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Medicare Advantage and Prescription Drug Plan Appeals Guidance– Are You Ready?

By June 12, 2019June 28th, 2019HPMS, Medicare, PDBM

Chapter 13 of the Medicare Managed Care Manual (MMCM) and Chapter 18 of the Prescription Drug Benefit Manual (PDBM) have been consolidated into one chapter. CMS announced the release of the final Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance in an HPMS Memo published February 22, 2019. Any changes or updates from the prior chapters are not expected to be audited until January 2020, unless the final guidance provides clarification that is to the plan’s benefit.

Summary of updates as outlined in the HPMS memo:

  • Receipt of request –
    • Standard requests, the processing timeframe starts when any unit in the plan or delegated entity receives the request.
    • Expedited requests, the processing timeframe begins when the appropriate department receives the request.
  • Outreach for Additional Information to Support Coverage Decisions –
    • Plans must make reasonable and diligent efforts to obtain all necessary information to make a timely coverage decision. Best practice remains making multiple outreaches via different methods.
    • When outreach is required, CMS clarified only one outreach attempt is required.
    • Plans are not required to conduct outreach prior to denying claims payments if they believe they have all the necessary information needed to make a coverage decision.
    • For a Part D expedited redetermination requests, if medical information is needed, the plan must request information within 24 hours of receipt of the request.
    • Tolling when a supporting statement has not been received is permissible for a reasonable amount of time. CMS does not believe this should exceed 14 calendar days.
  • Representatives Filing on Behalf of Enrollees –
    • Representation must be made in writing.
    • An Appointment of Representation (AOR) can be kept on file and utilized for one year from the date it is signed by both parties.
    • If a representative makes a request, plans must send notices or correspondences to the representative and may, but are not required to, send a copy to the enrollee.
    • When an appointment of representation form is not received, a reasonable timeframe to dismiss the request or grievance is the conclusion of the associated timeframe, plus extension, if applicable.
  • Classification between Grievances, Inquiries, Coverage Requests, and Appeals – Plans must inform enrollees, verbally or in writing, if their issue is a grievance or appeal.
  • Quality of Care Grievance – A grievance related to whether the quality of covered services provided meets the professionally recognized standards of health care based on what the enrollee considers to be true.
  • Dismissals – Plans do not automatically forward dismissed cases to the IRE.
  • Reopening –
    • Request can be verbal or in writing.
    • Revised decisions should be completed within 60 days from the receipt.
    • A change in a denial rationale is a revised determination and requires notification to the parties of the revised determination.
  • Level 1 Appeals –
    • For Part C favorable reconsiderations, the plan must notify the enrollee in writing.
    • Written notice must explain the conditions of the approval which include, but are not limited to, the duration of the approval and any associated limitations.
    • If the plan upholds its adverse decision, in whole or in part, the plan does not have to notify the enrollee their case is being forwarded to the IRE.
  • Forwarding untimely cases to the IRE – Is not required if the fully favorable decision is made less than 24 hours after the end of the adjudication timeframe. The plan should adjudicate the favorable decision and make notification to the enrollee.
  • Alternate formats –
    • Plans must provide notices in alternate formats and language consistent with Section 1557 of the Affordable Care Act and Section 504 of the Rehabilitation Act of 1973.
    • If the enrollee agrees, the Plan may deliver written notice to the enrollee by fax or e-mail.
  • Withdrawals –
    • The party filing an initial request or grievance may request it be withdrawn, verbally or in writing. Verbal request to withdraw must be clearly documented in the plan’s system.
    • The Plan may, but is not required to, send written confirmation of the withdrawal of the initial request or grievance to the appropriate party.
    • Withdrawn Quality of Care grievances must be investigated by the Plan, however enrollee notification of the outcome is not required.
    • An appellant may withdraw the request for a level 1 appeal in writing at any time prior to the Plan mailing the appeal decision. Verbal request to withdraw must be followed by a written confirmation within 3 days of the verbal request. The plan must forward the request to withdraw to the IRE if the request to withdraw is received after the plan has forwarded the case file to the IRE.

Are you Ready?

The HPMS memo also announced CMS’ intent to hold a webinar to discuss the consolidated guidance. What can the plan do to prepare while awaiting the details of the CMS webinar?

  • Review policies and procedures and ensure they align with the final guidance.
  • Assess operations, evaluate processes and ensure outputs demonstrate compliance with processing requirements.
  • Evaluate the ability to provide notification to enrollees for requests processed under the expedited timeframe:
    • Are enrollees consistently notified of the decisions within the applicable timeframe? The current audit protocols require the plan to report the date the written notification enters the mail stream, however, mailing the notice within the timeframe in and of itself is insufficient.  If plans do not notify the enrollee verbally, written notification must be sent with a way to track receipt.
    • Are verbal notifications of a favorable decision followed with written confirmation, within 3 days of the verbal notification, for initial organization determinations processed under the expedited timeframe?
  • Evaluate the outreach process:
    • Is sufficient outreach performed to make a substantive decision, within applicable timeframes? Are initial decisions overturned on appeal because information that should have been available at the time of the initial review is received? One outreach attempt is all that is required for compliance with the guidance, however plans should make the necessary outreach to obtain the information required to make a substantive decision for the initial request.
    • Are claims developed when information needed to make a substantive payment decision is not submitted with the initial claim? The plan is responsible for making outreach to develop the claim before rendering an adverse determination, regardless of whether a contracted or non-contracted provider is aware of requirements prior to submitting the claim.
  • Evaluate the process for enrollee representation:
    • Are the correct documents obtained to demonstrate a valid representative has been appointed or authorized? What documents are accepted as evidence of valid representation?
    • Is timeliness for representative request being correctly calculated? If the valid AOR, or equivalent written notice, is on file at the time the request is made, timeliness is calculated by the date of receipt. If the AOR is received after the request is made, timeliness is calculated by the AOR receipt date.
    • When an authorized representative makes a request, is notice provided to the representative?
    • Before dismissing a request or grievance on the grounds a valid request was not received, is the full adjudication timeframe allowed to exhaust? When the timeframe is exhausted occurs on a weekend or holiday do you wait until the following business day to dismiss the request, to allow the full review period?
  • Evaluate the process to re-open request –
    • Is there a process in place to reopen decisions when necessary? Does the process ensure a request is not reopened while an appeal is active?
    • Are the requests appropriately identified and excluded from program audit reporting yet included in Part C annual reporting?
    • Is the enrollee, or other relevant parties, notified of the revised decision in writing?
    • Are reopening procedures separate and distinct from reconsiderations and used sparingly?
    • Are claims frequently reopened to revise the initial determination due to a failure to properly develop the claim?
  • Evaluate the processes for dismissals and withdrawals –
    • If the plan makes a decision not to review an initial request, appeal, or grievance because it is invalid, is the request classified and reported as dismissed? Is written notification of the dismissal provided to the appropriate parties?
    • If the request is dismissed on the grounds a valid request or grievance is not received and the plan allows the adjudication time frame to lapse, plus the applicable extension time frame, is the plan invoking a formal extension? If the plan is not executing the extension in accordance with regulatory requirements (which includes sending the enrollee written notice of the timeframe extension) the plan is likely utilizing a “grace period” to allow the maximum time in the best interest of the enrollee. The differentiation is important for purposes of program audit reporting.
    • If the requestor asks, verbally or in writing, to rescind or cancel an initial request, appeal, or grievance, is the request classified as withdrawn?
  • Determine if reconsiderations are consistently processed within timeframes:
    • Is the timeliness for filing an appeal calculated from the date of the notice of the initial determination, not the date the initial determination is made? Are requests made outside of the filing period evaluated for good cause exceptions for late filing?
    • Is timeliness for processing being correctly calculated? The processing timeframe begins when any business area in the plan, or a delegated entity, receives the appeal.
    • Are the decision, effectuation and enrollee notification timely? The plan must make a decision, effectuate and make enrollee notice for favorable decision within the applicable adjudication timeframe.
      • Reconsiderations processed under the standard and expedited timeframe require written notice to the enrollee for favorable determinations.
      • If the plan first makes verbal notice to the enrollee for a favorable reconsideration processed under the expedited timeframe, it must provide written confirmation of the approval within 3 days of the oral notice.
    • Are untimely cases appropriately forwarded to the IRE? If the plan fails to provide the enrollee with notification of an appeal decision within the applicable adjudication timeframe, the failure constitutes an adverse decision and the plan must forward the case file to the IRE.
      • If the plan makes a fully favorable decision less than 24 hours after the end of the adjudication timeframe, the plan may effectuate the decision and notify the enrollee of the favorable decision in lieu of forwarding the case to the IRE. The effectuation and enrollee notification should also occur within 24 hours of the adjudication timeframe ending.
      • Notification and effectuation of favorable reconsiderations should be provided to the enrollee within the required timeframe. If a plan is not notifying and effectuating within the applicable timeframes, this implies there is an issue with a plan’s procedure for processing appeals. The plan should notify its CMS Account Manager when it fails to consistently meet the timeliness requirements for processing appeals.
    • Do enrollees get notice of a decision to uphold the initial denial? When the plan affirms its original decision, in part or in whole, the case must be forwarded to the IRE within the applicable timeframe. The plan is not required by CMS to provide written enrollee notice for denied reconsideration request. Is there opportunity to update and streamline procedures for more timely processing?

BluePeak Can Help

  • BluePeak can help plans identify issues in their policies and procedures or operations by performing an operational assessment. Additionally, BluePeak can help with a mock program audit to ensure the sponsor is prepared to undergo a program audit.
  • Don’t wait until CMS has a call to discuss the final guidance or until you receive your program audit notice. BluePeak can help you prepare now. BluePeak is experienced in CMS interpretive chapters and CMS program audits. BluePeak can review universes, identify risk and outliers, and coach your team and your vendors (FDRs) on how to present the data.
  • Contact BluePeak at (469) 319-1228 or for more information about how we can help you navigate the updated guidance.