Prior to 2019, plan sponsors were required to make an effort determine whether an immunosuppressant should be paid under Part D or Part B based upon information they had or information they obtained from the patient or provider. . Beginning in 2019, CMS has developed the Additional Beneficiary Information Initiatives (ABII) portal, which provides plan sponsors with a list of beneficiaries who have received a Medicare-covered transplant. Plan sponsors will now have up to four sources of data to determine if the beneficiary has a Medicare-covered transplant. In addition to the ABII database, plan sponsors can obtain transplant information through the Medicare Advantage Prescription Drug (MARx) system, directly though CMS during any audits, or based off the beneficiary’s medical claims history (if available).
BluePeak has been supporting plan sponsors with 2019 CMS program audits and has observed CMS selecting immunosuppressant drugs and reviewing the plan sponsor’s source information to determine if the rejection was appropriate. Payment under the D benefit would be appropriate if the plan sponsor does not have any transplant information or if the transplant information provided indicates the transplant was not Medicare-covered. Any information indicating a Medicare-covered transplant should result in the claim rejecting under the D benefit or paying under the B benefit for any MAPD plans.
BluePeak has developed several proprietary rules to validate the accuracy of rejected claims, paid claims, and PDE submissions.
Bluepeak has over 50 rule sets that are used to target inappropriate rejections during mock formulary administration audits, daily rejected claim testing, and end of year testing, which includes rules around immunosuppressant medications. Ensuring claims are rejecting, paying, and reporting correctly will mitigate compliance risk, increase beneficiary satisfaction, and optimize CMS payments.