Medicare Advantage Organizations (MAOs) and Prescription Drug Plan (PDP) sponsors have to submit Parts C and D reports to the Centers for Medicare & Medicaid Services (CMS) annually. The reporting data are quarterly. These reports are to show: 

  1. Costs of its operations 
  1. Patterns of utilization of its services 
  1. Availability, accessibility, and acceptability of its services 
  1. Information demonstrating the fiscal soundness of the MAO/PDP 
  1. Pharmacy performance measures (opioid safety edits) for PDP 
  1. Other matters that CMS may require 

Reporting organizations should generate these reports at the end of each quarter of the contract year and hold them for the annual submission. Report due dates vary — the first Monday or the last Monday in February. 

The Technical Specifications (Tech Specs) and the reporting requirements provided by CMS define data elements and alert plans on how CMS reviews and analyzes the data. CMS establishes benchmarks from the collected data to identify outliers or data that are potentially erroneous. 

Plans with values above the 95th percentile for their plan type or below the 5th percentile for their plan type will be flagged as outliers. The Tech Specs also spell out the edits and validation checks. Aggregate data from two of the Parts C and D reports are the data sources STAR rating determination — Special Needs Plan (SNP) Care Management and Medication Therapy Management Program (MTMP). 

For instance, CMS evaluates the percent of beneficiaries who are offered and receive a Comprehensive Medication Review (CMR) with written summary in CMS’ standardized format. The higher the percentage for CMR, the higher is the score. The Star Rating for each measure is calibrated by applying a clustering algorithm to the measure’s numeric value scores from all contracts.

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The Tech Specs also enumerate data rules for the reports, such as: 

  • Signs for greater than (>) or less than (<) are unacceptable
  • Negative values are not allowed 
  • Semicolons and decimals are also not allowed 

Furthermore, there are additional notes in the Tech Specs to delineate what to include and what to exclude, similar to universes submitted for a CMS Program Audit. 

For example: 

“Organization determinations, reconsiderations, and re-openings should be included, if requested consistent with the applicable regulations. For instances, when the organization approves an initial request for an item or service (e.g., physical therapy services) and the organization approves a separate additional request to extend or continue coverage of the same item or service, include the decision to extend or continue coverage of the same item or service as another, separate, fully favorable organization determination.”

For each table in the reporting requirements, a set of notes clarifies inclusions and exclusions. The list can consist of as many as 20 criteria for MTMP. For Organization Determination/Reconsideration, the list has nine criteria for Report, and 14 for “Do not Report”. 

MAOs and PDPs can submit the reports multiple times until 11:59 p.m. Pacific Time on the date of the reporting deadline. CMS may issue warning notices or requests for corrective action plans to non-compliant organizations in response to reporting requirement failures. Should the non-compliance persist, CMS may impose intermediate sanctions. CMS would notify MAOs of outlier data to give reporting organizations the opportunity to resubmit corrected data, if needed. Outlier notification does not indicate that submitted data are incorrect, or that resubmissions are required. 

Parts C and D reports play a central role in CMS’ evaluation of a plan-sponsor’s performance. Data integrity and accuracy are essential. Inovaare has a number of solutions (e.g., Universe Scrubber) to support MAOs with their universe submission for a CMS Program Audit and Parts C and D reporting. 

Universe Scrubber eases the burden of manual data validation and improves data accuracy. As the name suggests, the universe data are scrubbed to detect format and logic discrepancies by following the rules and notes in the Tech Specs. If you would like to try out Universe Scrubber to ease the burden of data validation prior to submission, please contact us 1.408.850.2235.