CMS 2022 Audit Protocols for A&G
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It is that time again! CMS Program Audits are imminent and the protocols have officially changed for 2022. This blog is to inform California MMP Plans of the changes to the CMS 2022 protocols for MMP SARAG & MMP CDAG Universes (as it relates to Appeals & Grievances).

Each table below highlights the related inclusion and exclusion criterion for each. Armed with this regulatory compliance information, you should be in a better position to create accurate universes that comply with the latest Medicare and Medicaid protocols.

CMS 2022 protocols for MMP SARAG Universes

Table 2: MMP Standard and Expedited Plan Level Appeals (M_PLA)

  • Include all pre-service plan level appeals the MMP approved, denied, or auto forwarded to the IRE/IAHO or dismissed during the universe request period. The date of the MMP’s determination (Column ID P) must fall within the universe request period.
  • Include all pre-service plan level appeals for Part B drugs.
  • If a pre-service plan level appeal includes more than one service, include all the request’s line items in a single row and enter multiple line items as a single appeal. Enter any appeal denied in whole or in part as denied.
  • Enter all fields for a single appeal in the same time zone. For example, if the MMP has systems in EST and CST, all data in a single line item must be in a single time zone.
  • Exclude all requests processed as service authorization requests, payment requests, reopenings, and withdrawals.
  • Exclude all requests for concurrent reviews for inpatient hospital and inpatient SNF services, and notifications of admissions.
  • Exclude all requests for Value Added Items and Services.

Table 3: MMP Provider Payment Requests and Appeals (M_PYMT)

  • Include all claims and payment appeals the MMP approved, denied, or dismissed from non-contract providers, and non-contract pharmacies during the universe request period.
  • Submit provider payment requests (claims) based on the date the claim was paid (Column N) or notification of the denial to the provider (if provider submitted the claim – Column P). Submit payment appeals based on the date the overturned appeal was paid or, for upheld payment appeals, submit based on the date the case was forwarded to the IRE. Submit dismissed requests based on the date of the decision to dismiss (Column M).
  • Submit claims based on the date the claim was paid (Column N) or notification of the denial to the provider (Column P).
  • Include all claims for Part B drugs if applicable.
  • If a claim includes more than one service, include all of the claim’s line items in a single row and enter the multiple line items as a claim. o Enter any request denied in whole or in part as denied.
  • Enter all fields for a single case in the same time zone. For example, if the MMP has systems in EST and CST, all data in a single line item must be in a single time zone.

Table 4: MMP Effectuations of Overturned Decisions by IRE, SFH, ALJ, or MAC (M_EFF)

  • Include all plan level appeals fully or partially overturned by the IRE, SFH, ALJ, or MAC requiring an effectuation as pre-service or post-service (payment) that were received from the IRE, SFH, ALJ, or MAC during the universe request period. The date of the MMP’s receipt of the overturn decision (Column ID J) must fall within the universe request period.
  • For the purposes of the Table 4 Record Layout, SFH is inclusive of the IAHO.
  • Exclude any cases that were dismissed or upheld by the IRE, SFH, ALJ, or MAC.

Table 5: MMP Standard and Expedited Grievances (M_GRV)

  • Include all MMP grievances the MMP responded to during the universe request period. The date of the MMP’s notification (Column ID Q or S) must fall within the universe request period.
  • Grievances with multiple issues must be entered as a single line item,

unless the Sponsoring organization issued separate notifications.

  • Exclude all grievances that were withdrawn and dismissed during the universe request period.
  • Exclude complaints filed only within the Complaints Tracking Module (CTM) in HPMS. If a complaint was processed both within the CTM and was also received as a grievance, exclude the CTM complaint but include the grievance as processed by the MMP.

CMS 2022 protocols for MMP CDAG Universes

Table 3: Payment Coverage Determinations and Redeterminations (PYMT_D)

  •  Include all payment coverage determinations and redeterminations the Sponsoring organization approved, denied, re-opened approved, re-opened denied, auto-forwarded to the IRE or dismissed for Part D coverage during the universe request period. The date of the Sponsoring organization’s determination (Column ID T) must fall within the universe request period.
  • For cases with a Request Determination of re-opened approved or re-opened denied, the date and time the request was received must be the date and time the case was re-opened (i.e., the determination was made to re-open the case). The original coverage determination or redetermination is considered a separate case for purposes of audit and must be included in the universe if the original determination date falls within the audit review period.
  •  Each payment request must be listed as its own line item in the submitted universe. o If a request for multiple drugs is made at the same time, enter each drug in a separate row.
  • Requests for a single drug must be entered as a single line item.
  • Enter any request denied in whole or in part as denied.
  • Enter all fields for a single request in the same time zone. For example, if the Sponsoring organization has systems in EST and CST, all data in a single line item must be in a single time zone.
  • Exclude requests for coverage that were withdrawn.

Table 4: Standard and Expedited Redeterminations (RD)

  • Include all redeterminations the Sponsoring organization approved, denied, re-opened approved, re-opened denied, auto-forwarded to the IRE or dismissed for Part D coverage during the universe request period. The date of the Sponsoring organization’s determination (Column ID X) must fall within the universe request period.
  • For cases with a Request Determination of re-opened approved or re-opened denied, the date and time the request was received must be the date and time the case was re-opened (i.e., the determination was made to re-open the case). The original coverage determination or redetermination is considered a separate case for purposes of audit and must be included in the universe if the original determination date falls within the audit review period.
  • Each redetermination request must be listed as its own line item in the submitted universe. o If a request for multiple drugs is made at the same time, enter each drug in a separate row.
  • Requests for a single drug involving multiple UM criteria (e.g. step therapy and a prior authorization) must be entered as a single line item.
  • Requests for a single drug involving multiple UM criteria and exception types must be entered as a single line item.
  • If a request has multiple exception types and includes a tiering exception, enter the case as a tiering exception.
  • Enter any request denied in whole or in part as denied.
  • Enter all fields for a single request in the same time zone. For example, if the Sponsoring organization has systems in EST and CST, all data in a single line item must be in a single time zone.
  • Exclude all requests processed as payment redeterminations and withdrawn cases.

Table 5: Part D Effectuations of Overturned Decisions by IRE, ALJ, or MAC (EFF_D)

  • Include all coverage determinations, redeterminations, or at-risk determinations fully or partially overturned by the IRE, ALJ, or MAC requiring an effectuation as pre-benefit, post- service (payment), or an at-risk determination received from the IRE, ALJ, or MAC during the universe request period. The date of the Sponsoring organization’s receipt of the overturn decision (Column ID J) must fall within the universe request period.

  • If a case contains multiple drugs, enter each drug in a separate row.
  • Exclude any cases that were re-opened by the Sponsoring organization or that were dismissed or upheld by the IRE, ALJ, or MAC.

Table 6: Part D Standard and Expedited Grievances (GRV_D)

  • Include all grievances the Sponsoring organization responded to during the universe request period. The date of the Sponsoring organization’s notification (Column ID P or R) must fall within the universe request period.
  • Grievances with multiple issues must be entered as a single line item unless the Sponsoring organization issued separate notifications.
  • Exclude all grievances that were withdrawn and dismissed during the universe request period.
  • Exclude complaints filed only within the Complaints Tracking Module (CTM) in HPMS. If a complaint was processed both within the CTM and was also received as a grievance, exclude the CTM complaint but include the grievance as processed by the Sponsoring organization.

California MMP Plans should be able to analyze the generated Appeals & Grievances universes to determine if they contain the correct inclusion and exclusion criteria. 

Inovaare has been providing healthcare organizations with quality services that help them comply to Medicare/Medicaid regulations since 2008. We can work with your organization to create a comprehensive plan that ensures you are following all the right steps and complying with all regulatory guidelines, including those related to Appeals and Grievances. Give us a call today to explore how we may be able to support your needs and support your healthcare organization’s compliance processes!