Universe Reference · Part of the CMS Program Audit Guide
The CDAG Universe: Tables, Timeliness Standards, and Failure Modes
CDAG (Coverage Determinations, Appeals, and Grievances) is the Part D protocol in a CMS Program Audit. It looks like ODAG on the surface, but the clocks are tighter, the case types are different, and the data almost always comes from a PBM.
What CDAG Covers
CDAG traces how the plan handles requests for Part D drugs: the coverage determination or exception request, the redetermination if denied, the reimbursement request if the member paid cash, the effectuation if approved, and the grievance process alongside. Part D uses its own vocabulary: what ODAG calls a reconsideration is a redetermination here.
The compressed timeframes are the defining feature. A 72-hour standard window means a request received Friday afternoon is due Monday afternoon, and a 24-hour expedited window means weekends count. Small delays in receipt logging blow timeliness in a way ODAG's 14-day standard rarely does.
The Six CDAG Tables
CD
Coverage DeterminationsPrior authorization requests, B vs. D coverage decisions, and other standard coverage determinations, whether initiated by the member, the prescriber, or the pharmacy at point of sale.
CDER
Exception RequestsTier, formulary, step therapy, and quantity limit exceptions. A separate table because every exception requires a prescriber’s supporting statement.
PYMT_D
Payment DeterminationsMember requests for reimbursement of Part D drugs already paid for out of pocket. Usually assembled from a separate source feed.
RD
RedeterminationsFirst-level Part D appeals of denied CDs, exception requests, or payment determinations. Each case must link back to its parent determination.
EFF_D
EffectuationsEvidence that approved drugs became available to fill and approved reimbursements were paid, on the required clocks.
GRV_D
GrievancesComplaints about pharmacy access, customer service, mail order, and other Part D experience issues. Distinct from the coverage determination process.
Timeliness Standards CMS Tests Against
All clocks run in calendar time from receipt of the request from any source, including pharmacy point-of-sale rejections when the member is at the counter.
| Case Type | Standard |
|---|---|
| Standard coverage determination | 72 hours from receipt |
| Expedited coverage determination | 24 hours from receipt |
| Exception request (CDER) | Same clocks as CD: 72 hours standard, 24 hours expedited |
| Payment determination | 14 calendar days (42 CFR 423.568) |
| Standard redetermination | 7 calendar days |
| Expedited redetermination | 72 hours |
| Effectuation of a reversed standard CD | 72 hours |
| Effectuation of a reversed expedited CD | 24 hours |
| Effectuation of a favorable redetermination | 72 hours |
| Effectuation of an IRE-favorable decision | 72 hours from notification |
| Payment effectuations | 30 days |
| Standard grievance | 30 days |
| Expedited quality of care grievance | 24 hours |
Where CDAG Universes Fail
- •Pharmacy point-of-sale rejections never become CDs. When a claim rejects for a coverage reason with the member at the counter, the coverage determination clock can start. Plans that only count formal intake channels understate the CD universe, and CMS finds the gap by comparing FA rejected claims against CDAG.
- •PBM categories that do not map to CMS values. Internal disposition codes and case types that were never reconciled against the CMS allowed values, including tier exceptions coded as formulary exceptions inside CDER.
- •Effectuations that exist on paper only. The UM platform marks the case approved, but the PBM adjudication override posts hours or days later. CMS pulls claim history during case review, and the gap between the recorded effectuation date and the first clean fill is where findings emerge.
- •The 7-day redetermination trap. Seven calendar days usually includes a weekend. Manual hand-offs between intake, clinical review, and notification routinely consume the margin, and untimely cases that are not auto-forwarded to the IRE compound the finding.
- •Case IDs that do not carry forward. If the PBM assigns a new ID at the appeal stage, redeterminations float with no parent record, which is a cross-table consistency failure.
- •Format-level errors. NDCs truncated or dashed, missing prescriber NPIs, dates not in CCYY/MM/DD, MBIs inconsistent with the FA universe, and missing time stamps on expedited cases.
Go Deeper
- •The CDAG universe, table by table covers each table's fields, the PBM delegation patterns, and pre-submission checks in full detail.
- •The FA universe reference covers the point-of-sale side of the same prescriptions. CMS reads the two protocols together.
- •The free Universe Header Check tool validates your CDAG file headers against the current CMS spec in your browser.
Frequently Asked Questions
If the PBM produces the CDAG universe, is the plan covered?
No. CMS holds the sponsor accountable for the data regardless of who produced it. PBM disposition codes that do not match CMS allowed values, sub-delegate cases missing from the extract, and plan-handled cases that never flow back into the PBM file are all common findings. The PBM’s file should be treated as input to validation, not as a finished submission.
Why are exception requests a separate table from coverage determinations?
Exception requests (tier, formulary, step therapy, and quantity limit exceptions) validate against different criteria: each requires a prescriber’s supporting statement, and fields like requested tier versus approved tier have to tell a coherent story. CMS collects them in their own table, CDER, so plans whose systems do not distinguish exception cases internally have to reconstruct the split, which is where classification errors get introduced.
What timeframes apply to Part D coverage determinations?
Standard coverage determinations are due within 72 hours of receipt and expedited determinations within 24 hours. The clocks run on calendar time: a standard request received Friday at 4pm is due Monday at 4pm. Redeterminations get 7 calendar days standard or 72 hours expedited, and untimely appeals must be auto-forwarded to the Independent Review Entity.
How does CMS check whether a CDAG universe is complete?
Auditors cross-reference. Pharmacy point-of-sale rejections in the FA universe should generally have corresponding coverage determinations in CDAG when the member was at the counter, every redetermination should trace to a parent case, and every favorable outcome should have an effectuation. Large mismatches between related tables signal missing cases.
Validate Your CDAG Universe Before CMS Does
The CMS Universe Scrubber checks all six CDAG tables against the CMS record layouts: formats, timeliness logic, disposition code mapping, and cross-table consistency against FA.