Medicare Advantage Compliance Glossary
Plain-English definitions for the terms MA and Part D compliance teams live with, from audit classifications to universe tables, each linked to a deeper guide where we have one.
Ad Hoc CAP
A corrective action plan CMS requests outside a formal program audit, typically through account management, to address a specific compliance issue. Distinct from the corrective actions that follow audit findings classified as CAR.
AIP (Applicable Integrated Plan Reductions, Suspensions and Terminations)
ODAG Table 6, covering D-SNP applicable integrated plan reductions, suspensions, and terminations. Not routinely collected in a program audit; CMS requests it only when applicable.
CAR (Corrective Action Required)
One of the three classifications for CMS Program Audit findings under the 2026 framework: a finding of noncompliance that requires a corrective action plan and follow-up validation. The CAR classification exists only within a formal program audit. See the CMS Program Audit guide.
CARA At-Risk Determination (AR)
ODAG Table 7, covering at-risk determinations made under drug management programs established by the Comprehensive Addiction and Recovery Act. Not routinely collected; submitted only on CMS instruction.
CDAG (Coverage Determinations, Appeals, and Grievances)
The Part D program audit protocol. Six routinely submitted tables: Coverage Determinations (CD), Exception Requests (CDER), Payment Determinations (PYMT_D), Redeterminations (RD), Effectuations (EFF_D), and Grievances (GRV_D). See the CDAG universe guide.
CDER (Coverage Determination Exception Requests)
CDAG Table 2: tier, formulary, step therapy, and quantity limit exceptions. Tracked in a separate table from standard coverage determinations because each exception requires a prescriber's supporting statement.
CMP (Civil Money Penalty)
A monetary enforcement action CMS can impose on a sponsor. CMPs sit on the enforcement track, handled by CMS's enforcement function, rather than the routine compliance-action track handled through account management.
CMS-10717
The OMB-approved form under which CMS publishes its Program Audit protocols and the field-level universe record layout specifications. Sevana's platform translates those specs into 1,600+ discrete validation rules.
COA (Compliance Oversight Activities)
The universe within the CPE protocol: a listing of the sponsor's auditing, monitoring, and investigation activities during the review period. Under the 2026 discussion-based CPE approach, the COA universe is effectively the agenda for the conversation with auditors. See the CPE COA universe guide.
"Collaborating on Compliance"
Industry shorthand, not an official CMS program name, for the discussion-based CPE review pilot introduced in CMS's November 2025 Program Audit memo. CPE evaluation moved out of its own session and into fieldwork as a conversation grounded in the sponsor's COA universe.
Compliance Actions
The non-enforcement steps CMS takes on identified issues, typically through account management and the regional offices: notices of non-compliance, warning letters, and ad hoc corrective action plans. Distinct from enforcement actions.
Compliance Program (Seven Elements)
The effective compliance program every MA organization must adopt under 42 CFR 422.503(b)(4)(vi), with a Part D counterpart at 423.504(b)(4)(vi): written policies and standards of conduct, a compliance officer and committee, training, effective lines of communication, well-publicized disciplinary standards, routine monitoring and auditing, and prompt response to issues. See CMS compliance requirements.
Concurrent DUR (Drug Utilization Review)
Review of prescribed drug therapy performed before each prescription is dispensed, typically at the point of sale, required at 42 CFR 423.153(c)(2). CMS's opioid safety edits operate within the concurrent DUR framework.
Coverage Determination (CD)
A Part D sponsor's decision about whether and how a drug is covered for a member, including prior authorization decisions. CDAG Table 1. The Part C equivalent is the organization determination.
CPE (Compliance Program Effectiveness)
The program audit protocol that evaluates whether the sponsor's compliance program actually operates as required. One universe: COA. Under the 2026 approach, CPE runs as a discussion-based review during fieldwork.
Effectuation (EFF_C / EFF_D)
Carrying out a favorable decision: authorizing the service, paying the claim, or covering the drug after an approval or an overturned appeal, within required timeframes. The effectuation universes are cross-checked against appeal outcomes, and overturned decisions with no matching effectuation are a classic audit finding.
Enforcement Actions
The escalated track for serious or systemic noncompliance, handled by CMS's enforcement function (currently the Medicare Oversight and Enforcement Group): civil money penalties, intermediate sanctions, and contract termination.
Engagement Letter
The formal notice from CMS that begins a program audit. The submission clocks run from it: universes are due 15 business days out, and several supplemental questionnaires are due in 5. See the 30-day playbook.
FA (Formulary Administration)
The Part D program audit protocol testing whether the formulary administered at the pharmacy counter matches what CMS approved. Routine submissions: Rejected Claims Formulary Administration (RCFA), Rejected Claims Transition (RCT), and New Enrollees (NE). PDE data is collected only on CMS instruction. See the FA universe guide.
FDR (First Tier, Downstream, and Related Entities)
The contractors and subcontractors that perform functions on a sponsor's behalf, such as PBMs and TPAs. The sponsor remains accountable for delegated work under the contracting requirements at 42 CFR 422.504(i), and the compliance program must extend to FDRs.
Fieldwork
The live phase of a program audit, roughly two weeks of webinars in which auditors walk samples from the universes with the plan's operational teams. Under the 2026 approach, the discussion-based CPE review happens during fieldwork.
Grievance (GRV_C / GRV_D)
A member complaint about anything other than a coverage decision: access, quality, customer service, plan operations. Grievances are distinct from appeals and are tracked in their own ODAG and CDAG tables. Misclassifying grievances as inquiries is a recurring audit issue.
HPMS (Health Plan Management System)
CMS's web-based system for plan operations: guidance distribution, data submissions, formulary and edit submissions, and audit communications all flow through it.
HPMS Memo
Guidance and operational notices CMS distributes to sponsors through HPMS, week after week. Each memo carries the same unstated question: what does this change for us? See the Friday afternoon HPMS memo.
HRA (Health Risk Assessment)
The assessment Special Needs Plans must complete for each enrollee: initially within 90 days before or after the enrollment effective date under 42 CFR 422.101(f), then annually, with the annual clock measured from the prior HRA rather than the enrollment date. Building the SNPCC universe off the wrong clock is a classic error. See the SNPCC guide.
ICAR / ORCA
The pre-2026 program audit classifications, retired by CMS's November 2025 Program Audit memo along with audit scoring. Findings are now classified as CAR, Observation, or IDS. See the 2026 audit changes.
IDS (Invalid Data Submission)
The audit classification cited when a sponsor cannot produce an accurate, complete universe, including after three failed submission attempts. IDS made data quality a standalone failure mode. See IDS in 2026.
Intermediate Sanctions
Enforcement actions short of contract termination, such as suspension of enrollment or marketing. Handled on the enforcement track alongside CMPs.
IRE (Independent Review Entity)
The CMS contractor that conducts second-level appeal reviews. Decisions overturned by the IRE (or at higher levels) route back to the plan for effectuation, which the EFF universes test.
MBI (Medicare Beneficiary Identifier)
The 11-character identifier for Medicare beneficiaries, used throughout universe files. Format and validity errors in MBI fields are among the most common universe validation failures.
MOC (Model of Care)
The care framework every Special Needs Plan must maintain, describing how the plan coordinates care for its population. Approved MOCs are a supplemental submission in the SNPCC protocol.
NONC (Notice of Non-Compliance)
The lowest-severity compliance action CMS issues for an identified issue, ahead of a warning letter or an ad hoc CAP on the compliance-action ladder.
Observation
An audit finding of noncompliance that does not require a corrective action plan. The sponsor is expected to monitor and address it through routine operations.
ODAG (Organization Determinations, Appeals, and Grievances)
The Part C program audit protocol. Five routinely submitted tables: Organization Determinations (OD), Reconsiderations (RECON), Payment Determinations (PYMT_C), Effectuations (EFF_C), and Grievances (GRV_C). See the ODAG universe guide.
Organization Determination (OD)
A Part C plan's decision on a request for a service or payment, on standard or expedited timeframes. ODAG Table 1. The Part D equivalent is the coverage determination.
PDE (Prescription Drug Event)
Record-level data on Part D drug claims. In the program audit context, PDE data (FA Table 3) is not routinely collected; CMS requests it only when instructed. Do not treat it as a routine FA submission.
Program Audit
CMS's formal evaluation of how a sponsor actually operates, run by pulling universes of real cases across five protocol areas and sampling from them. See the complete CMS Program Audit guide.
RCFA / RCT (Rejected Claims Formulary Administration / Rejected Claims Transition)
FA Tables 1 and 2: pharmacy claims rejected for formulary reasons, and rejected claims implicating transition fill rights. Together they test whether members experienced the formulary CMS approved.
Reconsideration (RECON)
The Part C first-level appeal of an adverse organization determination. ODAG Table 2. The Part D equivalent is the redetermination.
Record Layout
The field-level specification for each universe table: column order, formats (dates in CCYY/MM/DD), allowed values, and inclusion rules. Published through CMS-10717. Building files against an outdated layout is a leading cause of failed submissions.
Redetermination (RD)
The Part D first-level appeal of an adverse coverage determination. CDAG Table 4.
SNPCC (Special Needs Plans Care Coordination)
The program audit protocol for Special Needs Plans, centered on health risk assessments and care plans. One universe table, SNP Enrollees (SNPE), plus supplemental submissions: approved Models of Care and the SNPCC Questionnaire. See the SNPCC guide.
Transition Fill
The temporary supply of a non-formulary drug that Part D sponsors must provide in qualifying situations, such as new enrollees stabilized on a drug the new plan does not cover. Tested through the RCT table in the FA protocol.
Universe
A structured data file listing every case a plan handled in a category during the audit review period, built to CMS's record layouts. Auditors sample from universes to trace how real members were handled. The term is CMS's, defined by its audit protocols.
Universe Scrubber
Software that validates universe files against CMS's record layout specifications before submission: structure, formats, timeliness logic, cross-table consistency, and completeness. See what a CMS universe scrubber is.
Missing a term?
This glossary grows as our guides do. Start with the complete CMS Program Audit guide or tell us what to add.