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Common - UC 16: Universe and Operational reports

Updated on January 31, 2022

All through case workflow, the system captures data and publishes them for some of out of box reports. There are two sets of reports – Universe and Operational reports.

Pega Foundation for Healthcare
  • Universe reports: - List of standard CMS ODAG (Organization Determination, Appeals, Grievances) and CDAG (Coverage Determination, Appeals, Grievances) universe reports
    CMS Part D Coverage Determination Appeals & Grievances (CDAG) Universe ReportsCMS Part C Organization Determination Appeals & Grievances (ODAG) Universe Reports
    Standard Coverage Determinations (SCD)Standard Pre-service Organization Determinations (SOD)
    Standard Coverage Determination Exception Requests (SCDER)Expedited Pre-service Organization Determinations (EOD)

    Direct Member Reimbursement Request

    Coverage Determination (DMRCD)

    Requests for Payment Organization Determinations


    Expedited Coverage Determinations (ECD)Direct Member Reimbursement (DMR) Requests
    Expedited Coverage Determinations Exception Requests (ECDER)Standard Pre-service Reconsiderations (SREC)
    Standard Redeterminations (SRD)Expedited Pre-service Reconsiderations (EREC)
    Direct Member Reimbursement Request Redeterminations (DMRRD)Requests for Payment Reconsiderations (PREC)
    Expedited Redeterminations (ERD)Pre-service IRE Cases Requiring Effectuation (IREEFF)
    Standard IRE, ALJ, or MAC Determinations (SIAM)IRE Payment Cases Requiring Effectuation (IREClaimsEFF)
    Direct Member Reimbursements decided by review entity other than sponsor (DMRRE)Part C ALJ and MAC Cases Requiring Effectuation (ALJMACEFF)
    Expedited IRE, ALJ or MAC Determinations (EIAM)Part C Oral & Written Standard Grievances (GRV_S)
    Standard Grievances Part D (SGD)Part C Oral & Written Expedited Grievances (GRV_E)
    Expedited Grievances Part D (EGD)Dismissals Record Layout

  • Operational reports: - List of reports on the workflow process
    • Detailed Complaint Inventory
    • Appeal Inventory Summary
    • Grievance Inventory Summary
    • Open Cases Report
    • Late Case Report
    • Case closure and Inventory details report
    • Processed case counts

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