Three reporting sections were updated to include additional data elements. Reporting Section # 6 (Organization Determinations/Reconsiderations), The dues dates for Grievances and Employer Group Plan Sponsors were also changed to the first Monday in February. Reporting Section #13 (Special Needs Plans Care Management), and Reporting Section #14 (Enrollments/Dis-enrollments) The due dates for Enrollment/Disenrollment were changed to last Monday of August and February.

1. CMS Medicare Part C
Plan Reporting Requirement Changes
April 22nd Updates
www.inovaare.com
June 23, 2016, 11:00 am – 11:30 am PST
Sponsored by
WEBINAR

2. Today’s Speaker – Gabriel Viola
• 31 Years of experience in Healthcare Operations
o Government Programs (MEDICAID, MAPD, PDP)
o Commercial Large Accounts
o Small Group and Individual plans
• Past 12 years focused in Medicare
o Enrollments, Claims, Customer Service, Delegated Oversight,
Appeals and Grievances, and Compliance
• Key Accomplishments
o Moved from 3 to 4-Star rating and maintenance for 3 years.
o Achieved a 100% score in the CMS Validation Audit for ODAG
and CDAG in 2014
o Achieved the highest Audit Rating from CMS on the OEV process
for 2014

3. • What reports are Suspended
• No Longer required
• Summary of the Major changes from 2015
• CMS 2016 Part C Reporting changes
• General discussion affecting Appeals and Grievances (A&G) process
• Review of the additional guidance provided by CMS
• Make sure the math adds up
Discussion Topics

4. What Reports are Suspended

5. • Reporting sections…
o # 1 - Benefit Utilization
o # 2 - Procedure Frequency
o # 3 - Serious Reportable Adverse Events
o # 4 - Provider Network Adequacy
o #10 - Agent Compensation Structure
o #11 - Agent Training and Testing
What Reports are Suspended

6. Summary of Major Report Changes
• Three reporting sections were updated to include additional data elements.
o Reporting Section # 6 (Organization Determinations/Reconsiderations),
The dues dates for Grievances and Employer Group Plan Sponsors were also changed
to the first Monday in February.
o Reporting Section #13 (Special Needs Plans Care Management), and
o Reporting Section #14 (Enrollments/Dis-enrollments)
The due dates for Enrollment/Disenrollment were changed to last Monday of August
and February.

7. Summary of Major Report Changes
• In addition three new reporting sections were added:
o Rewards and Incentives Programs,
o Mid-Year Network Changes, and
o Payments to Providers. Reporting
• Section # 12 Plan Oversight of Agents was changed to
“Sponsor Oversight of Agents”
The data due date was changed to the first Monday in February of the following
year.

8. Part C Report Changes Affecting
Appeals and Grievances (A&G) Process

9. Part C Reporting Changes for A&G - Definitions
Let First Review a few of the Reporting Rules and
definitions:
• A grievance is defined in the CMS Managed Care
Manual as “Any complaint or dispute, other than
an organization determination, expressing
dissatisfaction with the manner in which a
Medicare health plan or delegated entity provides
health care services.”
• Part C reporting, grievances are defined as those
grievances completed during the reporting period.

10. • Only those grievances processed in accordance with
the grievance procedures outlined in 42 CFR Part 422,
Subpart M (i.e., Part C grievances).
• Report grievances involving multiple issues under
each applicable category.
• Report grievances if the member is ineligible on the
date of the complaint or notification to the plan but
was eligible on the date the incident occurred.
Part C Reporting Changes for A&G – Must Report

11. Part C Reporting Changes for A&G – Do Not Report

12. • Now due on the Last Monday of
February of the following year still
requires a breakdown by quarter
• Two new data elements have been
added:
o #6.10, Number of Requests for
Organization Determinations—Dismissals
o #6.20, Number of Requests for
Reconsiderations—Dismissals
Organization Determinations / Reconsiderations
Reporting

13. A dismissal is an action taken when an organization determination or
reconsideration request lacks required information or otherwise does not meet
CMS requirements to be considered a valid request.
The most common reasons for a Medicare plan’s dismissal are:
Lack of proper appointment of representative
Failure of the enrollee or other party to file a timely appeal request
No waiver of liability submitted with an appeal filed by a non-contract provider
Failure to exhaust the prior level of adjudication
Organization Determinations / Reconsiderations
Reporting – Dismissal

14. Organization Determinations/Reconsiderations Reporting must Report:
Completed Org Determinations. & Reconsiderations
All Part B drug claims processed & paid by PBM are reported as org. determinations or reconsiderations.
Re-openings across multiple reporting periods are reported in each applicable reporting period.
Claims with multiple line items at the “summary level.”
A request for payment as a separate and distinct org determination, even if a pre-service request for that same
item or service was also processed.
A denial of a Medicare request for coverage of an item or service as either partially favorable or adverse,
Report denials based on exhaustion of Medicare benefits.
In cases where an extension is requested after the required decision making timeframe has elapsed, the plan is
to report the decision as non-timely.
Dismissals
Organization Determinations / Reconsiderations
Reporting – Must Report

15. • Independent Review Entity (IRE) decisions.
• Re-openings requested or completed by the IRE, Administrative Law Judge (ALJ), and
Medicare Administrative Contractor (MAC).
• Concurrent reviews during
o Concurrent hospitalization
o review of Skilled Nursing Facility (SNF)
o Home Health Agency (HHA) or
o Comprehensive Outpatient Rehabilitation Facility CORF care
• Duplicate payment requests concerning the same service or item.
• Payment requests returned to a provider/supplier in which a substantive decision (fully
favorable, partially favorable or adverse) has not been made.
• Enrollee complaints only made through the CMS Complaints Tracking Module (CTM).
Organization Determinations / Reconsiderations
Reporting – Do Not Report

16. Review of Additional Guidance
Provided by CMS

17. Additional Guidance

18. About Inovaare

19. Confidential: Internal use only

20. • Offers highly configurable software solutions exclusively for the healthcare industry.
• Inovaare solutions are built on a flexible and integrated platform that supports
application areas including risk assessment, internal control, Internal audit,
compliance management and incident management.
• Compliance and Quality Management System (CQMS) is a unified platform to plan
and manage compliance and quality requirements.
• Users of CQMS platform have the option of building their own application or,
choosing from among ready-to-go solutions from Inovaare, when quick
implementation is required.
• Inovaare’s A&G software provides a powerful business improvement solution that
reduces cost and effort needed to proactively manage risk, quality, and
sustainability.
Inovaare – A leader in Compliance and A&G Software

22. Question & Answer

24. 24
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If you would like to obtain additional information or are interested in discussing how Inovaare can help you with your
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