Thus, delegation to a PBM does not free the plan up from contact. When adjudicating requests for Part D coverage for beneficiaries who are enrolled in MA-PD plans, CMS expects the plan to leverage its contractual relationship when the request involves the need for information from a contracted provider.Across the board, lack of sufficient delegated oversight has been a huge finding for plans in program audits. The plan is responsible for ensuring delegated entities adhere to appropriate procedures.This points to medical director intervention in these cases before denial for lack of information. CMS expects medical directors to design their outreach policies for expedited requests to reflect the immediate need for access to critically needed items, services or drugs, including consideration of how the outreach is conducted and who is making the outreach attempts.The plan’s medical director should be involved in the development and oversight of policies and procedures to ensure the appropriateness of the plan’s clinical decision-making.CMS will determine whether sufficient outreach occurred in cases by looking at whether plans used multiple modes of communication (e.g., phone, fax, e-mail) to obtain required information.Requests made by telephone should be documented with the date and time of the call. The date/time of the postmark or timestamp on e-mails and faxes are considered the date/time of the request to the provider for the information. The plan must clearly identify the records, information, and documents it needs when requesting information from a provider. Plans are required to conduct outreach within the applicable adjudication timeframe and to document their efforts.The plan is expected to make reasonable efforts to gather all of the information needed to make substantive and accurate decisions as early in the coverage process as possible. Plans must make reasonable and diligent efforts to obtain all necessary information, including medical records and other pertinent documentation.General Guidance For All Authorization and Appeals Requests: Here is what CMS views as the minimum necessary outreach for each case, much of which is taken verbatim from the CMS memo to avoid any potential confusion given the technical nature of the guidance: Because timeframes vary between medical and pharmacy requests, in addition to standard and expedited requests, CMS details exactly what it wants plans to do in each type of case. The memo serves as sub-regulatory guidance plans must adhere to and supersedes anything that may conflict in the various Medicare health plan manuals (the manuals will be updated in the future). To further bolster its guidance, on October 18, 2016, CMS released a health plan memo that provides additional guidance on outreach attempts. In a last effort to obtain documentation, plans didn’t use medical directors to engage providers to submit documentation.ĬMS expects plans will address all of the above to pass the outreach requirements moving forward.CMS expects that because providers are contracted, there should be no reason to fail to obtain necessary clinical documentation. Took extensions on cases when contracted providers were non-responsive on the need for documentation or plans did not conduct required outreach to obtain information.(This is a careful balancing act as CMS expects that plans not deny services too soon but at the same time make accurate coverage decisions as early in the allowable timeframe as possible.) Prematurely denied cases prior to expiration of timeframes when clinical information was not available.Failed to conduct sufficient attempts at various times of the day (at least three) to gain information.In recent audits, CMS has told plans it is their duty to get required information from providers and avoid denials for lack of documentation. Its argument is sloppy practices by plans have meant unnecessary denials, extra steps and time for members to file for and wait on both appeals and external reviews, and potential health effects and complications for beneficiaries. Audit findings and penalties have been common for plans that do not conduct sufficient outreach because CMS views this as violating its “no beneficiary harm” standard. One important requirement is that plans must exercise due diligence to obtain sufficient documentation from providers for authorization and appeals requests before denying them for lack of medical necessity criteria met. As anyone involved in a Medicare Advantage Part D (MA-PD) or standalone Part D (PDP) plan knows, the Centers for Medicare and Medicaid Services (CMS) has made compliance with regulatory guidelines a strong focus.
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