Track Change - Service Level Data Collection

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. Medicare- Medicaid Plans (MMPs) are also excluded from this reporting due to the
transition of the Financial Alignment Initiative demonstrations to dual eligible special needs plan
(D-SNP) models.
Overview of the parameters for data elements in this collection.
Organization
Types Required
to Report
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.

REPORTING SECTIONS
I.

Initial Determinations

Report
Frequency
Level
4/Year
Plan

Report Period

Due Date(s)

1/1-3/31
4/1-6/30
7/1-9/30
10/1-12/31

5/25/XXLast
Monday of May
(1/1-3/31)
8/31/XXLast
Monday of
August (4/16/30)
11/30/XXLast
Monday of
November (7/19/30)
2/22/XX Last
Monday of
February in the
following year
(10/1-12/31)

Data Element ID
Subsection
#I.A.1
A.
B.
C.
D.
E.
F.
G.
G.H.
H.I.
I.J.
J.K.
K.
L.
M.
N.
O.
P.
Q.
R.
S.
T.
U.
V.
W.
Subsection
#I.B.2
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.

Data Element NameDescription
Coverage Decisions (made in the reporting period above)Initial
Determinations (coverage decisions)
Organization Determination (OD) Number
Contract Number
Plan Benefit Package (PBP)
Enrollee MBI
Requesting Party
Provider NPI
Was this a contracted provider referral?
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
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?
For partially or fully favorable decisions, was the approved
item/service/Part B drug different from what was requested?
If element V is yes, provide the procedure code for the approved
item/service/Part B drug.
Payment Decisions (made in the reporting period above)Initial
Determinations (payment)
Organization Determination (OD) 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
Start Date of Service
End Date of Service

L.M.
N.
M.O.
N.P.
O.
P.Q.
Q.R.
R.S.
S.T.
T.U.
U.V.
V.W.
W.X.
X.Y.
Y.Z.
II.

Provider NPI
Was this a contracted provider referral?
Date Claim Received
Date of Decision Notification
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 WV is yes, provide the ODorganization determination number
for associated prior approval request.
If element WV 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?

Reconsiderations

Data Element ID
Subsection
#II.A.1
A.
B.
C.
D.
E.
F.
F.G.
G.H.
H.I.
I.J.
J.K.
K.L.
L.M.
M.N.
N.O.
O.P.
P.Q.

Data Element NameDescription
Coverage Decisions (made in the reporting period
above)Reconsiderations (coverage decisions)
Associated Organization Determination (OD) Number
Appeal Number
Contract Number
Plan Benefit Package (PBP)
Enrollee MBI
Was this a contracted provider referral?
Date Request Received
Date of Decision Notification
Processing Priority
Was expedited processing requested?
Is this an appeal of an OD organization determination dismissal?
Disposition
Dismissal Rationale (if applicable)
Decision Rationale
Was the initial OD 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?

R.
S.
Subsection
#II.B.2
A.
B.
C.
D.
E.
F.
F.G.
G.H.
H.
I.
J.
K.
L.
M.
N.
O.

For partially or fully favorable decisions, was the approved
item/service/Part B drug different from what was requested?
If element R was yes, provide the procedure code for the approved
item/service/Part B drug.
Payment Decisions (made in the reporting period
above)Reconsiderations (payment)
Associated Organization Determination (OD) Number
Appeal Number
Contract Number
Plan Benefit Package (PBP)
Enrollee MBI
Was this a contracted provider referral?
Date Request Received
Date of Decision Notification
Date Claim was Paid
Is this an appeal of an OD organization determination dismissal?
Disposition
Dismissal Rationale (if applicable)
Decision Rationale
Was the initial OD 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?