The Centers for Medicare & Medicaid Services (CMS) has finalized the Medicare Part C Utilization Management Annual Data Submission (CMS-10913) and published the approved data collection tool. This memo explains what was finalized (and what wasn’t) and how Medicare Advantage (MA) organizations should prepare to submit the required data.
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TL;DR — The essentials
CMS finalized an annual submission for utilization management (UM) data, but narrowed the scope: CMS will collect internal coverage criteria that apply to Medicare Part C services (including Medicare Part B drugs) that require prior authorization. It will not collect criteria used exclusively in concurrent reviews or payment reviews.
CMS did not finalize the proposed audit protocol or audit tools (they were removed after review of comments). CMS may still incorporate review of internal coverage criteria into future program audits.
Submission timing: MA organizations must submit via HPMS annually by February 28 each year — but for calendar year 2026, CMS extended the deadline to April 30, 2026 to give plans time to prepare.
Help is coming: CMS will issue technical guidance on how to submit in HPMS and will respond to plan questions via a dedicated mailbox. CMS may hold an industry call or publish a Q&A summary if many similar questions arise. Questions can be sent to CMS_PartC_UM_Audits@cms.hhs.gov.
Why this matters
This is the first finalized, recurring annual collection of UM internal coverage criteria for MA plans — it increases transparency into how plans apply prior authorization for Part C services and Part B drugs.
Even though the audit protocol wasn’t finalized, CMS’ yearly collection creates a new compliance milestone and will require operational coordination across clinical, compliance, and IT teams.
What CMS will (and won’t) collect
Will collect
Internal coverage criteria that apply to Medicare Part C services, including Medicare Part B drugs, that require prior authorization.
Will NOT collect
Criteria used only for concurrent reviews or payment reviews.
The previously proposed audit protocol and audit tools were removed from the final package.
Practical next steps — an action plan (ready-to-use checklist)
Use this as your internal playbook. Assume you’ll need to submit by April 30, 2026 for the first year (then Feb 28 annually).
Immediate (this week)
Notify stakeholders (Compliance, Medical Affairs, UM operations, IT, Data) and assign a submission owner.
Create a project folder (secure) labeled “CMS UM Annual Submission — CY2026”.
0–30 days
Inventory all UM rules that impose prior authorization for Part C services and Part B drugs. Export decision logic, effective dates, affected service codes, and any accompanying clinical rationale.
Document owners for each rule (who can explain/defend the clinical criteria).
30–60 days
Map each rule to data fields you’ll likely need for HPMS (service name, CPT/HCPCS/DRG or drug NDC info, rule effective date, clinical criteria summary).
QA the inventory — sample 10–20 rules with clinical SMEs to ensure accuracy.
60–90 days
Build a transfer-ready file (spreadsheet or database export) with clean field names and version history. Don’t finalize until CMS issues technical guidance — but the hard work of collecting and validating content should be done.
Plan for HPMS upload: identify who has HPMS access and confirm permissions.
Ongoing / Pre-submission
Monitor CMS guidance and the Part C UM Annual Data Submission webpage for templates, crosswalks, and FAQs.
Information You Need to Get Started
To prepare for the CMS Part C UM Annual Data Submission, your organization should start gathering and organizing internal coverage criteria that require prior authorization for Part C services (including Part B drugs). Key information to collect includes:
Rule Name and ID – Identify each prior authorization rule.
Service or Drug Codes – Include CPT, HCPCS, DRG, or NDC codes affected by each rule.
Clinical Criteria Summary – Provide a concise description of the clinical rationale behind each rule.
Effective and Review Dates – Track when each rule was implemented and last reviewed.
Rule Owner – Record the person responsible for maintaining or explaining the rule.
Collecting and validating this information early will make the HPMS submission process smoother once CMS releases technical guidance. Starting now ensures you meet the first submission deadline of April 30, 2026 for calendar year 2026, and prepares your team for future annual submissions.
FAQs (quick answers)
Q: Is CMS collecting audit tools and protocols?
A: No — CMS reviewed comments and chose not to finalize the proposed audit protocol or audit tools at this time. They may add them to future audit protocols.
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Q: Which UM criteria are in scope?
A: Only internal coverage criteria that apply to Part C services (including Part B drugs) that require prior authorization. Criteria used exclusively for concurrent or payment review are out of scope.
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Q: When is the first submission due?
A: For calendar year 2026, CMS extended the due date to April 30, 2026. Thereafter, submissions are due February 28 each year.
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Q: Where do we submit questions?
A: Send them to CMS_PartC_UM_Audits@cms.hhs.gov. CMS will respond and may schedule an industry call or publish a summary of Q&As if many similar questions are received.
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Q: Where can we find the tools and crosswalk?
A: CMS has posted the data collection tools, the supporting statement, the crosswalk of changes, and their responses to public comments on the CMS Part C UM Annual Data Submission webpage. Check that CMS page for updates.
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Common pitfalls to avoid
Waiting for the HPMS template before starting your inventory — start collecting now.
Failing to include Part B drugs that require prior authorization.
Not documenting rule owners or version history — CMS is asking for internal criteria, so provenance and dates matter.
Assuming the audit protocol is finalized — it’s not; however the annual collection itself is now required.