Organization Determinations, Appeals and Grievances (ODAG) protocols help to evaluate performance in the areas outlined in the Centers for Medicare and Medicaid Services (CMS) Program Audit Protocol and Data Request related to Medicare Part C ODAG. The CMS performs its program audit activities in accordance with the ODAG Program Audit 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 ODAG 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 2021 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.

Table 1: OD (Combines 2020 Table 1. SOD, 2. EOD and 13. Dismissals)

Enrollee First Name 50 CHAR Enter the first name of the enrollee.
Enrollee Last Name 50 CHAR Enter the last name of the enrollee.
Enrollee ID 11 CHAR 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.
Contract ID 5 CHAR Enter the contract number (e.g., H1234).
Plan Benefit Package (PBP) 3 CHAR Enter the PBP (e.g., 001).
First Tier, Downstream, and Related Entity 70 CHAR 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 Sponsoring organization to provide administrative or health care services to an enrollee under the Part C or D program) that processed the request.
Enter None if the Sponsoring organization processed the request.
Authorization or Claim Number 40 CHAR 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.
Date the request was received 10 CHAR 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.
Time the request was received 8 CHAR 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 and dismissed requests.
Part B Drug Request? 1 CHAR Enter:
Y for Yes
N for No
Sponsors must indicate ‘Y’ for any pre-service request that includes a Part B drug (primary or ancillary) or Part D drug that is part of a Sponsor’s step therapy requirement for a Part B drug.
AOR/Equivalent notice Receipt Date 10 CHAR Enter the date the Appointment of Representative (AOR) form or equivalent written notice was received by the Sponsoring organization. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None for dismissed requests or if no AOR or equivalent written notice was received or required.
AOR/Equivalent notice Receipt Time 8 CHAR 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 Sponsoring organization. Submit in HH:MM:SS format (e.g., 23:59:59).
Enter None for standard requests, dismissed requests or if no AOR or equivalent written notice was received or required.
Request Determination 9 CHAR Enter:
• Approved
• Denied
• Dismissed
Was the request processed as Standard or Expedited? 1 CHAR Enter the manner by which the request was processed:
S for Standard
E for Expedited
Was a timeframe extension taken? 1 CHAR Enter:
Y for Yes
N for No
Date of Determination 10 CHAR Enter the date of the determination. Submit in CCYY/MM/DD format (e.g., 2020/01/01). For dismissed requests, enter the date the Sponsor dismissed the request.
Time of Determination 8 CHAR 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.
Date oral notification provided to enrollee 10 CHAR 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.
Time oral notification provided to enrollee 8 CHAR 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 requests, dismissed requests, or if no oral notification was provided.
Date written notification provided to enrollee 10 CHAR Enter the date written notification of determination 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.
Time written notification provided to enrollee 8 CHAR 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 requests, dismissed requests, or if no written notification was provided.
Who made the request? 3 CHAR Enter who made the request:
E for enrollee
ER for enrollee’s representative
CP for requests by a contract provider
NCP for requests by a non-contract provider
“Provider” includes physicians and facilities.
Issue description and type of service 2000 CHAR Provide a description of the service or item requested and why it was requested (if known). For denials, also provide an explanation of why the pre-service request was denied.
For dismissed requests, provide the reason for dismissal.
For Part B drugs requests, include the J-Code, National Drug Code (NDC), or both.
Was an expedited request made but processed as standard? 4 CHAR 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)
Was the request denied for lack of medical necessity? 4 CHAR Enter:
Y for Yes
N for No
None if the request was approved or dismissed.

Table 2: RECON (Combine 5. SREC, 6. EREC and 13. DIS)

Enrollee First Name 50 CHAR Enter the first name of the enrollee.
Enrollee Last Name 50 CHAR Enter the last name of the enrollee.
Enrollee ID 11 CHAR 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.
Contract ID 5 CHAR Enter the contract number (e.g., H1234).
Plan Benefit Package (PBP) 3 CHAR Enter the PBP (e.g., 001).
First Tier, Downstream, and Related Entity 70 CHAR 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 Sponsoring organization to provide administrative or health care services to an enrollee under the Part C or D program) that processed the request.
Enter None if the Sponsoring organization processed the request.
Authorization or Claim Number 40 CHAR 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.
Date the request was received 10 CHAR 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.
Time the request was received 8 CHAR 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 and dismissed requests.
Part B Drug Request? 1 CHAR Enter:
Y for Yes
N for No
Sponsors must indicate ‘Y’ for any pre-service request that includes a Part B drug (primary or ancillary) or Part D drug that is part of a Sponsor’s step therapy requirement for a Part B drug.
AOR/Equivalent Notice Receipt Date 10 CHAR Enter the date the Appointment of Representative (AOR) form or equivalent written notice was received by the Sponsoring organization. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None for dismissed requests or if no AOR or equivalent written notice was received or required.
AOR/Equivalent Notice Receipt Time 8 CHAR 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 Sponsoring organization. Submit in HH:MM:SS format (e.g., 23:59:59).
Enter None for standard requests, dismissed requests or if no AOR or equivalent written notice was received or required.
Request Determination 9 CHAR Enter:
• Approved
• Denied
Was the request processed as Standard or Expedited? 1 CHAR Enter the manner by which the request was processed:
S for Standard
E for Expedited
Was a timeframe extension taken? 1 CHAR Enter:
Y for Yes
N for No
Date of Determination 10 CHAR Enter the date of the determination. Submit in CCYY/MM/DD format (e.g., 2020/01/01). For dismissed requests, enter the date the Sponsor dismissed the request.
Time of Determination 8 CHAR 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.
Date oral notification provided to enrollee 10 CHAR 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.
Time oral notification provided to enrollee 8 CHAR 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 requests, dismissed requests, or if no oral notification was provided.
Date written notification provided to enrollee 10 CHAR Enter the date written notification of determination 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.
Time written notification provided to enrollee 8 CHAR 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 requests, dismissed requests, or if no written notification was provided.
Date reconsidered determination effectuated in the system 10 CHAR Enter the date the reconsidered determination was effectuated in the system. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None if the determination was denied or dismissed.
Time reconsidered determination effectuated in the system 8 CHAR For all expedited requests, enter the time the reconsidered determination was effectuated in the system. Submit in HH:MM:SS military time format (e.g., 23:59:59).
Enter None for standard cases, dismissed cases, or if the request was denied.
Date forwarded to IRE 10 CHAR Enter the date the request was forwarded to the IRE. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None if the beneficiary was notified of the approved reconsideration, or if the request was not forwarded to the IRE.
Time forwarded to the IRE 8 CHAR For all expedited requests, enter the time the request was forwarded to the IRE. Submit in HH:MM:SS military time format (e.g., 23:59:59).
Enter None if the beneficiary was notified of the approved reconsideration or if the request was not forwarded to the IRE.
Who made the request? 3 CHAR Enter the person who made the request:
E for enrollee
ER for enrollee’s representative
CP for requests by a contract provider/facility
NCP for requests by a non-contract provider/facility
Issue description and type of service 2000 CHAR Provide a description of the service or item requested and why it was requested (if known). For denials, also provide an explanation of why the pre-service request was denied.
For dismissed requests, provide the reason for dismissal.
For Part B drugs requests, include the J-Code, National Drug Code (NDC), or both.
Was an expedited request made but processed as standard? 4 CHAR 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.)
• For dismissed requests, populate based on how the request was received.
Was the initial organization determination request denied for lack of medical necessity? 1 CHAR Enter:
Y for Yes
N for No

Table 3: PYMT_C (Combines 3. Claims, 4. DMR, 7. PREC and 13. DIS)

Enrollee First Name 50 CHAR Enter the first name of the enrollee.
Enrollee Last Name 50 CHAR Enter the last name of the enrollee.
Enrollee ID 11 CHAR 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.
Contract ID 5 CHAR Enter the contract number (e.g., H1234).
Plan Benefit Package (PBP) 3 CHAR Enter the PBP (e.g., 001).
First Tier, Downstream, and Related Entity 70 CHAR 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 Sponsoring organization to provide administrative or health care services to an enrollee under the Part C or D program) that processed the request.
Enter None if the Sponsoring organization processed the request.
Authorization or Claim Number 40 CHAR 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.
Date the request was received 10 CHAR 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.
AOR/Equivalent notice Receipt Date 10 CHAR Enter the date the Appointment of Representative (AOR) form or equivalent written notice was received by the Sponsoring organization. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None for dismissed requests or if no AOR or equivalent written notice was received or required.
Waiver of Liability (WOL) Receipt Date 10 CHAR 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 ODs, enrollee submitted requests, or if a WOL was never received.
Was it a clean claim? 4 CHAR Enter:
Y for clean claim
N for unclean claim
None for payment reconsiderations
Was the request processed as an OD or Recon? 5 CHAR Enter the manner by which the request was processed:
• OD
• Recon
Request Determination 9 CHAR Enter:
• Approved
• Denied
• Dismissed
Date of Determination 10 CHAR 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 Sponsor dismissed the request.
Date claim/reconsideration was paid 10 CHAR Enter the date the claim/reconsideration 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.
(Audit Review Period-Payment)
Date written notification provided to enrollee 10 CHAR 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.
(Audit Review Period DMR denial)
Date written notification provided to provider 10 CHAR 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 or if the enrollee submitted the request.
(Audit Review Period-involving Claim denial)
Date forwarded to IRE 10 CHAR Enter the date the reconsideration request was forwarded to the IRE. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None for organization determination requests, or if the reconsideration request was approved, dismissed, or not forwarded to the IRE.
Who made the request? 3 CHAR Enter who made the request:
E for enrollee
ER for enrollee’s representative
NCP for requests by a non-contract provider
NCP includes non-contract pharmacies.
Issue description and type of service 2000 CHAR Provide a description of the service or item requested and why it was requested (if known). For denials, also provide an explanation of why the payment organization determination or payment reconsideration request was denied.
For dismissed requests, please provide the reason for dismissal.
For Part B drugs requests, include the J-Code, National Drug Code (NDC), or both.
Was the initial organization determination request denied for lack of medical necessity? 4 CHAR Enter:
Y for Yes
N for No
None if the request was approved or dismissed.

Table 4: EFF_C (Combines 8. IREEFF. 9. IREClaimsEFF and 10. ALJMACEFF)

Enrollee First Name 50 CHAR Enter the first name of the enrollee.
Enrollee Last Name 50 CHAR Enter the last name of the enrollee.
Enrollee ID 11 CHAR 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.
Contract ID 5 CHAR Enter the contract number (e.g., H1234).
Plan Benefit Package (PBP) 3 CHAR Enter the PBP (e.g., 001).
First Tier, Downstream, and Related Entity 70 CHAR 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 Sponsoring organization to provide administrative or health care services to an enrollee under the Part C or D program) that processed the request.
Enter None if the Sponsoring organization processed the request.
Authorization or Claim Number 40 CHAR 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.
Type of reconsideration case 9 CHAR Enter the type of reconsideration case submitted to IRE/ALJ/MAC:
• Standard
• Expedited
• Payment
For pre-service cases, enter Standard or Expedited.
For post-service cases, enter Payment.
Review Entity 3 CHAR Enter the entity that overturned the decision:
• IRE
• ALJ
• MAC
Date the overturned decision was received 10 CHAR Enter the date the overturned decision was received. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Time the overturned decision was received 8 CHAR 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 for Standard (pre-service) and Payment reconsideration cases.
Date overturned decision or payment effectuated in the system 10 CHAR 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.
Time overturned decision or payment effectuated in the system 8 CHAR 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) and Payment reconsideration cases, or if the overturned decision was not effectuated.

Table 5: GRV_C (Combines 11. GRV_S and 12 GRV_E)

Enrollee First Name 50 CHAR Enter the first name of the enrollee.
Enrollee Last Name 50 CHAR Enter the last name of the enrollee.
Enrollee ID 11 CHAR 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.
Contract ID 5 CHAR Enter the contract number (e.g., H1234).
Plan Benefit Package (PBP) 3 CHAR Enter the PBP (e.g., 001).
First Tier, Downstream, and Related Entity 70 CHAR 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 Sponsoring organization to provide administrative or health care services to an enrollee under the Part C or D program) that processed the request.
Enter None if the Sponsoring organization processed the request.
Date the grievance was received 10 CHAR Enter the date the grievance was received. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Time the grievance was received 8 CHAR 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.
AOR/Equivalent notice Receipt Date 10 CHAR Enter the date the Appointment of Representative (AOR) form or equivalent written notice was received by the Sponsoring organization. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None if no AOR or equivalent written notice was received or required.
AOR/Equivalent notice Receipt Time 8 CHAR For expedited grievances, enter the time the Appointment of Representative (AOR) form or equivalent written notice was received by the Sponsoring organization. Submit in HH:MM:SS format (e.g., 23:59:59).
Enter None for standard grievances, dismissed grievances, or if an AOR or equivalent written notice was not received or required.
How was the grievance received? 7 CHAR Enter the method of receipt of the grievance:
• Oral
• Written
Was the grievance processed as Standard or Expedited? 1 CHAR Enter how the grievance was processed:
S for Standard
E for Expedited
Category of the issue 50 CHAR Enter the category of the grievance as assigned by the Sponsoring organization. Enter based on the Sponsoring organization’s internal labeling system.
Grievance Description 1800 CHAR Enter a description of the grievance.
Was this processed as a quality of care grievance? 1 CHAR Enter:
Y for Yes
N for No
Was a timeframe extension taken? 1 CHAR Enter:
Y for Yes
N for No
Date oral notification provided to enrollee 10 CHAR 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.
Time oral notification provided to enrollee 8 CHAR 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.
Date written notification provided to enrollee 10 CHAR 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.
Time written notification provided to enrollee 8 CHAR 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.

Table 6: DSNP-AIP (NEW)

Enrollee First Name 50 CHAR Enter the first name of the enrollee.
Enrollee Last Name 50 CHAR Enter the last name of the enrollee.
Enrollee ID 11 CHAR 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.
Contract ID 5 CHAR Enter the contract number (e.g., H1234).
Plan Benefit Package (PBP) 3 CHAR Enter the PBP (e.g., 001).
First Tier, Downstream, and Related Entity 70 CHAR 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 Sponsoring organization to provide administrative or health care services to an enrollee under the Part C or D program) that processed the request.
Enter None if the Sponsoring organization processed the request.
Authorization or Claim Number 40 CHAR 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.
Date DSNP-AIP notified enrollee of its decision to terminate, reduce or suspend services. 10 CHAR Enter the date the DSNP-AIP notified the enrollee of the reduction, suspension, or termination. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Effective date of reduction suspension, or termination of services 10 CHAR Indicate the intended date of action (that is, the date on which reduction, suspension, or termination became effective). Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Was the decision appealed? 1 CHAR Enter:
Y for Yes
N for No
If ‘N’ is entered, populate all remaining fields with None.
Who made the request? 4 CHAR Enter who made the plan level appeal:
E for enrollee
ER for enrollee’s representative
CP for requests by a contract provider
NCP for requests by a non-contract provider
“Provider” includes physicians and facilities.
Enter None if the decision was not appealed as indicated by N in column ID J.
Date the appeal was received 10 CHAR Enter the date the request was received. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None if the decision was not appealed as indicated by N in column ID J.
AOR/Equivalent notice receipt date 10 CHAR Enter the date the Appointment of Representative (AOR) form or equivalent written notice was received by the Sponsoring organization. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None for dismissed requests, if no AOR or equivalent written notice was received or required, or if the decision was not appealed as indicated by N in column ID J.
Was the appeal processed as Standard or Expedited? 4 CHAR Enter the manner by which the appeal was processed:
S for Standard
E for Expedited
Enter None if the decision was not appealed as indicated by N in column ID J.
Was appeal made under the expedited timeframe but process by the plan under the standard timeframe: 4 CHAR Yes (Y)/No (N) indicator of whether the request was received as expedited but was downgraded and processed under the standard timeframe (e.g., based on the DSNP-AIP deciding that the expedited plan level appeal was unnecessary).
Enter None if the request was received as a standard request or if the decision was not appealed as indicated by N in column ID J.
Was a timeframe extension taken? 4 CHAR Yes (Y)/No (N) indicator of whether the DSNP-AIP extended the timeframe to make the appeal decision.
Enter None if the decision was not appealed as indicated by N in column ID J.
If an extension was taken, did the DSNP-AIP notify the member of the reason(s) for the delay and of their right to file an expedited grievance? 4 CHAR Yes (Y)/No (N) indicator of whether the DSNP-AIP notified the enrollee of the delay.
Enter None if no extension was taken or if the decision was not appealed as indicated by N in column ID J.
Did the enrollee request continuation of benefits? 4 CHAR Yes (Y)/No (N) indicator of whether the enrollee requested continuation of benefits.
Enter None if someone other than the enrollee requested continuation of benefits or if the decision was not appealed as indicated by N in column ID J.
Were the benefits under appeal provided to the member during the plan level appeal process? 4 CHAR Yes (Y)/No (N) indicator of whether the benefits under appeal were provided to the enrollee during the reconsideration process.
Enter None if no request for continuation of benefits was made or if the decision was not appealed as indicated by N in column ID J.
Request Disposition 9 CHAR Enter:
• Approved
• Denied
• Dismissed
Enter None if the decision was not appealed as indicated by N in column ID J.
Date of DSNP-AIP decision 10 CHAR Date of the DSNP-AIP decision. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None if the decision was not appealed as indicated by N in column ID J.
Date oral notification provided to enrollee 10 CHAR Date oral notification provided to enrollee. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None if no oral notification provided or if the decision was not appealed as indicated by N in column ID J.
Date written notification provided to enrollee/provider 10 CHAR Date written notification provided to enrollee, or if applicable the non-contract provider. Do not enter the date when a letter is generated or printed within the DSNP-AIP’s organization. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None if no written notification was provided or if the decision was not appealed as indicated by N in column ID J.
Date reconsidered determination effectuated in the DSNP-AIP system 10 CHAR Date reconsidered determination effectuated in the DSNP-AIP ‘s system. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None for denials and or if the decision was not appealed as indicated by N in column ID J.
Date forwarded to IRE if denied or untimely 10 CHAR Date the AIP forwarded request to the IRE if request for Medicare service was denied or processed untimely. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None if approved or not forwarded to IRE or if the decision was not appealed as indicated by N in column ID J.
If request denied, date services were terminated, reduced, suspended 10 CHAR Enter the date the services were terminated, reduced, suspended. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None if the decision was not appealed as indicated by N in column ID J.
  • Yellow: Audit Review Period
  • Blue: valid values
  • Red: important information to recognize

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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.