Service Level Data Collection for Initial Determinations and Appeals

SERVICE LEVEL DATA COLLECTION FOR INITIAL DETERMINATIONS AND APPEALS

Effective January 1, 20XX

PRA Disclosure Statement

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is [0938-New]. This information collection will provide data to CMS on the utilization of benefits, ensure plans are operating in accordance with CMS requirements, and ensure appropriate access to covered services and benefits. The time required to complete this information collection is estimated to average less than 30 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is mandatory under the Part C and D Reporting Requirements authority set forth at §§ 422.516(a) and 423.514(a). If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

Background and Introduction

The Part C Reporting Requirements, as set forth in 42 CFR § 422.516(a), provide CMS with the ability to collect data on plan procedures related to, and utilization of, its items and services. This includes collecting service-level data related to plan coverage and appeal decisions that are processed in accordance with the requirements of part 422, subpart M. Pursuant to that authority, each MAO must have an effective procedure to develop, compile, evaluate, and report information to CMS in the time and manner that CMS requires.

Organizations for which these specifications apply are required to collect these data. Reporting will vary depending on the plan type. All reporting sections will be reported quarterly.

National PACE Plans and 1833 Cost Plans are excluded from reporting the data in this collection.

Overview of the parameters for data elements in this collection.

Organization Types Required to Report	Report Frequency Level	Report Period	Due Date(s)
CCP; PFFS; 1876 Cost; MSAs, Religious Fraternal Benefit (RFB) PFFS; (includes all 800 series plans), Employer/Union Direct Contracts should also report this section regardless of organization type.	4/Year Plan	1/1-3/31 4/1-6/30 7/1-9/30 10/1-12/31	Last Monday of May (1/1-3/31) Last Monday of August (4/1-6/30) Last Monday of November (7/1-9/30) Last Monday of February in the following year (10/1-12/31)

REPORTING SECTIONS

I. Initial Determinations

Data Element ID	Data Element Description
Subsection #1	Initial Determinations (coverage decisions)
	Organization Determination Number
	Contract Number
	Plan Benefit Package (PBP)
	Enrollee MBI
	Requesting Party
	Provider NPI
	Item/Service/Part B Drug Code
	Item/Service/Part B Drug Description
	Diagnosis Codes
	Was prior authorization required?
	Was this a concurrent review decision?
	Processing Priority
	Was expedited processing requested?
	Date Request Received
	Date of Decision Notification
	Disposition
	Dismissal Rationale (if applicable)
	Decision Rationale
	Reviewer Qualifications
	Were internal plan coverage criteria applied?
	Did a third-party vendor participate, in any capacity, in the determination’s review or decision-making?
Subsection #2	Initial Determinations (payment)
	Organization Determination Number
	Contract Number
	Plan Benefit Package (PBP)
	Enrollee MBI
	Requesting Party
	Item/Service/Part B Drug Code
	Item/Service/Part B Drug Description
	Diagnosis Codes
	Service Location
	Place of Service
	Date of Service
	Provider NPI
	Date Claim Received
	Date of Decision
	Date Claim was Paid
	Was it a clean claim?
	Disposition
	Dismissal Rationale (if applicable)
	Decision Rationale
	Reviewer Qualifications
	Were internal plan coverage criteria applied?
	Was prior approval (e.g., a prior authorization or voluntary pre-service request) requested?
	If element V is yes, provide the organization determination number for associated prior approval request
	If element V is yes, was prior authorization a required condition for coverage?
	Did a third-party vendor participate, in any capacity, in the determination’s review or decision-making?

II. Reconsiderations

Data Element ID	Data Element Description
Subsection #1	Reconsiderations (coverage decisions)
	Associated Organization Determination Number
	Appeal Number
	Contract Number
	Plan Benefit Package (PBP)
	Enrollee MBI
	Date Request Received
	Date of Decision Notification
	Processing Priority
	Was expedited processing requested?
	Is this an appeal of an organization determination dismissal?
	Disposition
	Dismissal Rationale (if applicable)
	Decision Rationale
	Was the initial organization determination request denied for lack of medical necessity?
	Was the reconsideration request reviewed by a physician?
	Did a third-party vendor participate, in any capacity, in the determination’s review or decision-making?
Subsection #2	Reconsiderations (payment)
	Associated Organization Determination Number
	Appeal Number
	Contract Number
	Plan Benefit Package (PBP)
	Enrollee MBI
	Date Request Received
	Date of Decision Notification
	Date Claim was Paid
	Is this an appeal of an organization determination dismissal?
	Disposition
	Dismissal Rationale (if applicable)
	Decision Rationale
	Was the initial organization determination request denied for lack of medical necessity?
	Was the reconsideration request reviewed by a physician?
	Did a third-party vendor participate, in any capacity, in the determination’s review or decision-making?