notification of its decision
Number of Customer Service Grievances
Number of Customer Service Grievances which the Sponsor provided timely notification of its decision
Number of Coverage determinations/Exceptions and Appeals process (e.g. untimely decisions) Grievances
Number of Coverage determinations/Exceptions and Appeals process (e.g. untimely decisions) Grievances which the Sponsor provided timely notification of its decision
Number of Other Grievances
Number of Other Grievances which the Sponsor provided timely notification of its decision

Coverage Determinations and Exceptions
Table 13: Coverage Determinations and Exceptions

Element
Number
A
B
C
D
E
F
G
H
I
J

Data Elements for Coverage Determinations and Exceptions Measure
The total number of pharmacy transactions in the time period above
Of the total reported in A, the number of pharmacy transactions rejected due to formulary restrictions, including
non-formulary status, prior authorization requirements, step therapy, and quantity limits (QL). Rejections due
to early refills should be excluded.
The total number of prior authorizations requested in the time period above
Of the total reported in C, the number approved
The total number of exceptions requested to the Plan’s utilization management tools, e.g. prior authorization,
quantity limits, or step therapy requirements, in the time period above
Of the total reported in E, the number approved
The number of tier exceptions requested in the time period above
Of the total reported in G, the number approved
The number of exceptions requested for non-formulary medications in the time period above
Of the total reported in I, the number approved

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2.2.5

Appeals
Table 14: Appeals

Element
Number
A
B
C
2.2.6

Data Elements for Appeals Measure
The total number of redeterminations made in the time period specified above
Of the total reported in A, the number resulting in full reversal of original coverage determination
Of the total reported in A, the number resulting in partial reversal of original coverage determination

Long-Term Care Utilization
Table 15: Long-Term Care Utilization

Element
Number
A
B
C
D

E

Data Elements for Long-Term Care Utilization Measure
The total number of network LTC pharmacies in the service area (PDPs and regional PPOs will report for each
state, MA-PDs will report for the service area)
The total number of network retail pharmacies in the service area (PDPs and regional PPOs will report for each
state, MA-PDs will report for the service area)
The total number of beneficiaries in LTC facilities for whom Part D drugs have been provided under the
Contract
For each network LTC pharmacy in the service area:
a. LTC pharmacy name
b. LTC pharmacy NPI
c. Contract entity name of LTC pharmacy
d. Chain code of LTC pharmacy
e. Number of 31-day equivalent formulary prescriptions dispensed
f. Number of 31-day equivalent non-formulary prescriptions dispensed
g. Cost of formulary prescriptions
h. Cost of non-formulary prescriptions
In aggregate, for all retail pharmacies in the service area:
a. Number of 30-day equivalent formulary prescriptions dispensed
b. Number of 30-day equivalent non-formulary prescriptions dispensed
c. Cost of formulary prescriptions
d. Cost of non-formulary prescriptions

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2.2.7

Employer/Union-Sponsored Group Health Plan Sponsors (Part D)
Table 16: Employer/Union-Sponsored Group Health Plan Sponsors

Element
Number
A
B
C
D
E
F
G
H
I
2.2.8

Data Elements for Employer/Union-Sponsored Group Health Plan Sponsors (Part D) Measure
Employer Legal Name
Employer DBA Name
Employer Federal Tax ID
Employer Address
Type of Group Sponsor (employer, union, trustees of a fund)
Organization Type (State Government, Local Government, Publicly Traded Organization, Privately Held Corporation, Non-Profit, Church Group, Other)
Type of Contract (insured, ASO, other)
Employer Plan Year Start Date
Current/Anticipated Enrollment

Plan Oversight of Agents (Part D)
Table 17: Plan Oversight of Agents

Element
Number
A
B
C
D
E
F

Data Elements for Plan Oversight of Agents (Part D) Measure
Total number of agents
Number of agents investigated based on complaints
Number of agents receiving disciplinary actions from the Sponsor based on complaints
Number of complaints reported to State by MAO or Cost contractor
Number of agents whose selling privileges were revoked by the plan based on conduct or discipline
Number of agent-assisted enrollments

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