Medicare-Medicaid Plan Service Authorization Requests, Appeals, and Grievances (MMP-SARAG) protocols help to evaluate performance in the Centers for Medicare and Medicaid Services (CMS) Program Audit Protocol and Data Request related to MMP-SARAG service authorization requests, provider payment requests, appeals and grievances for medical, behavioral health, substance use disorder, and long-term services and supports (LTSS) services. The CMS performs its program audit activities in accordance with the MMP-SARAG Program Audit Protocol and 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 three-way contract 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: M_SAR (Combines 1. MSSAR and 2. MESAR)

2021

Enrollee First Name 50 Enter the first name of the enrollee.
Enrollee Last Name 50 Enter the last name of the enrollee.
Enrollee ID 11 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 Enter the contract number (e.g., H1234).
Plan Benefit Package (PBP) 3 Enter the PBP (e.g., 001).
First Tier, Downstream, and Related Entity) 70 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 MMP to provide administrative or health care services to an enrollee under the MMP program) that processed the request.
Enter None if the MMP processed the request.
Authorization or Claim Number 40 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 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 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 service requests and dismissed requests.
Part B Drug Request 1 Enter:
Y for Yes
N for No
AOR/Equivalent notice Receipt Date 10 Enter the date the Appointment of Representative (AOR) form or equivalent written notice was received by the MMP. 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 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 MMP. Submit in HH:MM:SS format (e.g., 23:59:59).
Enter None for standard service requests, dismissed requests, or if no AOR or equivalent written notice was received or required.”
Request Determination 9 Enter:
• Approved
• Denied
• Dismissed
Was the request processed as Standard or Expedited? 1 Enter the manner by which the request was processed:
S for Standard
E for Expedited
Was a timeframe extension taken? 1 Enter:
Y for Yes
N for No
Date of Determination 10 Enter the date of the determination. Submit in CCYY/MM/DD format (e.g., 2020/01/01). For dismissed requests, enter the date the MMP dismissed the request.
Time of Determination 8 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 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 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 service requests, dismissed requests, or if no oral notification was provided.
Date written notification provided to enrollee 10 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 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 service requests, dismissed requests, or if no written notification was provided.
Who made the request? 3 Enter who made the request:
E for enrollee
ER for enrollee’s representative or purported 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 Provide a description of the service or item requested and why it was requested (if known). If describing behavioral health services, long-term services and supports (LTSS), or substance use disorder services, include the terms behavioral health, LTSS, and substance use disorder service in the description, as applicable. For denials, also provide an explanation of why the pre-service request was denied. For dismissed requests, provide the reason for dismissal.
Was an expedited request made but processed as standard? 4 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 Enter:
Y for Yes
N for No
None if the request was approved or dismissed.

Table 2: M_PLA (Combines 4. MSPLA and 5. MEPLA)

2021

Enrollee First Name 50 Enter the first name of the enrollee.
Enrollee Last Name 50 Enter the last name of the enrollee.
Enrollee ID 11 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 Enter the contract number (e.g., H1234).
Plan Benefit Package (PBP) 3 Enter the PBP (e.g., 001).
First Tier, Downstream, and Related Entity 70 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 MMP to provide administrative or health care services to an enrollee under the MMP program) that processed the request.
Enter None if the MMP processed the request.
Authorization or Claim Number 40 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 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.
If the MMP obtained information establishing good cause after the 60-day filing timeframe, enter the date the MMP received the information establishing good cause.
Time the request was received 8 For all expedited 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. If the MMP obtained information establishing good cause after the 60-day filing timeframe, enter the time the MMP received the information establishing good cause.
Enter None for standard and dismissed requests.
Part B Drug Request 1 Enter:
Y for Yes
N for No
AOR/Equivalent notice Receipt Date 10 Enter the date the Appointment of Representative (AOR) form or equivalent written notice was received by the MMP. 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 For all expedited requests, enter the time the Appointment of Representative (AOR) form or equivalent written notice was received by the MMP. Submit in HH:MM:SS format (e.g., 23:59:59).
Enter None for standard requests or if no AOR or equivalent written notice was received or required.
Request Determination 9 Enter:
Approved
Denied
Dismissed
Was the request processed as Standard or Expedited? 1 Enter the manner by which the request was processed:
S for Standard
E for Expedited
Was a timeframe extension taken? 1 Enter:
Y for Yes
N for No
Date of Determination 10 Enter the date of the determination. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
For dismissed requests enter the date the MMP dismissed the request.
Time of Determination 8 For all expedited 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 Enter the date oral notification was provided to enrollee. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None for dismissed requests or if no oral notification was provided.
Time oral notification provided to enrollee 8 For all expedited 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 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 no written notification was provided.
Time written notification provided to enrollee 8 For all expedited requests, enter the time written notification was provided to enrollee. Do not enter the time a letter is 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 appeal effectuated in the system 10 Enter the date the appeal was effectuated in the system. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None if the appeal was denied or dismissed.
Time appeal effectuated in the system 8 For all expedited requests, enter the time the appeal 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/IAHO 10 Enter the date the request was forwarded to the IRE/IAHO. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None if the enrollee was notified of the approved appeal, or if the request was not forwarded to the IRE/IAHO.
Time forwarded to IRE/IAHO 8 For all expedited requests, enter the time the request was forwarded to the IRE/IAHO. Submit in HH:MM:SS military time format (e.g., 23:59:59).
Enter None if the enrollee was notified of the approved appeal, if the request was not forwarded to the IRE/IAHO, or for standard requests.
Who made the request? 3 Enter who made the request:
E for enrollee
ER for enrollee’s representative or purported 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 Provide a description of the service or item requested and why it was requested (if known). If describing behavioral health services, long-term services and supports (LTSS), or substance use disorder services, include the terms behavioral health, LTSS, and substance use disorder service in the description, as applicable. For denials, also provide an explanation of why the pre-service request was denied. For dismissed requests, provide the reason for dismissal
Was an expedited request made but processed as standard? 4 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, or the request was dismissed.)
Was the initial service authorization request denied for lack of medical necessity? 2 Enter:
Y for Yes
N for No
NA for Not Applicable
Did the enrollee request to continue services pending an appeal resolution for a previously approved service that was being terminated or modified? 1 Enter:
Y for Yes
N for No
Were the services under appeal provided to the enrollee during the plan level appeal process? 2 Enter:
Y for Yes
N for No
NA for Not Applicable if the service under appeal was not a previously approved service that was being appealed due to the termination or modification of the service.
Is the requested service a Medicaid-only service? 1 Enter:
Y for Yes
N for No

Table 3: M_Claims

2021

Enrollee First Name 50 Enter the first name of the enrollee.
Enrollee Last Name 50 Enter the last name of the enrollee.
Enrollee ID 11 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 Enter the contract number (e.g., H1234).
Plan Benefit Package (PBP) 3 Enter the PBP (e.g., 001).
First Tier, Downstream, and Related Entity 70 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 MMP to provide administrative or health care services to an enrollee under the MMP program) that processed the request.
Enter None if the MMP processed the request.
Authorization or Claim Number 40 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 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.
If the MMP obtained information establishing good cause after the 60-day filing timeframe, enter the date the MMP received the information establishing good cause.
Waiver of Liability (WOL) Receipt Date 10 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 claims, or if a WOL was never received.
Was it a clean claim? 4 Enter:
Y for clean claim
N for unclean claim
None for payment appeals
Was the request processed as a claim or an appeal? 6 Enter the manner by which the request was processed:
Claim
Appeal
Request Determination 9 Enter:
Approved
Denied
Dismissed
Date of Determination 10 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 MMP dismissed the request.
(Audit Period (Dismissed))
Date claim/ payment appeal was paid 10 Enter the date the claim 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 Period (Paid claims/ overturn appeal))
Date written notification provided to enrollee 10 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.
Date written notification provided to provider 10 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.
(Audit Period (Denied to Provider))
Date forwarded to IRE 10 Enter the date the payment appeal was forwarded to the IRE. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Enter None for claims, or if the payment appeal was approved, dismissed, or not forwarded to the IRE.
(Audit Period (upheld appeals))
Issue description and type of service 2000 Provide a description of the service or item requested and why it was requested (if known). If describing behavioral health services, long-term services and supports (LTSS), or substance use disorder services, include the terms behavioral health, LTSS, and substance use disorder service in the description, as applicable. For denials, also provide an explanation of why the claim or payment appeal was denied. For dismissed requests, please provide the reason for dismissal.
Was the initial claim denied for lack of medical necessity? 4 Enter:
Y for Yes
N for No
None if the request was approved or dismissed.
Is the requested service a Medicaid-only service? 1 Enter:
Y for Yes
N for No

Table 4: M_EFF (Combines 6: M_SFHEFF, 7. M_IREEFF, 8. M_IREClaimsEFF and M_ALJMACEFF)

2021

Enrollee First Name 50 Enter the first name of the enrollee.
Enrollee Last Name 50 Enter the last name of the enrollee.
Enrollee ID 11 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 Enter the contract number (e.g., H1234).
Plan Benefit Package (PBP) 3 Enter the PBP (e.g., 001).
First Tier, Downstream, and Related Entity 70 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 MMP to provide administrative or health care services to an enrollee under the MMP program) that processed the request.
Enter None if the MMP processed the request.
Authorization or Claim Number 40 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 appeal case 9 Enter the type of appeal case submitted to IRE/SFH/ALJ/MAC:
Standard
Expedited
Payment
For pre-service cases, enter Standard or Expedited. Default to Standard for pre-service cases if the three-way contract has one effectuation timeframe for the applicable external appeals entity’s overturns. For post-service cases, enter Payment.
Review Entity 3 Enter the entity that overturned the decision:
IRE
SFH (including the IAHO)
ALJ
MAC
Date the overturned decision was received 10 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 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 if not an expedited or Part B drug request.
Part B Drug Request 1 Enter:
Y for Yes
N for No
Date overturned decision or payment effectuated in the system 10 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 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 requests and payment appeals, or if the overturned decision was not effectuated.
Did the enrollee request to continue services pending an appeal resolution for a previously approved service that was being terminated or modified? 1 Enter:
Y for Yes
N for No
Were the services under appeal provided to the enrollee during the external appeal process? 2 Enter:
Y for Yes
N for No
NA for Not Applicable if the service under appeal was not a previously approved service that was being appealed due to the termination or modification of the service.

Table 5: M_GRV (Combines 10. MGRV_S and 11. MGRV_E)

2021

Enrollee First Name 50 Enter the first name of the enrollee.
Enrollee Last Name 50 Enter the last name of the enrollee.
Enrollee ID 11 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 Enter the contract number (e.g., H1234).
Plan Benefit Package (PBP) 3 Enter the PBP (e.g., 001).
First Tier, Downstream, and Related Entity 70 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 MMP to provide administrative or health care services to an enrollee under the MMP program) that processed the request.
Enter None if the MMP processed the request.
Date the grievance was received 10 Enter the date the grievance was received. Submit in CCYY/MM/DD format (e.g., 2020/01/01).
Time the grievance was received 8 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 Enter the date the Appointment of Representative (AOR) form or equivalent written notice was received by the MMP. 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 For expedited grievances, enter the time the Appointment of Representative (AOR) form or equivalent written notice was received by the MMP. Submit in HH:MM:SS format (e.g., 23:59:59).
Enter None for standard grievances, or if an AOR or equivalent written notice was not received or required.
How was the grievance received? 7 Enter the method of receipt of the grievance:
Oral
Written
Was the grievance processed as Standard or Expedited? 1 Enter how the grievance was processed:
S for Standard
E for Expedited
Category of the issue 50 Enter the category of the grievance as assigned by the MMP. Enter based on the MMP’s internal labeling system.
Grievance Description 2000 Enter a description of the grievance.
Was this processed as a quality of care grievance? 1 Enter:
Y for Yes
N for No
Was a timeframe extension taken? 1 Enter:
Y for Yes
N for No
Date oral notification provided to enrollee 10 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 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 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 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.
Who made the request? 2 Enter who made the request:
E for enrollee
ER for enrollee’s representative or purported representative
  • 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.