Weekly CMS Insights: 10/6/14 – 10/10/14

Contract Year 2014 Part D Formulary Administration Analysis

CMS released a memo providing information about an analysis that will evaluate whether Part D sponsors are appropriately adjudicating Medicare Part D drug claims consistent with Part D requirements and sponsors’ CMS-approved benefits. The memo also describes the methodology that will be used by CMS to complete the monitoring process for this program.

Note: CMS initiated the CY2014 analysis due to their concerns with results from the 2013 formulary administration analysis. Unlike 2013 where only select sponsors had to provide claims, for 2014, CMS broadened the scope of eligible plans. Unless your plan is already identified to undergo a program audit in 2014 or if you participated in BOTH a program audit and Formulary and Benefits Administration validation audit in 2013, expect to receive a request.

Recommended Action: Review the attached memo for details. Information regarding the types of rejected claims (i.e. non-formulary, prior authorization, step therapy, and quantity limits) as well as the date ranges based on plan size are included within the methodology section.

CMS expects a 48-hour turnaround time on providing the data, so request the data NOW from your PBM and begin review of the claims to identify any potential issues. June 2014 data will be used.

For questions regarding data extraction, submission, or the secure website, please contact Acumen at FormularyBenefits@AcumenLLC.com. For questions regarding Formulary Administration Analysis, please contact LeAnn Poole at leann.poole@cms.hhs.gov or Réna McClain at rena.mcclain@cms.hhs.gov.

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Weekly CMS Insights: 9/29/14 – 10/3/14

2013 Final Part D Payment Reconciliation

CMS released a memo informing sponsors that calculations for the 2013 Final Part D Payment Reconciliation have been completed and reflect PDE records submitted through June 30, 2014.  The reports were made available in reconciliation mailboxes at the CSSC on Tuesday, September 30, 2014.  Please contact CSSC at 877-534-2772 if you are unable to access the reports.  In addition, sponsors will receive the Part D Exclusion from Reconciliation Report, which will identify PDEs that were excluded from the 2013 Part D payment reconciliation.

Recommended Action: Review the attached memo for details.  Please note that if filing for an appeal, you must do so by October 15, 2014.  Requests for appeal should be directed to Cheri Rice, and sent to the Reconciliation Support Contractor, Acumen LLC.  You may also file an electronic appeal by submitting the appeal to Acumen at PartDPaymentSupport@acumenllc.com.  Please direct questions regarding this memo to Acumen.

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