Universe Reference · Part of the CMS Program Audit Guide
The ODAG Universe: Tables, Timeliness Standards, and Failure Modes
ODAG (Organization Determinations, Appeals, and Grievances) is the Part C protocol in a CMS Program Audit. This page is the working reference: what each table captures, the deadlines CMS tests against, and the errors that produce findings.
What ODAG Covers
ODAG traces the lifecycle of a member's interaction with the plan: a request for a service, the plan's decision, the appeal if denied, the payment request if the service already happened, the effectuation if approved, and the grievance process that runs alongside all of it. CMS pulls the universes, tests timeliness at the universe level (every case, not a sample), and samples cases for file review.
Two tables that existed in earlier protocol versions, AIP (Dual SNP benefit reductions) and CARA At-Risk Determinations (AR), are not routinely collected and are submitted only when CMS instructs the sponsor to do so.
The Five ODAG Tables
OD
Organization DeterminationsEvery pre-service request, Part B drug request, and other organization determination processed during the audit review period. The foundation table.
RECON
ReconsiderationsFirst-level appeals of denied or partially denied organization determinations. Each case must trace back to a parent OD.
PYMT_C
Payment DeterminationsRequests for payment of services already received. Usually sourced from the claims system rather than the UM platform.
EFF_C
EffectuationsEvidence that favorable and partially favorable decisions were actually carried out, and on time.
GRV_C
GrievancesComplaints about quality, access, and service. A separate process from determinations and appeals, with no appeal rights.
Timeliness Standards CMS Tests Against
Timeliness runs from when a request is received from any source (member, provider, or pharmacy), not from when it reaches the responsible department. Extensions of up to 14 additional days are available for some determination types with proper documentation.
| Case Type | Standard |
|---|---|
| Standard pre-service organization determination | 14 calendar days from receipt |
| Expedited organization determination | 72 hours from receipt |
| Part B drug request | 72 hours standard, 24 hours expedited |
| Payment determination (clean claim) | 60 calendar days (42 CFR 422.568) |
| Standard reconsideration | 30 calendar days |
| Expedited reconsideration | 72 hours |
| Effectuation of a reversed standard OD | 72 hours |
| Effectuation of a reversed expedited OD | 24 hours |
| Effectuation of a favorable reconsideration | 72 hours from the decision |
| Standard grievance | 30 days |
| Expedited quality of care grievance | 24 hours |
Where ODAG Universes Fail
- •Receipt dates measured from the wrong point. If a provider faxes a request on Monday and intake logs it Wednesday, Monday is the receipt date. Systematic errors here inflate timeliness rates, and auditors catch them during case file review.
- •Missing time stamps on expedited cases. A 72-hour or 24-hour standard cannot be tested from a date alone. Missing times make timeliness uncomputable, which is an IDS trigger.
- •Cross-table inconsistencies. Reconsiderations without a parent OD, favorable decisions without matching effectuations, MBIs that differ across tables sourced from different systems, and tables covering mismatched date ranges.
- •Grievance misclassification. A complaint about a denied service is usually an appeal, not a grievance. Routing it to the wrong queue creates compliance problems in both universes.
- •Missing delegated entity data. Cases processed by TPAs and vendors belong in the universe. CMS holds the plan accountable for delegate data quality.
- •Format-level errors. Dates not in CCYY/MM/DD, MBIs that break the 11-character structure, headers that deviate from the CMS-10717 record layout, and hidden characters introduced by Excel.
Go Deeper
- •The ODAG universe, table by table covers each table's fields, the mistakes we see most, and pre-submission checks in full detail.
- •Invalid Data Submission in 2026 explains the three-attempt mechanics and why data quality is now a standalone failure mode.
- •The free Universe Header Check tool validates your ODAG file headers against the current CMS spec in your browser.
Frequently Asked Questions
Who is subject to an ODAG audit?
Any Medicare Advantage organization selected for a CMS Program Audit can be audited under ODAG, and it is one of the most frequently included protocols. It covers the plan’s Part C organization determinations, appeals, payment requests, effectuations, and grievances, including cases processed by delegated entities on the plan’s behalf.
What is the difference between ODAG and CDAG?
ODAG covers Part C (medical services and Part B drugs); CDAG covers Part D (prescription drugs). The structures are parallel but the clocks differ sharply: a standard organization determination gets 14 calendar days under ODAG, while a standard Part D coverage determination gets 72 hours under CDAG. The appeal stage is called a reconsideration in ODAG and a redetermination in CDAG.
How long does a plan have to submit ODAG universes?
Universes are due 15 business days from the engagement letter. CMS allows up to three submission attempts per universe; files that still fail integrity testing after the third attempt can be cited as an Invalid Data Submission (IDS) for each element CMS could not test.
What happens when a reconsideration misses its deadline?
Untimely reconsiderations must be auto-forwarded to the Independent Review Entity (IRE). The universe has to show that the forwarding happened and when. Missed deadlines with no evidence of IRE forwarding are a direct compliance failure that auditors check for specifically.
Validate Your ODAG Universe Before CMS Does
The CMS Universe Scrubber checks all five ODAG tables against the CMS record layouts: formats, timeliness logic, and cross-table consistency.