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What should plans do when COVID-19 impacts provider response times to standard and expedited appeals?

By March 31, 2020COVID19
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Plans have speculated that CMS might relax  the standard and expedited Appeals timeframes to allow more time for prescribers to respond since a large portion of prescriber’s offices are on limited hours or closed.

However, CMS has confirmed that Plans must continue to follow current CMS regulations and guidance for processing coverage determinations and redeterminations and issue a decision within the required timeframes for Part B/D drugs. However, plans are permitted to utilize all flexibilities available in the process, such as the ability to invoke extensions for Part C requests related to items/services. Per our regulations at §422.568(b)(1)(i), §422.572(b)(1) and §422.590(f)(1), Part C plans may extend the timeframe to adjudicate organization determinations and reconsiderations for medical items and services (but not Part B drugs) by up to 14 calendar days if: the enrollee requests the extension; the extension is justified and in the enrollee’s interest due to the need for additional medical evidence from a noncontract provider that may change an MA organization’s decision to deny an item or service; or, the extension is justified due to extraordinary, exigent, or other non-routine circumstances and is in the enrollee’s interest. If a plan believes it will be unable to meet timeframes, the plan should contact its account manager. Medicare Advantage Organizations and Part D sponsors are reminded of the requirement sunder 42 CFR 422.504 (o) and 423.505(p) to have business continuity plans to ensure restoration of business operations following disruptions, including emergencies. Medicare Advantage Organizations and Part D sponsors should review their business continuity plans to ensure that any necessary planning for business operations disruption due to a disaster or emergency is included.

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