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

Condensed Appeals & Grievance Guidance

What do the changes really mean?

www.inovaare.com

Date: May 15, 2019 Time: 10–11 a.m. PT (1–2 p.m. ET)

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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.

Role of the Medical Director

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
• r 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

• r 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.

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.

Delegation of Responsibilities

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.

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.

WARNING!!!

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.

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.

Representatives

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).

METHOD FOR FILING REQUEST STANDARD EXPEDITED WRITTEN Must Accept Must Accept VERBAL May Accept Note: In the event the plan does not accept a verbal request, the plan must explain to the party how to file a written request. Must Accept Note: If a verbal request to expedite a level 1 appeal is denied by the plan, the plan cannot require the party to re-file the request in writing. Instead, the plan must automatically transfer the request to the standard process.

Guidelines for Accepting Level 1 Appeal Requests

• For Part C plans, an acknowledgement

letter should be sent to the enrollee to confirm receipt of the appeal, to confirm the facts and the basis of the appeal, and to instruct the member to call the health plan back immediately if the acknowledgement letter does not accurately capture the member’s

• request. (Section 50.5.2)

Acknowledgement Letters

• If an enrollee misses the deadline for immediate QIO review of an inpatient

discharge (SNF, HHA, CORF) then the enrollee may request an expedited reconsideration with the plan.

• MA plans should have a process in place to distinguish between misdirected

requests that should go to the QIO or requests that the MA plan should process.

• Lastly- MA plans are encouraged to automatically expedite all valid requests

for reconsideration requests.

How to Process Requests for Expedited Level 1 Appeals

See page 59

• MA plans are expected to have sufficient and appropriate contract terms to

get information and records from contracted providers as necessary for expedited (and standard) reconsiderations.

• MA plans should not generally or regularly extend the timeframe for an

expedited reconsideration to seek information or records from a contracted provider but may do so if it is justified and decided to be in the enrollee’s information and only due to extraordinary, exigent or other non-routine circumstances.

• Example- provider medical record

database goes down

Plan Responsibilities with Contracted Providers

Enrollee Requests for Case File Content

• Rule- plans must provide the parties of the appeal with a reasonable
• pportunity to present evidence related to the appeal.
• Though they are not required to submit additional evidence, each party may

exercise their right to do so.

• In the case of an expedited level 1 appeal, the opportunity to present

evidence is limited by the short timeframe for making a decision, therefore, the plan must inform the parties of the conditions for submitting the evidence.

• ON PART C ONLY-
• An MA plan must inform the party of their right to request a 14 day extension

if the party feels they will need additional time to submit the evidence.

Effect of Failure to Meet the Timeframe for Level 1 Appeals

• Failure to meet the required timeframes is an adverse decision.
• For Part C: MA plans are not required to notify beneficiaries upon

forwarding cases to the Part C IRE. Enrollees will receive notification from the IRE.

• MA plans opting to inform parties when a case has been forwarded to the IRE

may use the model Notice of Appeal Status.

• For Part D: Plans should notify the enrollee that the appeal decision

was not made timely and is being forwarded to the IRE for review.

• Use the Notice of Case Status letter to send to the member in lieu of the

adverse decision notice.

• Must send within 24 hours of the expiration of the timeframe

Service of Benefit Received Prior to Notice of Decision

• Part C
• If an enrollee requests a standard pre-service reconsideration, but the plan

becomes aware that the member has received the services before the plan completes their review, processing should stop and the plan must dismiss the request.

• Part D
• If an enrollee has requested a standard pre-benefit redetermination, and the

plan becomes aware that the enrollee has obtained the prescription drug before it completes its redetermination, the plan sponsor must stop processing the claim as a pre-benefit redeterm, and process the claim as a request for payment instead.

Notifications

NEW GUIDANCE OLD CHAPTER 13 GUIDANCE Section 50 Section 10.4.2 Plans may provide notice to both the representative and the enrollee, but are not required to for favorable or non- favorable (adverse) decisions. **This also supports the guidance that dismissals should be sent to both. Under “NOTE” in the above section of Chapter 13, “All notices or other correspondence intended for the enrollee must be sent to the enrollee’s representative instead of the enrollee.

Timeframes and Responsibilities for Forwarding Case Files to the IRE

Special Note If a plan makes a fully favorable determination in less than 24 hours after the end of the applicable adjudication timeframe, the plan should consider promptly notifying the enrollee of the favorable decision in lieu

• f forwarding the case to the IRE.

Summary

Documentation is key: ✓ Document everything you are doing ✓ Lay out policies and procedures for those situations previously discussed- AND FOLLOW THEM ✓ Make every effort to communicate in a clear, concise manner to the member what you are doing and why throughout the process (not necessarily required but strongly recommended)

Question & Answer Time

33

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