Guidance What do the changes really mean? Sponsored by Date: May - PowerPoint PPT Presentation

WEBINAR Condensed Appeals & Grievance Guidance What do the changes really mean? Sponsored by Date: May 15, 2019 Time: 10 – 11 a.m. PT (1 – 2 p.m. ET) www.inovaare.com

Role of the Medical Director Section 10.4.2 • All plans must employ a medical director who is responsible for ensuring the clinical accuracy of all coverage decisions involving medical necessity. • CMS does not; however, expect that the medical director review every medical necessity decision. • The plan must establish a process for when a medical director must be involved.

QUESTION FROM THE AUDIENCE QUESTION • Does a Medical Director or Physician needs to see all denied coverage determinations with lack of medical necessity? • Can it be a Pharmacist?

ANSWER TO QUESTION ANSWER Section 40.0: Who Must Review an Initial Determination • If a plan initially reviews a request and expects to issue a partially or fully adverse decision based on medical necessity, the review must be completed by a physician, as defined in section 1861(r) of the Act, or other appropriate healthcare professional who has: • Sufficient medical and other expertise; • Knowledge of the Medicare coverage criteria; and • A current and unrestricted license to practice within the scope of his or her profession in a State, Territory, Commonwealth of the United States (that is, Puerto Rico), or the District of Columbia.

Additional Answer to Question • Lastly, specifically in the language of Section 40.9: • For Part D Only • A pharmacist would generally be considered an appropriate health care professional for purposes of meeting this requirement. • In general, the application of a clear statutory or contract exclusion set forth in the plan sponsor’s Evidence of Coverage, does not constitute a decision based on the lack of medical necessity. Conversely, an adverse decision based on a determination that the clinical documentation supporting the coverage request is unavailable or insufficient (i.e., there is unmet criteria) is generally considered a denial based on the lack of medical necessity.

Last Clarification on Role of Medical Director • The medical director has overall responsibility for the plan’s clinical decision-making, and as such, is expected to be involved in various aspects of related plan policies and operations which may include: 1. medical and utilization review 2. benefits and claims management 3. formulary administration 4. processing coverage decisions in accordance with adjudication timeframes and notice requirements 5. provider/prescriber outreach 6. staff training, and 7. oversight of delegated entities.

Delegation of Responsibilities Section 10.4.3 • The plan must have a comprehensive and on-going monitoring and auditing process in place to validate the performance of the delegated entities’ compliance with all CMS requirements.

Plan Communication to an Enrollee • If the enrollee agrees to this, the MA plan may deliver written notices by fax or email. ➢ This should be DOCUMENTED • Please be sure to reference the marketing guidelines regarding electronic communication with enrollees.

Calculation of Days for Assessing Plan Timeliness Section 10.5 For standard cases (level one appeals and standard grievances), the day the plan receives the request is not counted as “day one”.

QUESTION FROM THE AUDIENCE Of all the 2019 changes in the condensed appeals and grievance guidance the impact of Section 10.5.2 is one where our plan is most interested in interpretation. Specifically the language regarding when the processing time begins for an expedited appeal. The new guidance states “For expedited requests, the processing timeframe begins when the appropriate department receives the request”. • Does Inovaare have any opinion on this change?

When a Request is Considered Received by the Plan ▪ For standard requests, the processing timeframe begins when the plan, any unit in the plan, or delegated entity receives a request. ▪ For expedited requests, the processing timeframe begins with the appropriate department receives the request. The caveat… 1. The plan material should clearly state where all requests should be sent. 2. Plan policy and procedure should clearly indicate how to route requests that are received in an incorrect location to the appropriate location as expeditiously as possible.

WARNING!!! Notice Section 50.2.1-Guidelines for Accepting Level 1 Appeal Requests states the opposite!! • Page 55 (last bullet) specifically states: • For both standard and expedited level 1 appeal requests, the following guidelines apply…. • The processing timeframe begins when the plan, any unit in the plan, or a delegated entity (including a delegated entity who is not responsible for processing the request) receives the request.

QUESTION FROM THE AUDIENCE • For expedited requests, the processing timeframe begins when the appropriate department receives the request. • Appropriate Departments means for example, Customer Service receives a call with a drug request at 8am. They then send the request to pharmacy at 2:00pm the same day; • Would the received day/time be 2:00pm?

ANSWER TO THE QUESTION ANSWER • Based on the previous slides, the answer to this question would be the 8:00am start time. • For one, expedited requests must be accepted verbally. Most of the time, this will come in through Customer Service. This is a department that should be highly trained in how to thoroughly document the call and redirect to the A&G Department immediately. • Additionally, based on the contradicting language within the new guidance, I would suspect CMS will correct the contradiction and be very clear as the previous Chapter 18 language was.

Good Faith Effort to Provide Verbal Notification Plans may satisfy the notification requirement by first providing verbal notice of its decision to the enrollee, so long as the written notification requirements are met as well as long as: a) The good faith effort is documented in writing and included in the case file; b) The written notice of the decision (when written notice is required) is sent to the enrollee within the applicable timeframe; and c) The plan is not at fault for its inability to reach the enrollee by phone (i.e., the plan did not make a transcribing error when writing the telephone number).

QUESTION FROM THE AUDIENCE • Good Faith Effort to Provide Verbal Notification when a plan is unable to contact the member during oral notifications is just to clarify the needs of documentation and the needs of send a letter within the applicable timeframe… • Applicable time frame means case due date but is not adding 3 extra days for a written notification. Right?

ANSWER TO THE QUESTION ANSWER The good faith oral notification requirement just clarifies what counts as “good faith” in the cases where verbal notification is required (i.e. Expedited Part D Appeal). As long as you attempt to make outreach to the member, document accordingly those good faith attempts, and it wasn’t due to your own error that you were unable to reach the member, then you have satisfied the verbal requirement. **FYI- for reporting purposes, in the verbal notification, CMS has directed to enter the last good faith effort attempt that was made during the turn- around-time.

Representatives Section 20 • If a purported representative makes a verbal request and the enrollee verbally confirms they want to file the request described by the purported rep, the request must be documented and processed as a request from the enrollee, not the representative. • All communication (written and verbal) must be delivered to the enrollee until a valid, written rep form is on file- though plans, in instances such as this, are not required to make an effort to obtain the written form.

Missing or Defective Representative Form Appeal requests may be dismissed, but the plan should notify the enrollee and the person asserting rep status of the dismissal in writing. PART C ONLY- The health plan may explain that if the rep documentation is submitted after the 60 day filing deadline for requesting an appeal has expired, a good cause statement explaining why the form was not filed timely should be included with the request for an IRE review. PART D ONLY- The health plan must send a written dismissal notice stating the reason for dismissal and explain that if the rep documentation is submitted after the 60 day filing deadline for appealing has been met, a good cause statement explaining why the form was not filed timely should be included with the requested documentation.

Withdrawn Grievances Section 30.4 If the plan receives a verbal request to withdraw a grievance, it is highly encouraged to document that the enrollee does not want to proceed with the grievance. The plan should but is not required to, send a written confirmation of that withdrawal to the enrollee within 3 calendar days of receiving the withdrawal request. QOC still needs to be investigated but the plan is not required to notify the enrollee of the outcome.

Effect of Failure to Meet the Timeframe for an Initial Determination The MA plan must explain in its EOC that enrollees have the right to a level 1 appeal if the MA plan fails to provide timely notice of the decision. (of course, this constitutes an adverse decision for reporting purposes).