2012 CMS Fall Conference Part D Coverage Determinations, Appeals & Grievances (CDAG) Jennifer Smith, Director Division of Appeals Policy Medicare Enrollment and Appeals Group Jeffrey Kelman, M.D., MMSc Chief Medical Officer Center for Medicare Image of 5 medical staff CMS logo

Through audits and monitoring we have discovered common deficiencies across plans This presentation will: – Highlight important policies – Explain our performance expectations Presentation Overview 2

Effectuation Processing of Exception Requests Grievances Clinical Decision-Making Part D 3

Effectuation Definition: Payment of claim, authorization or provision of a benefit the plan sponsor has approved, or compliance with a complete or partial reversal of the sponsor’s adverse coverage determination 4

Effectuation Common Deficiencies: – Timely effectuation of approval in system – Accurate/appropriate effectuation – Timely notification of beneficiary 5

Effectuation Timeframes Timelines for Effectuation – Coverage Determination - 72 hours/24 hours – Redetermination - 7 days/72 hours – IRE decisions - 72 hours/24 hours – Request for payment - 14 days Timelines are based on calendar days, not business days 6

Exception Requests Rules for supporting statements – Exception requests – Timeframes begin with receipt – Outreach must be conducted 7

Part D Grievances Definition: Any complaint or dispute, other than a coverage determination or an LEP determination, expressing dissatisfaction with any aspect of the operations, activities, or behavior of a Part D plan sponsor, regardless of whether remedial action is requested. A grievance may also include a complaint that a Part D sponsor refused to expedite a coverage determination or redetermination. Grievances may include complaints regarding the timeliness, appropriateness, access to, and/or setting of a provided item. 8

Part D Grievances Common Deficiencies: Misclassification Proper resolution Timeliness and notification 9

Part D Grievances Must determine whether a complaint is a grievance, a coverage determination, or both Each issue must be resolved appropriately 10

Part D Grievances May be filed orally or in writing Must notify beneficiary of the resolution within 30 days If grievance is about the refusal to expedite a decision, sponsor must respond within 24 hours 11

Coverage Determination vs. Grievance General complaints about services of the plan- grievance Complaints about a lack of coverage, or a statement that a plan should have covered a specific drug-coverage determination (or appeal) If a coverage or appeal request is processed as a grievance-the beneficiary does not get his/her appeal rights 12

Part C Effectuation Appointment of Representative form Part C Grievances Clinical Decision-Making 13

Effectuation Pre-service requests for coverage (medical services/care) Claims for payment from non-contract providers Does not include claims adjustments or contracted provider claims 14

Effectuation Common Deficiencies: Timeliness of effectuation into system Timeliness of notification to beneficiary Inappropriate extension of deadline or inappropriate understanding of timeline 15

Plan Level Effectuations Must both effectuate and notify the beneficiary within the decision making timeframe 16

Effectuation Timeframes ODs-72 hours (expedited), 14 days (pre-service), 60 days (payment) Plan Reconsideration-72 hours (expedited), 30 days (pre- service), or 60 days (payment) IRE Reconsiderations-72 hours (expedited), authorize within 72 hours or provide NLT 14 days (pre-service), or 30 days (payment) 14 day extension-when applicable Timelines are based on calendar days, not business days 17 Plan must effectuate as expeditiously as the enrollee’s health condition requires, but no later than:

Appointment of Representative AOR Forms: A physician is not required to submit an AOR form: When requesting a pre-service OD request on behalf of an enrollee When requesting a pre-service appeal on behalf of an enrollee 18

Part C Grievances Definition: A complaint or dispute, other than an organization determination Expresses dissatisfaction about how plan provides services Made by either the enrollee or their representative May include complaints regarding timeliness, appropriateness, access to and/or setting of a provided health service, procedure or item 19

Part C Grievances Common Deficiencies: Misclassification of grievances/organization determinations Untimely resolution/notification Mishandling quality of care complaints 20

Part C Grievances Must respond within 30 days (24 hours for expedited grievances) For quality of care grievances, must be responded to in writing and include the enrollee’s right to file a complaint with the QIO Procedures for tracking and maintaining records Must accept oral or written grievances 21

Questions? 22