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Prepared to Implement the CMS Preclusion List Requirement?

By December 3, 2018February 8th, 2019CMS, Part D

Along with the new year also comes a new CMS requirement known as the Preclusion List. This requirement was adopted in the April 2018 final rule as an alternative to the rescinded Medicare enrollment requirement that mandated contracted providers to enroll in Medicare to ensure the prescriptions they were writing would be covered under Part D.

CMS has now extended the preclusion guidance to providers and entities for medical benefits as well as providers writing prescriptions. CMS published guidance outlining how to implement and comply with the newly adopted Preclusion List requirements in an HPMS Memo on November 2, 2018. The requirement defines that contracted and non-contracted providers will not be eligible to receive payments from a Medicare plan, 1876 Cost Plan, or PACE organizations if they are included on the Preclusion List. Additionally, this will also be a requirement for providers writing prescriptions for Part D drugs to be covered by a Part D plan.

The Preclusion List will consist of providers who are currently revoked from Medicare, under an active reenrollment bar, or have engaged in behavior for which Medicare would have revoked them for if they had been enrolled in Medicare at the time. CMS will also take into consideration if the underlying conduct that led to the revocation is determined to be detrimental to the Medicare program.

The initial Preclusion List will be made available on a secure website on January 1, 2019. Routine updates to the list will then be made available around the first business day of every month. This will require plans to implement procedures for regular, ongoing reviews of the list.

In addition to the ongoing review of the Preclusion list, Medicare and Part D plans will be required to remove any precluded contracted provider or pharmacy who is included on the list and then notify enrollees who have received care or a prescription in the last 12 months from those providers. CMS is currently recommending that beneficiaries are provided at least 60 days’ advance notice prior to denying payment for health care or pharmacy claims. To allow for initial reviews of the list and notices to be implemented, CMS suggests that payment denials and claim rejections begin April 1, 2019 for the initial January Preclusion List. However, CMS commented that reimbursements or claim payments are also prohibited for any covered items, services, or prescriptions associated with any providers on the initial January Preclusion List.

It is important to note that the Preclusion List does not eliminate the requirement to review the OIG exclusion file, as the preclusion and exclusion files are not entirely interchangeable. While excluded providers will be on the preclusion list, precluded providers may not always be on the OIG exclusion file.

Review the Quick Reference Guide here that CMS has developed for additional information regarding the Preclusion List requirement along with instructions on accessing the list.

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