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Transition Monitoring Program Audit-Coming Soon!

By December 1, 2018February 8th, 2019CMS, TPMA, Uncategorized

History and Methodology

The transition monitoring program analysis (TMPA) has been in effect since 2012 and will likely be a staple in the Part D program for several years to come.  The program evaluates point-of-sale rejected claims to ensure Sponsors are meeting their Part D transition of care requirements for new and continuing enrollees.

Based on the most recent TMPA requirements, sponsors must submit January claims that rejected for formulary reasons (non-formulary (NF), prior authorization (PA), step therapy (ST), and quantity limit (QL)).  All claims must be submitted into CMS within the first two weeks of February.

CMS will select up to 30 samples for new and continuing enrollees and for protected and non-protected products.  Plan sponsors must carefully review the samples selected by CMS and provide valuable feedback stating if the claim rejection was appropriate along with the sponsor’s rationale.

Prior Findings

A failure rate greater than 20% will result in, at minimum, a notice of non-compliance for the plan sponsor.  An identified issue must be aggressively remediated, or the plan sponsor may face further CMS compliance action.  In 2017, 5.7% of all contracts selected for the TMPA failed the assessment.  Although an improvement over 2016’s failure rate (6.1%), plan sponsors continue to struggle in ensuring compliance with new and existing transition of care requirements.


CMS has noted several data challenges they have experienced with plan sponsors.  These challenges include submitting claims that should not have been included, inappropriately categorizing the rejection reason, or having data integrity issues within the TMPA file.

CMS has also noted trends observed within the rejections that were deemed inappropriately.  These trends include having safety edits more restrictive than the FDA labeled maximum dose, general transition processing errors, and not providing appropriate justification for rejecting a transition claim for non-D purposes

Is Your Plan Ready?

Plan sponsors should make it a priority to ensure compliance with transition of care requirements.  As noted within the 2018 Call letter, CMS is considering including TPMA (and Formulary Administration Analysis) monitoring in Star Ratings as beneficiary access measures.  Plan sponsors have three ways to mitigate their compliance risk during the TMPA audit.

  1. Comprehensive testing of transition of care claims is a critical part of year-end testing. Strategize on what scenarios need to be included in testing and validate new products and new requirements are being managed appropriately for both new and continuing enrollees.
  2. Plans sponsors must institute a daily monitoring process to review transition of care claims and validate claims are both paying and rejecting appropriately. Any issues identified should be aggressively resolved and an impact analysis should be completed to understand exposure.
  3. A comprehensive review process of the data that is initially submitted into CMS and responses that are returned to CMS on the selected samples. Plan sponsors must highly scrutinize the claims being submitted into CMS to ensure data completeness as well as determine if there are any additional risks not identified through the daily monitoring process.  Plan sponsors should ensure all responses back to CMS are complete and fully address all CMS’ concerns.  Plan Sponsors should involve multiple groups in both the initial review and feedback review to gain multiple perspectives

BluePeak Can Help

BluePeak has supported plans with all aspects of TMPA as well as ongoing claims testing and analysis.  Medicare Part D claims are under more scrutiny than ever and BluePeak can help you put together comprehensive oversight programs to identify potential issues and mitigate risks.

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