| Special Needs Plans (SNPs) Care Management 2026 | ||||
| To determine compliance with standards, the data validation contractor will assess the following information: - Organization meets deadline for reporting annual data to CMS. - Data submitted or re-submitted to CMS via HPMS. - Written response to OAI Sections 3 and 4, and documentation requested per OAI Sections 5 and 6. - Outlier/data integrity notification(s)- See OAI 4.3.3 for instructions on how to retrieve notices. - Results from the organization’s data systems changes during the reporting period (e.g., because of a merger, acquisition, vendor change, or upgrade). - Definitions are in accordance with 42 CFR § 422.2 “Specialized MA Plans for Special Needs Individuals”. - Results of interviews with organization staff. - Census or sample data. - Other relevant information provided by organization. |
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| Organization Name: | no data | |||
| Contract Number: | no data | |||
| Reporting Section: | Special Needs Plans (SNPs) Care Management 2026 | |||
| Last Updated: | no data | |||
| Date of Site Visit (on-site or virtual): | no data | |||
| Name of Reviewer: | no data | |||
| Name of Peer Reviewer: | no data | |||
Instructions: 1) In the "Data Sources and Review Results:" column, enter the review results and/or data sources used. 2) Enter "Y" if the requirements have been met. If any requirement has not been met, enter "N". For Standards 6 and 7, if these standards do not apply, enter "N/A". 3) Enter 'Findings' as follows based on the five-point scale: Select "1" if plan data has more than 20% error, select "2" if plan data has between 15.1% - 20.0% error, select "3" if plan data has between 10.1% - 15.0% error, select "4" if plan data has between 5.1% - 10.0% error, select "5" if plan data has less than or equal to a 5% error. |
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| Standard / Sub-Standard ID | Standard/Sub-Standard Description | Data Elements | Data Sources and Review Results: Enter review results and/or data sources | Enter 'Findings' using the applicable choice in the appropriate cells. Cells marked with an '*' should not be edited. |
| 1 | Database management and structure: A review of source documents (for example, programming code, spreadsheet formulas, analysis plans, saved data queries, file layouts, process flows) shows that all source documents accurately capture required data fields and the SO has properly documented them. |
No data | Data Sources: | * |
| 1.a | SOs properly secured source documents and output, and have referenced data file locations correctly so that DVCs can retrieve source documents at any time to validate the information submitted to CMS via CMS systems. | No data | Review Results: | |
| 1.b | SOs clearly and adequately documented source documents. |
No data | Review Results: | |
| 1.c | SOs accurately captured required data fields including all data fields for RR in source documents. All data fields have meaningful, consistent labels (for example, label field for patient ID as Patient ID, rather than Field1 and maintain the same field name across data sets). |
No data | Review Results: | |
| 1.d | Source documents are error-free (for example, programming code and spreadsheet formulas have no messages or warnings indicating errors). |
No data | Review Results: | |
| 1.e | SOs appropriately applied version control of source documents. |
No data | Review Results: | |
| 1.f | SOs captured the appropriate date range(s) for the reporting period(s). SO reports data based on the required reporting period of 1/1 - 12/31. |
No data | Review Results: | |
| 1.g | SOs assigned data at the applicable level (for example, plan benefit package (PBP) or contract level). | No data | Review Results: | |
| 2 | Database Extraction Function: Review of source data, preliminary data sets, and interim data sets (for example, programming code, spreadsheet formulas, analysis plans, saved data queries, file layouts, process flows) indicates the following: a. SOs accurately identify, process, and verify the population for each reporting section (including calculations for the number of enrollees, claims, grievances, procedures, etc.). They apply QA checks/thresholds to detect outlier or erroneous data. |
No data | Data Sources: | * |
| 2.a | SOs accurately identify, process, and verify the population for each reporting section (including calculations for the number of enrollees, claims, grievances, procedures, etc.). They apply QA checks/thresholds to detect outlier or erroneous data. | No data | Review Results: | |
| 3 | Organization implements policies and procedures in their final stage data sets for submission into HPMS, including the following: a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. |
No data | Data Sources: | * |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | A | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | B | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | C | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | D | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | E | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | F | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | G | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | H | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | A | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | B | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | C | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | D | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | E | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | F | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | G | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | H | Review Results: | |
| 4 | All source, intermediate, and final stage data sets and other outputs relied upon to enter data into CMS systems are archived. | No data | Review Results: | |
| 5 | Organization implements policies and procedures for the following: i. Periodic data system updates (for example, changes in enrollment, provider/pharmacy status, and claims adjustments). ii. Restoring data in each data system (for example, disaster recovery plan). |
No data | Review Results: | |
| 6 | If organization’s data systems underwent any changes during the reporting period (for example, because of a merger, acquisition, vendor change or upgrade): Organization provided documentation on the data system changes and, upon review, changes were implemented correctly and did not adversely impact the reported data. | No data | Review Results: | |
| 7 | If data collection and/or reporting for this reporting section is delegated to another entity: Organization regularly routinely monitors the quality and timeliness of the data collected and/or reported by the delegated entity or first tier/downstream contractor. | No data | Review Results: | |
| Organization Determinations and Reconsiderations (Part C) 2026 | ||||
| To determine compliance with standards, the data validation contractor will assess the following information: - Organization meets deadline for reporting annual data to CMS. - Data submitted or re-submitted to CMS via HPMS. - Written response to OAI Sections 3 and 4, and documentation requested per OAI Sections 5 and 6. - Outlier/data integrity notification(s)- See OAI 4.3.3 for instructions on how to retrieve notices. - Results from the organization’s data systems changes during the reporting period (e.g., because of a merger, acquisition, vendor change, or upgrade). - Definitions are in accordance with 42 CFR § 422, Subpart M and the Parts C & D Enrollee Grievances, Organization/Coverage Determinations and Appeals Manual when performing calculations. - Results of interviews with organization staff. - Census or sample data. - Other relevant information provided by organization. |
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| Organization Name: | no data | |||
| Contract Number: | no data | |||
| Reporting Section: | Organization Determinations and Reconsiderations (Part C) 2026 | |||
| Last Updated: | no data | |||
| Date of Site Visit (on-site or virtual): | no data | |||
| Name of Reviewer: | no data | |||
| Name of Peer Reviewer: | no data | |||
Instructions: 1) In the "Data Sources and Review Results:" column, enter the review results and/or data sources used. 2) Enter "Y" if the requirements have been met. If any requirement has not been met, enter "N". For Standards 6 and 7, if these standards do not apply, enter "N/A". 3) Enter 'Findings' as follows based on the five-point scale: Select "1" if plan data has more than 20% error, select "2" if plan data has between 15.1% - 20.0% error, select "3" if plan data has between 10.1% - 15.0% error, select "4" if plan data has between 5.1% - 10.0% error, select "5" if plan data has less than or equal to a 5% error. |
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| Standard / Sub-Standard ID | Standard/Sub-Standard Description | Data Elements | Data Sources and Review Results: Enter review results and/or data sources | Enter 'Findings' using the applicable choice in the appropriate cells. Cells marked with an '*' should not be edited. |
| 1 | Database management and structure: A review of source documents (for example, programming code, spreadsheet formulas, analysis plans, saved data queries, file layouts, process flows) shows that all source documents accurately capture required data fields and the SO has properly documented them. |
No data | Data Sources: | * |
| 1.a | SOs properly secured source documents and output, and have referenced data file locations correctly so that DVCs can retrieve source documents at any time to validate the information submitted to CMS via CMS systems. | No data | Review Results: | |
| 1.b | SOs clearly and adequately documented source documents. |
No data | Review Results: | |
| 1.c | SOs accurately captured required data fields including all data fields for RR in source documents. All data fields have meaningful, consistent labels (for example, label field for patient ID as Patient ID, rather than Field1 and maintain the same field name across data sets). |
No data | Review Results: | |
| 1.d | Source documents are error-free (for example, programming code and spreadsheet formulas have no messages or warnings indicating errors). |
No data | Review Results: | |
| 1.e | SOs appropriately applied version control of source documents. |
No data | Review Results: | |
| 1.f | SOs captured the appropriate date range(s) for the reporting period(s). SO reports data based on the required reporting period of 1/1 - 3/31, 4/1 - 6/30, 7/1 - 9/30, 10/1 - 12/31. |
No data | Review Results: | |
| 1.g | SOs assigned data at the applicable level (for example, plan benefit package (PBP) or contract level). | No data | Review Results: | |
| 2 | Database Extraction Function: Review of source data, preliminary data sets, and interim data sets (for example, programming code, spreadsheet formulas, analysis plans, saved data queries, file layouts, process flows) indicates the following: a. SOs accurately identify, process, and verify the population for each reporting section (including calculations for the number of enrollees, claims, grievances, procedures, etc.). They apply QA checks/thresholds to detect outlier or erroneous data. |
No data | Data Sources: | * |
| 2.a | SOs accurately identify, process, and verify the population for each reporting section (including calculations for the number of enrollees, claims, grievances, procedures, etc.). They apply QA checks/thresholds to detect outlier or erroneous data. | No data | Review Results: | |
| 3 | Organization implements policies and procedures in their final stage data sets for submission into HPMS, including the following: a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. |
No data | Data Sources: | * |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.A | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.B | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.C | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.D | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.E | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.F | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.G | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.A | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.B | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.C | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.D | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.E | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.F | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.G | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.H | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.I | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.J | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.K | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.L | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 3.A | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 3.B | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 3.C | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 3.D | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 3.E | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 3.F | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 3.G | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 4.A | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 4.B | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 4.C | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 4.D | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 4.E | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 4.F | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 4.G | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 4.H | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 4.I | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 4.J | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 4.K | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 4.L | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 5.A | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 5.B | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 5.D | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 5.E | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 5.F | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 5.G | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 5.H | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 5.I | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 5.J | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 5.K | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 5.M | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 5.N | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.A | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.B | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.C | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.D | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.E | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.F | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.G | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.A | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.B | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.C | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.D | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.E | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.F | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.G | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.H | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.I | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.J | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.K | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.L | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 3.A | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 3.B | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 3.C | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 3.D | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 3.E | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 3.F | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 3.G | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 4.A | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 4.B | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 4.C | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 4.D | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 4.E | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 4.F | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 4.G | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 4.H | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 4.I | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 4.J | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 4.K | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 4.L | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 5.A | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 5.B | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 5.D | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 5.E | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 5.F | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 5.G | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 5.H | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 5.I | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 5.J | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 5.K | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 5.M | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 5.N | Review Results: | |
| 4 | All source, intermediate, and final stage data sets and other outputs relied upon to enter data into CMS systems are archived. | No data | Review Results: | |
| 5 | Organization implements policies and procedures for the following: i. Periodic data system updates (for example, changes in enrollment, provider/pharmacy status, and claims adjustments). ii. Restoring data in each data system (for example, disaster recovery plan). |
No data | Review Results: | |
| 6 | If organization’s data systems underwent any changes during the reporting period (for example, because of a merger, acquisition, vendor change or upgrade): Organization provided documentation on the data system changes and, upon review, changes were implemented correctly and did not adversely impact the reported data. | No data | Review Results: | |
| 7 | If data collection and/or reporting for this reporting section is delegated to another entity: Organization regularly routinely monitors the quality and timeliness of the data collected and/or reported by the delegated entity or first tier/downstream contractor. | No data | Review Results: | |
| Grievances (Part C) 2026 | ||||
| To determine compliance with standards, the data validation contractor will assess the following information: - Organization meets deadline for reporting annual data to CMS. - Data submitted or re-submitted to CMS via HPMS. - Written response to OAI Sections 3 and 4, and documentation requested per OAI Sections 5 and 6. - Outlier/data integrity notification(s)- See OAI 4.3.3 for instructions on how to retrieve notices. - Results from the organization’s data systems changes during the reporting period (e.g., because of a merger, acquisition, vendor change, or upgrade). - Definitions are in accordance with 42 CFR § 423, Subpart M and the Parts C & D Enrollee Grievances, Organization/Coverage Determinations and Appeals Manual when performing calculations. - Results of interviews with organization staff. - Census or sample data. - Other relevant information provided by organization. |
||||
| Organization Name: | no data | |||
| Contract Number: | no data | |||
| Reporting Section: | Grievances (Part C) 2026 | |||
| Last Updated: | no data | |||
| Date of Site Visit (on-site or virtual): | no data | |||
| Name of Reviewer: | no data | |||
| Name of Peer Reviewer: | no data | |||
Instructions: 1) In the "Data Sources and Review Results:" column, enter the review results and/or data sources used. 2) Enter "Y" if the requirements have been met. If any requirement has not been met, enter "N". For Standards 6 and 7, if these standards do not apply, enter "N/A". 3) Enter 'Findings' as follows based on the five-point scale: Select "1" if plan data has more than 20% error, select "2" if plan data has between 15.1% - 20.0% error, select "3" if plan data has between 10.1% - 15.0% error, select "4" if plan data has between 5.1% - 10.0% error, select "5" if plan data has less than or equal to a 5% error. |
||||
| Standard / Sub-Standard ID | Standard/Sub-Standard Description | Data Elements | Data Sources and Review Results: Enter review results and/or data sources | Enter 'Findings' using the applicable choice in the appropriate cells. Cells marked with an '*' should not be edited. |
| 1 | Database management and structure: A review of source documents (for example, programming code, spreadsheet formulas, analysis plans, saved data queries, file layouts, process flows) shows that all source documents accurately capture required data fields and the SO has properly documented them. |
No data | Data Sources: | * |
| 1.a | SOs properly secured source documents and output, and have referenced data file locations correctly so that DVCs can retrieve source documents at any time to validate the information submitted to CMS via CMS systems. | No data | Review Results: | |
| 1.b | SOs clearly and adequately documented source documents. |
No data | Review Results: | |
| 1.c | SOs accurately captured required data fields including all data fields for RR in source documents. All data fields have meaningful, consistent labels (for example, label field for patient ID as Patient ID, rather than Field1 and maintain the same field name across data sets). |
No data | Review Results: | |
| 1.d | Source documents are error-free (for example, programming code and spreadsheet formulas have no messages or warnings indicating errors). |
No data | Review Results: | |
| 1.e | SOs appropriately applied version control of source documents. |
No data | Review Results: | |
| 1.f | SOs captured the appropriate date range(s) for the reporting period(s). SO reports data based on the required reporting period of 1/1 - 3/31, 4/1 - 6/30, 7/1 - 9/30, 10/1 - 12/31. |
No data | Review Results: | |
| 1.g | SOs assigned data at the applicable level (for example, plan benefit package (PBP) or contract level). | No data | Review Results: | |
| 2 | Database Extraction Function: Review of source data, preliminary data sets, and interim data sets (for example, programming code, spreadsheet formulas, analysis plans, saved data queries, file layouts, process flows) indicates the following: a. SOs accurately identify, process, and verify the population for each reporting section (including calculations for the number of enrollees, claims, grievances, procedures, etc.). They apply QA checks/thresholds to detect outlier or erroneous data. |
No data | Data Sources: | * |
| 2.a | SOs accurately identify, process, and verify the population for each reporting section (including calculations for the number of enrollees, claims, grievances, procedures, etc.). They apply QA checks/thresholds to detect outlier or erroneous data. | No data | Review Results: | |
| 3 | Organization implements policies and procedures in their final stage data sets for submission into HPMS, including the following: a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. |
No data | Data Sources: | * |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | A | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | B | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | C | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | D | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | E | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | A | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | B | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | C | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | D | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | E | Review Results: | |
| 4 | All source, intermediate, and final stage data sets and other outputs relied upon to enter data into CMS systems are archived. | No data | Review Results: | |
| 5 | Organization implements policies and procedures for the following: i. Periodic data system updates (for example, changes in enrollment, provider/pharmacy status, and claims adjustments). ii. Restoring data in each data system (for example, disaster recovery plan). |
No data | Review Results: | |
| 6 | If organization’s data systems underwent any changes during the reporting period (for example, because of a merger, acquisition, vendor change or upgrade): Organization provided documentation on the data system changes and, upon review, changes were implemented correctly and did not adversely impact the reported data. | No data | Review Results: | |
| 7 | If data collection and/or reporting for this reporting section is delegated to another entity: Organization regularly routinely monitors the quality and timeliness of the data collected and/or reported by the delegated entity or first tier/downstream contractor. | No data | Review Results: | |
| Grievances (Part D) 2026 | ||||
| To determine compliance with standards, the data validation contractor will assess the following information: - Organization meets deadline for reporting annual data to CMS. - Data submitted or re-submitted to CMS via HPMS. - Written response to OAI Sections 3 and 4, and documentation requested per OAI Sections 5 and 6. - Outlier/data integrity notification(s)- See OAI 4.3.3 for instructions on how to retrieve notices. - Results from the organization’s data systems changes during the reporting period (e.g., because of a merger, acquisition, vendor change, or upgrade). - Definitions are in accordance with 42 CFR § 423, Subpart M and the Parts C & D Enrollee Grievances, Organization/Coverage Determinations and Appeals Manual when performing calculations. - Results of interviews with organization staff. - Census or sample data. - Other relevant information provided by organization. |
||||
| Organization Name: | no data | |||
| Contract Number: | no data | |||
| Reporting Section: | Grievances (Part D) 2026 | |||
| Last Updated: | no data | |||
| Date of Site Visit (on-site or virtual): | no data | |||
| Name of Reviewer: | no data | |||
| Name of Peer Reviewer: | no data | |||
Instructions: 1) In the "Data Sources and Review Results:" column, enter the review results and/or data sources used. 2) Enter "Y" if the requirements have been met. If any requirement has not been met, enter "N". For Standards 6 and 7, if these standards do not apply, enter "N/A". 3) Enter 'Findings' as follows based on the five-point scale: Select "1" if plan data has more than 20% error, select "2" if plan data has between 15.1% - 20.0% error, select "3" if plan data has between 10.1% - 15.0% error, select "4" if plan data has between 5.1% - 10.0% error, select "5" if plan data has less than or equal to a 5% error. |
||||
| Standard / Sub-Standard ID | Standard/Sub-Standard Description | Data Elements | Data Sources and Review Results: Enter review results and/or data sources | Enter 'Findings' using the applicable choice in the appropriate cells. Cells marked with an '*' should not be edited. |
| 1 | Database management and structure: A review of source documents (for example, programming code, spreadsheet formulas, analysis plans, saved data queries, file layouts, process flows) shows that all source documents accurately capture required data fields and the SO has properly documented them. |
No data | Data Sources: | * |
| 1.a | SOs properly secured source documents and output, and have referenced data file locations correctly so that DVCs can retrieve source documents at any time to validate the information submitted to CMS via CMS systems. | No data | Review Results: | |
| 1.b | SOs clearly and adequately documented source documents. |
No data | Review Results: | |
| 1.c | SOs accurately captured required data fields including all data fields for RR in source documents. All data fields have meaningful, consistent labels (for example, label field for patient ID as Patient ID, rather than Field1 and maintain the same field name across data sets). |
No data | Review Results: | |
| 1.d | Source documents are error-free (for example, programming code and spreadsheet formulas have no messages or warnings indicating errors). |
No data | Review Results: | |
| 1.e | SOs appropriately applied version control of source documents. |
No data | Review Results: | |
| 1.f | SOs captured the appropriate date range(s) for the reporting period(s). SO reports data based on the required reporting period of 1/1 - 3/31, 4/1 - 6/30, 7/1 - 9/30, 10/1 - 12/31. |
No data | Review Results: | |
| 1.g | SOs assigned data at the applicable level (for example, plan benefit package (PBP) or contract level). | No data | Review Results: | |
| 2 | Database Extraction Function: Review of source data, preliminary data sets, and interim data sets (for example, programming code, spreadsheet formulas, analysis plans, saved data queries, file layouts, process flows) indicates the following: a. SOs accurately identify, process, and verify the population for each reporting section (including calculations for the number of enrollees, claims, grievances, procedures, etc.). They apply QA checks/thresholds to detect outlier or erroneous data. |
No data | Data Sources: | * |
| 2.a | SOs accurately identify, process, and verify the population for each reporting section (including calculations for the number of enrollees, claims, grievances, procedures, etc.). They apply QA checks/thresholds to detect outlier or erroneous data. | No data | Review Results: | |
| 3 | Organization implements policies and procedures in their final stage data sets for submission into HPMS, including the following: a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. |
No data | Data Sources: | * |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | A | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | B | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | C | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | D | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | E | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | A | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | B | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | C | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | D | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | E | Review Results: | |
| 4 | All source, intermediate, and final stage data sets and other outputs relied upon to enter data into CMS systems are archived. | No data | Review Results: | |
| 5 | Organization implements policies and procedures for the following: i. Periodic data system updates (for example, changes in enrollment, provider/pharmacy status, and claims adjustments). ii. Restoring data in each data system (for example, disaster recovery plan). |
No data | Review Results: | |
| 6 | If organization’s data systems underwent any changes during the reporting period (for example, because of a merger, acquisition, vendor change or upgrade): Organization provided documentation on the data system changes and, upon review, changes were implemented correctly and did not adversely impact the reported data. | No data | Review Results: | |
| 7 | If data collection and/or reporting for this reporting section is delegated to another entity: Organization regularly routinely monitors the quality and timeliness of the data collected and/or reported by the delegated entity or first tier/downstream contractor. | No data | Review Results: | |
| Coverage Determinations, Redeterminations (including At–Risk Redeterminations under a Drug Management Program), and Reopenings (Part D) 2026 |
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| To determine compliance with standards, the data validation contractor will assess the following information: - Organization meets deadline for reporting annual data to CMS. - Data submitted or re-submitted to CMS via HPMS. - Written response to OAI Sections 3 and 4, and documentation requested per OAI Sections 5 and 6. - Outlier/data integrity notification(s)- See OAI 4.3.3 for instructions on how to retrieve notices. - Results from the organization’s data systems changes during the reporting period (e.g., because of a merger, acquisition, vendor change, or upgrade). - Definitions are in accordance with 42 CFR § 423.153(f), 42 CFR § 423, Subparts M and U, and the Parts C & D Enrollee Grievances, Organization/Coverage Determinations and Appeals Manual when performing calculations. - Results of interviews with organization staff. - Census or sample data. - Other relevant information provided by organization. |
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| Organization Name: | no data | |||
| Contract Number: | no data | |||
| Reporting Section: | Coverage Determinations, Redeterminations (including At–Risk Redeterminations under a Drug Management Program), and Reopenings (Part D) 2026 |
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| Last Updated: | no data | |||
| Date of Site Visit (on-site or virtual): | no data | |||
| Name of Reviewer: | no data | |||
| Name of Peer Reviewer: | no data | |||
Instructions: 1) In the "Data Sources and Review Results:" column, enter the review results and/or data sources used. 2) Enter "Y" if the requirements have been met. If any requirement has not been met, enter "N". For Standards 6 and 7, if these standards do not apply, enter "N/A". 3) Enter 'Findings' as follows based on the five-point scale: Select "1" if plan data has more than 20% error, select "2" if plan data has between 15.1% - 20.0% error, select "3" if plan data has between 10.1% - 15.0% error, select "4" if plan data has between 5.1% - 10.0% error, select "5" if plan data has less than or equal to a 5% error. |
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| Standard / Sub-Standard ID | Standard/Sub-Standard Description | Data Elements | Data Sources and Review Results: Enter review results and/or data sources | Enter 'Findings' using the applicable choice in the appropriate cells. Cells marked with an '*' should not be edited. |
| 1 | Database management and structure: A review of source documents (for example, programming code, spreadsheet formulas, analysis plans, saved data queries, file layouts, process flows) shows that all source documents accurately capture required data fields and the SO has properly documented them. |
No data | Data Sources: | * |
| 1.a | SOs properly secured source documents and output, and have referenced data file locations correctly so that DVCs can retrieve source documents at any time to validate the information submitted to CMS via CMS systems. | No data | Review Results: | |
| 1.b | SOs clearly and adequately documented source documents. |
No data | Review Results: | |
| 1.c | SOs accurately captured required data fields including all data fields for RR in source documents. All data fields have meaningful, consistent labels (for example, label field for patient ID as Patient ID, rather than Field1 and maintain the same field name across data sets). |
No data | Review Results: | |
| 1.d | Source documents are error-free (for example, programming code and spreadsheet formulas have no messages or warnings indicating errors). |
No data | Review Results: | |
| 1.e | SOs appropriately applied version control of source documents. |
No data | Review Results: | |
| 1.f | SOs captured the appropriate date range(s) for the reporting period(s). SO reports data based on the required reporting period of 1/1 - 3/31, 4/1 - 6/30, 7/1 - 9/30, 10/1 - 12/31. |
No data | Review Results: | |
| 1.g | SOs assigned data at the applicable level (for example, plan benefit package (PBP) or contract level). | No data | Review Results: | |
| 2 | Database Extraction Function: Review of source data, preliminary data sets, and interim data sets (for example, programming code, spreadsheet formulas, analysis plans, saved data queries, file layouts, process flows) indicates the following: a. SOs accurately identify, process, and verify the population for each reporting section (including calculations for the number of enrollees, claims, grievances, procedures, etc.). They apply QA checks/thresholds to detect outlier or erroneous data. |
No data | Data Sources: | * |
| 2.a | SOs accurately identify, process, and verify the population for each reporting section (including calculations for the number of enrollees, claims, grievances, procedures, etc.). They apply QA checks/thresholds to detect outlier or erroneous data. | No data | Review Results: | |
| 3 | Organization implements policies and procedures in their final stage data sets for submission into HPMS, including the following: a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. |
No data | Data Sources: | * |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.A | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.B | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.C | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.D | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.E | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.F | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.G | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.H | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.I | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.J | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.K | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.L | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.M | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.N | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.O | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.P | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.Q | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 1.R | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.A | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.B | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.C | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.D | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.E | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.F | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.G | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.H | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.I | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.J | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.K | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.L | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.M | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.N | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.O | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.P | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.Q | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.R | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.S | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.T | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.U | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 2.V | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 3.A | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 3.B.1 | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 3.B.3 | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 3.B.4 | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 3.B.5 | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 3.B.6 | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 3.B.7 | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 3.B.8 | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 3.B.9 | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 3.B.10 | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | 3.B.11 | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.A | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.B | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.C | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.D | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.E | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.F | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.G | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.H | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.I | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.J | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.K | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.L | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.M | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.N | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.O | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.P | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.Q | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 1.R | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.A | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.B | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.C | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.D | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.E | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.F | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.G | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.H | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.I | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.J | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.K | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.L | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.M | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.N | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.O | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.P | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.Q | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.R | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.S | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.T | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.U | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 2.V | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 3.A | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 3.B.1 | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 3.B.3 | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 3.B.4 | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 3.B.5 | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 3.B.6 | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 3.B.7 | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 3.B.8 | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 3.B.9 | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 3.B.10 | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | 3.B.11 | Review Results: | |
| 4 | All source, intermediate, and final stage data sets and other outputs relied upon to enter data into CMS systems are archived. | No data | Review Results: | |
| 5 | Organization implements policies and procedures for the following: i. Periodic data system updates (for example, changes in enrollment, provider/pharmacy status, and claims adjustments). ii. Restoring data in each data system (for example, disaster recovery plan). |
No data | Review Results: | |
| 6 | If organization’s data systems underwent any changes during the reporting period (for example, because of a merger, acquisition, vendor change or upgrade): Organization provided documentation on the data system changes and, upon review, changes were implemented correctly and did not adversely impact the reported data. | No data | Review Results: | |
| 7 | If data collection and/or reporting for this reporting section is delegated to another entity: Organization regularly routinely monitors the quality and timeliness of the data collected and/or reported by the delegated entity or first tier/downstream contractor. | No data | Review Results: | |
| Medication Therapy Management (MTM) Programs (Part D) 2026 | ||||
| To determine compliance with standards, the data validation contractor will assess the following information: - Organization meets deadline for reporting annual data to CMS. - Data submitted or re-submitted to CMS via HPMS. - Written response to OAI Sections 3 and 4, and documentation requested per OAI Sections 5 and 6. - Outlier/data integrity notification(s)- See OAI 4.3.3 for instructions on how to retrieve notices. - Results from the organization’s data systems changes during the reporting period (e.g., because of a merger, acquisition, vendor change, or upgrade). - Definitions are in accordance with 42 CFR § 423.153(d) when performing calculations. - Results of interviews with organization staff. - Census or sample data. - Other relevant information provided by organization. |
||||
| Organization Name: | no data | |||
| Contract Number: | no data | |||
| Reporting Section: | Medication Therapy Management (MTM) Programs (Part D) 2026 | |||
| Last Updated: | no data | |||
| Date of Site Visit (on-site or virtual): | no data | |||
| Name of Reviewer: | no data | |||
| Name of Peer Reviewer: | no data | |||
Instructions: 1) In the "Data Sources and Review Results:" column, enter the review results and/or data sources used. 2) Enter "Y" if the requirements have been met. If any requirement has not been met, enter "N". For Standards 6 and 7, if these standards do not apply, enter "N/A". 3) Enter 'Findings' as follows based on the five-point scale: Select "1" if plan data has more than 20% error, select "2" if plan data has between 15.1% - 20.0% error, select "3" if plan data has between 10.1% - 15.0% error, select "4" if plan data has between 5.1% - 10.0% error, select "5" if plan data has less than or equal to a 5% error. Note to reviewer: If the Part D sponsor has no MTM members, then it is not required to report this data and data validation is not required for this reporting section. |
||||
| Standard / Sub-Standard ID | Standard/Sub-Standard Description | Data Elements | Data Sources and Review Results: Enter review results and/or data sources | Enter 'Findings' using the applicable choice in the appropriate cells. Cells marked with an '*' should not be edited. |
| 1 | Database management and structure: A review of source documents (for example, programming code, spreadsheet formulas, analysis plans, saved data queries, file layouts, process flows) shows that all source documents accurately capture required data fields and the SO has properly documented them. |
No data | Data Sources: | * |
| 1.a | SOs properly secured source documents and output, and have referenced data file locations correctly so that DVCs can retrieve source documents at any time to validate the information submitted to CMS via CMS systems. | No data | Review Results: | |
| 1.b | SOs clearly and adequately documented source documents. |
No data | Review Results: | |
| 1.c | SOs accurately captured required data fields including all data fields for RR in source documents. All data fields have meaningful, consistent labels (for example, label field for patient ID as Patient ID, rather than Field1 and maintain the same field name across data sets). |
No data | Review Results: | |
| 1.d | Source documents are error-free (for example, programming code and spreadsheet formulas have no messages or warnings indicating errors). |
No data | Review Results: | |
| 1.e | SOs appropriately applied version control of source documents. |
No data | Review Results: | |
| 1.f | SOs captured the appropriate date range(s) for the reporting period(s). SO reports data based on the required reporting period of 1/1 - 12/31. |
No data | Review Results: | |
| 1.g | SOs assigned data at the applicable level (for example, plan benefit package (PBP) or contract level). | No data | Review Results: | |
| 2 | Database Extraction Function: Review of source data, preliminary data sets, and interim data sets (for example, programming code, spreadsheet formulas, analysis plans, saved data queries, file layouts, process flows) indicates the following: a. SOs accurately identify, process, and verify the population for each reporting section (including calculations for the number of enrollees, claims, grievances, procedures, etc.). They apply QA checks/thresholds to detect outlier or erroneous data. |
No data | Data Sources: | * |
| 2.a | SOs accurately identify, process, and verify the population for each reporting section (including calculations for the number of enrollees, claims, grievances, procedures, etc.). They apply QA checks/thresholds to detect outlier or erroneous data. | No data | Review Results: | |
| 3 | Organization implements policies and procedures in their final stage data sets for submission into HPMS, including the following: a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. |
No data | Data Sources: | * |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | B | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | F | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | G | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | H | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | I | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | J | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | K | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | L | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | M | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | N | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | O | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | P | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | Q | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | R | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | S | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | T | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | U | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | V | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | W | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | X | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | Y | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | Z | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | B | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | F | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | G | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | H | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | I | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | J | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | K | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | L | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | M | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | N | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | O | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | P | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | Q | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | R | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | S | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | T | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | U | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | V | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | W | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | X | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | Y | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | Z | Review Results: | |
| 4 | All source, intermediate, and final stage data sets and other outputs relied upon to enter data into CMS systems are archived. | No data | Review Results: | |
| 5 | Organization implements policies and procedures for the following: i. Periodic data system updates (for example, changes in enrollment, provider/pharmacy status, and claims adjustments). ii. Restoring data in each data system (for example, disaster recovery plan). |
No data | Review Results: | |
| 6 | If organization’s data systems underwent any changes during the reporting period (for example, because of a merger, acquisition, vendor change or upgrade): Organization provided documentation on the data system changes and, upon review, changes were implemented correctly and did not adversely impact the reported data. | No data | Review Results: | |
| 7 | If data collection and/or reporting for this reporting section is delegated to another entity: Organization regularly routinely monitors the quality and timeliness of the data collected and/or reported by the delegated entity or first tier/downstream contractor. | No data | Review Results: | |
| Improving Drug Utilization Review Controls (Part D) 2026 | ||||
| To determine compliance with standards, the data validation contractor will assess the following information: - Organization meets deadline for reporting annual data to CMS. - Data submitted or re-submitted to CMS via HPMS. - Written response to OAI Sections 3 and 4, and documentation requested per OAI Sections 5 and 6. - Outlier/data integrity notification(s)- See OAI 4.3.3 for instructions on how to retrieve notices. - Results from the organization’s data systems changes during the reporting period (e.g., because of a merger, acquisition, vendor change, or upgrade). - Definitions are in accordance with 42 CFR § 423.153(c) and CMS policy guidance, FAQs, and technical guidance on opioid safety edits when performing calculations. - Results of interviews with organization staff. - Census or sample data. - Other relevant information provided by organization. |
||||
| Organization Name: | no data | |||
| Contract Number: | no data | |||
| Reporting Section: | Improving Drug Utilization Review Controls (Part D) 2026 | |||
| Last Updated: | no data | |||
| Date of Site Visit (on-site or virtual): | no data | |||
| Name of Reviewer: | no data | |||
| Name of Peer Reviewer: | no data | |||
Instructions: 1) In the "Data Sources and Review Results:" column, enter the review results and/or data sources used. 2) Enter "Y" if the requirements have been met. If any requirement has not been met, enter "N". For Standards 6 and 7, if these standards do not apply, enter "N/A". 3) Enter 'Findings' as follows based on the five-point scale: Select "1" if plan data has more than 20% error, select "2" if plan data has between 15.1% - 20.0% error, select "3" if plan data has between 10.1% - 15.0% error, select "4" if plan data has between 5.1% - 10.0% error, select "5" if plan data has less than or equal to a 5% error. |
||||
| Standard / Sub-Standard ID | Standard/Sub-Standard Description | Data Elements | Data Sources and Review Results: Enter review results and/or data sources | Enter 'Findings' using the applicable choice in the appropriate cells. Cells marked with an '*' should not be edited. |
| 1 | Database management and structure: A review of source documents (for example, programming code, spreadsheet formulas, analysis plans, saved data queries, file layouts, process flows) shows that all source documents accurately capture required data fields and the SO has properly documented them. |
No data | Data Sources: | * |
| 1.a | SOs properly secured source documents and output, and have referenced data file locations correctly so that DVCs can retrieve source documents at any time to validate the information submitted to CMS via CMS systems. | No data | Review Results: | |
| 1.b | SOs clearly and adequately documented source documents. |
No data | Review Results: | |
| 1.c | SOs accurately captured required data fields including all data fields for RR in source documents. All data fields have meaningful, consistent labels (for example, label field for patient ID as Patient ID, rather than Field1 and maintain the same field name across data sets). |
No data | Review Results: | |
| 1.d | Source documents are error-free (for example, programming code and spreadsheet formulas have no messages or warnings indicating errors). |
No data | Review Results: | |
| 1.e | SOs appropriately applied version control of source documents. |
No data | Review Results: | |
| 1.f | SOs captured the appropriate date range(s) for the reporting period(s). SO reports data based on the required reporting period of 1/1 - 3/31, 1/1 - 6/30, 1/1 - 9/30, 1/1 - 12/31. |
No data | Review Results: | |
| 1.g | SOs assigned data at the applicable level (for example, plan benefit package (PBP) or contract level). | No data | Review Results: | |
| 2 | Database Extraction Function: Review of source data, preliminary data sets, and interim data sets (for example, programming code, spreadsheet formulas, analysis plans, saved data queries, file layouts, process flows) indicates the following: a. SOs accurately identify, process, and verify the population for each reporting section (including calculations for the number of enrollees, claims, grievances, procedures, etc.). They apply QA checks/thresholds to detect outlier or erroneous data. |
No data | Data Sources: | * |
| 2.a | SOs accurately identify, process, and verify the population for each reporting section (including calculations for the number of enrollees, claims, grievances, procedures, etc.). They apply QA checks/thresholds to detect outlier or erroneous data. | No data | Review Results: | |
| 3 | Organization implements policies and procedures in their final stage data sets for submission into HPMS, including the following: a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. |
No data | Data Sources: | * |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | A | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | B | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | C | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | D | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | E | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | F | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | G | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | H | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | I | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | J | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | K | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | L | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | M | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | N | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | O | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | P | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | Q | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | R | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | S | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | T | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | U | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | V | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | W | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | X | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | Y | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | Z | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | AA | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | BB | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | CC | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | DD | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | EE | Review Results: | |
| 3.a | a. Expected counts - Data elements are valid, complete, and accurate according to the source document that SOs use to upload/enter data into the HPMS; ranges of data fields are verified; all calculations (for example, derived data fields) are verified; they properly address missing data; reporting output matches corresponding source documents (for example, programming code, saved queries, analysis plans); they appropriately apply version control of reported data elements. | FF | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | A | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | B | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | C | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | D | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | E | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | F | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | G | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | H | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | I | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | J | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | K | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | L | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | M | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | N | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | O | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | P | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | Q | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | R | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | S | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | T | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | U | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | V | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | W | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | X | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | Y | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | Z | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | AA | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | BB | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | CC | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | DD | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | EE | Review Results: | |
| 3.b | b. Organization accurately captures data by applying data integrity/logical checks; they apply QA checks/thresholds to detect outlier or erroneous data. | FF | Review Results: | |
| 4 | All source, intermediate, and final stage data sets and other outputs relied upon to enter data into CMS systems are archived. | No data | Review Results: | |
| 5 | Organization implements policies and procedures for the following: i. Periodic data system updates (for example, changes in enrollment, provider/pharmacy status, and claims adjustments). ii. Restoring data in each data system (for example, disaster recovery plan). |
No data | Review Results: | |
| 6 | If organization’s data systems underwent any changes during the reporting period (for example, because of a merger, acquisition, vendor change or upgrade): Organization provided documentation on the data system changes and, upon review, changes were implemented correctly and did not adversely impact the reported data. | No data | Review Results: | |
| 7 | If data collection and/or reporting for this reporting section is delegated to another entity: Organization regularly routinely monitors the quality and timeliness of the data collected and/or reported by the delegated entity or first tier/downstream contractor. | No data | Review Results: | |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |