Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance

On December 30, 2019, the Centers for Medicare & Medicaid Services (CMS) announced updates to the Parts C & D Enrollee Grievance, Organization/Coverage Determination and Appeals Guidance, which became effective as of January 1, 2020.  Noteworthy changes are summarized below:

  • In Section 10.5.3, the guidance was expanded to include more detail about verbal notifications. This section details when and under what circumstances the verbal notification is considered delivered, what defines a successful verbal notification (e.g., speaking with the person that submitted the request or leaving a voicemail message), and the appropriate steps to take if written notice is required along with verbal notification. CMS also deleted subsection 10.5.4: Good Faith Effort to Provide Verbal Notification, which was a new section introduced in the February 2019 version of the Guidance. There is a notable revision to guidance for a favorable decision that a plan “may” deliver written confirmation of its decision after initially providing verbal notification of the decision. This is a change from the 2019 guidance indicating the plan “must” deliver written notification. (See updated Section 40.8.)
  • Throughout the Parts C & D Guidance, CMS revised existing requirements to now include Part B Drugs.
  • Section 40 (Coverage Determinations, Organization Determinations [Initial Determinations] and At-Risk Determinations) has several significant updates:
    • There is a more detailed description of the process for requesting a Part C pre-service organization determination or Prior Authorization (PA). CMS provides clarification that Medicare Advantage (MA) plans should be prepared to address medical necessity as required in these scenarios. (See Section 40.1.)
    • There is a new Part D provision that applies to circumstances where a plan is asked to waive a PA or other Utilization Management requirement. Updated language provides for tolling of the timeframe by up to 14 calendar days after the receipt of a request to receive the supporting statement. (See Sections 40.4 and 40.5.3.)
    • Also noted are new Part D notification timeframes surrounding Exception Requests. In previous guidance, plans were instructed not to keep requests for supporting statements open indefinitely. This language is deleted in the updated guidance, and in its place, CMS outlines specific new timeframes for enrollee and prescribing physician (as appropriate) notification of plan decisions for both expedited and standard requests, and includes notification timeframes for circumstances when the supporting statement is not received with the 14 calendar day timeframe.
    • CMS has included Part B Drugs in the decision timeframes (favorable, partially favorable, or adverse) as well as processing timeframes (72 hours for standard requests for Part B Drugs and 24 hours for expedited). CMS also clarified that requests for Part B Drugs and payment timeframes cannot be extended.
  • Section 50 Reconsiderations and Redeterminations (Level 1 Appeals) contains a number of updated clarifications to existing requirements. Most noteworthy changes are the provisions for adjudication timeframes for Part B Drugs. 
  • CMS clarifies Health Care Pre-Payment Plans (HCPPs) are not regulated by Section 100 (Provider Notices in Hospital, SNF, HHA and CORF Settings [Part C Only]) and clarifies that HCPP enrollees must follow Original Medicare immediate review processes.
  • The Medicare Managed Care Appeals Process Overview for Part C (Appendix 1) is amended to include timeframes for Part B Drugs in both the standard and expedited processes. Also, for both Parts C and D Process Overviews, the “Amount in Controversy” (AIC) is increased to $170 at the Administrative Law Judge (ALJ) Hearing stage. The AIC is also increased at the Federal District Court stage to $1,670.

Plans should carefully review the updates and incorporate the numerous changes to existing plan policy.

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GHG assists plans in implementing process improvements in relation to new CMS requirements. We also conduct assessments and mock audits to validate adherence. Contact us today for additional information.

Anita Green
Anita Green

Senior Director, Compliance Solutions

Anita Green is Senior Director of Compliance Solutions at Gorman Health Group (GHG). Anita is a Registered Nurse with more than 30 years of health care experience, beginning her healthcare career in the U.S. Air Force. Anita has functioned in the role of hospital administrator for a 200+ bed hospital, also serving as a member of the senior leadership team and director of risk management with oversight accountability of patient advocacy, hospital security, and provider credentialing. Her clinical experience includes (but is not limited to) critical care nursing in both military and civilian settings, case management, utilization review, discharge planning and diabetic nurse education. Anita is a former Compliance and Privacy Officer for a multi-state Medicare Advantage Prescription Drug health plan, and in that role she supported new Medicare Advantage applications, service area expansions, CMS and Department of Insurance audits, transitions to new pharmacy benefit managers, systems implementation, and sales and marketing oversight. In her consultant capacity Anita has stepped in as interim Compliance Officer for several organizations and is comfortable providing compliance support and leadership to all operational aspects of managed care. Anita holds a BSN from University of Texas Health Science Center in San Antonio, and a Juris Doctor from St. Mary’s University School of Law.

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