Organization: _________________________________ Date: _____________
Prepared by: _________________________________ Review Date: _________
1. File Submission & Validation
- CDAG (Coverage Determinations, Appeals, and Grievances) files validated before submission
- ODAG (Organization Determinations, Appeals, and Grievances) files checked for completeness
- FA (Formulary Administration) files reviewed for accuracy
- SNPCC (Special Needs Plan Care Coordination) files prepared per CMS guidelines
- All date formats match CMS requirements (CCYY/MM/DD)
- File naming conventions follow CMS standards
- Submission deadlines documented and tracked
2. Data Integrity & Quality
- Member ID validation completed
- Contract numbers verified against CMS records
- Duplicate record check performed
- Required fields populated (no null values where prohibited)
- Data type validation (numeric, alphanumeric, dates)
- Field length requirements met
- Cross-file consistency verified
3. Regulatory Requirements
- Current year CMS Technical Specifications reviewed
- HPMS (Health Plan Management System) user access current
- Compliance officer designated and trained
- Audit protocols documented
- Corrective Action Plans (CAPs) from previous audits addressed
- Universe submission deadlines calendar maintained
4. Documentation & Record Keeping
- File submission confirmation receipts saved
- Error reports from CMS documented and addressed
- Data source documentation maintained
- Processing logic documented
- Change log for data modifications kept
- Audit trail for all submissions preserved
5. Pre-Submission Review
- Test files validated in CMS test environment
- Record counts reconciled
- Business rules validation completed
- Peer review performed
- Management approval obtained
- Backup files created and stored securely
6. Post-Submission Follow-up
- CMS acceptance confirmation received
- Error reports reviewed if rejection occurs
- Resubmission completed within required timeframe
- Internal stakeholders notified of submission status
- Lessons learned documented for next submission
7. Ongoing Monitoring
- Monthly data quality reviews scheduled
- CMS bulletin updates monitored
- Staff training on updates completed
- Process improvement initiatives tracked
- Compliance metrics dashboard maintained