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New Guidance for Processing Requests to Withdraw Parts C and D Organization/Coverage Determination and Appeals

NEW!

Beginning January 1, 2022, plans must send a written notice of dismissal for Part C organization determination and reconsideration requests as well as for Part D coverage determination and redetermination request to parties of a dismissal when the party that initiated the request voluntarily removes the request from plan consideration (i.e., withdraws the request for review).  Written notice of dismissal will be required whether the request to withdraw is made verbally or in writing and applies to requests for pre-service and post-service determinations.

On January 19, 2021, the Centers for Medicare & Medicaid Services (CMS) issued Contract Year 2022 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicaid Program, Medicare Cost Plan Program, and Programs of All Inclusive Care for the Elderly (CMS-4190-F2) in which, amongst other things, the agency codified dismissal and withdrawal processes in regulation.  While CMS’ stated intent was to codify dismissal and withdrawal processes to align with what the agency believed to be current practices, plan sponsors should evaluate their processes against the regulations to determine if a change in operational procedures is required to be compliant.

READ THE FINE PRINT!

Dismissal and Withdrawal of Medicare Part C Organization Determination and Reconsideration and Part D Coverage Determination and Redetermination Requests (pgs. 94-99 of CMS-4190-F2 PDF) sets forth regulations to specifically address under what circumstances it is appropriate to dismiss or withdraw a Part C or D coverage request or appeal at the Plan.  While there is no change to what constitutes a dismissal or a withdrawal of a request for coverage or reconsideration, and CMS indicates the process of dismissing and withdrawing request will remain distinct categories for reporting purposes, the rule requires a significant change in the requirements for issuing notification of a request to withdraw.  The final rule codifies plans must dismiss a request for coverage or level 1 appeal when the party filing the request submits a timely request for withdrawal of their request for coverage or level 1 appeal.

HOW WILL THIS AFFECT YOUR OPERATIONAL PROCESSES?

CMS notes that there are specific provisions addressing the content of the notice of dismissal.  The notice must be sent to all parties (i.e., physician and enrollee) and state all the following: (1) the reason for the dismissal, (2) the right to request that the plan sponsor vacate the dismissal action, and (3) the right to request reconsideration of the dismissal. Additionally, at the level 1 appeal level the dismissal should also include the right to request review of the dismissal by the independent review entity (IRE).  Therefore, plans should evaluate any notices used to communicate the dismissal of a coverage request to ensure any needed updates are implemented  beginning January 1, 2022.

Another potentially significant change in operational processes is the requirement to apply the regulatory timeframe for the request to decisions that are dismissed.  Plans must ensure that they have internal controls and monitoring in place to ensure that dismissal notifications resulting from a timely withdrawal are issued before expiration of the adjudication timeframes.

Plan sponsors should also review and update their processes to ensure that they are able to appropriately process an enrollee’s request for reconsideration of the dismissal, including how the request will be handled if the plan decides to vacate the dismissal.  CMS-4190-F2 states that further operational guidance will be issued by CMS, as necessary.

CMS will continue to conduct ongoing monitoring and oversight activities for plan adherence to regulatory requirements.  Specific to the requirements of CMS-4190-F discussed in this article, CMS has established the means to evaluate plan performance in program audit beginning with the 2022 audit season. On May 26, 2021, CMS published the long anticipated Final Protocols for the Medicare Part C and Part D Program Audits and Industry-Wide Part C Timeliness Monitoring Project (CMS-10717) which will be used for Medicare Parts C and D Program audits starting in 2022.  As expected for ODAG, CMS removed the dismissal table and added Dismissed as a valid option for the Request Determination field on applicable tables.  Dismissed continues to be a valid option in the Request Determination fields on the applicable CDAG tables.  Additionally, the 2022 audit protocols include the evaluation of up to 10 dismissed cases to determine if the request was appropriately dismissed or whether it should have been treated as a coverage request or grievance.  Plans should ensure that they have processes in place to not only appropriately categorize dismissals, but also to ensure that they are able to create universes according to the updated protocols effective January 1, 2022.

The requirements specific to the dismissal and withdrawal of Part C and Part D request as discussed in this article make up a small portion of the regulation’s amendments for the Medicare Advantage and Medicare Prescription Drug Benefit program.  CMS plans to issue additional operational guidance specific to the new regulations for dismissals resulting from CMS-4190-F, as necessary, but plans should not wait. Now is the time to evaluate current policies and procedures and as needed, take action to ensure effective, compliant processes are in place at the start of 2022.  BluePeak can help plans identify gaps in their current processes that will need to be addressed prior to January 1, 2022.  Furthermore, as plan sponsors approach the 2022 contract year, BluePeak can help ensure your plan is ready for the 2022 audit season by performing mock audits using the 2022 program audit protocols.