CMS 2021 Audit Protocol Changes: Forewarned Is Forearmed

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CMS 2021 Audit Protocol Changes: Forewarned Is Forearmed

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Topics
@ 2020 Inovaare | All rights reserved Company confidential
› History
› By Universe
• Layout Changes
• Content Changes
› Health Plan Actions Recommended
› Q & A

Compliance
oversight
Manager
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History
› 12/6/2019: Draft 2021 Protocols released for 60-day comment
period
• 2/4/2020: Comment period closed
› 3/30/2020: CMS “reprioritizes” program audits
› 6/4/2020: Draft 2021 Protocols released for 30-day comment
period
• Included CMS responses to previous comments received
• 7/6/2020: Comment period closed
• Resumed a smaller scale Program Audit with Notices issued by
7/27/20

General Changes
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› Who made the request
• Column options change from B/BR to E/ER
› Approvals, denials and dismissals combined into a single table
(except Grievance tables)
› Open and untimely cases are no longer included
• Cases are included based on Date of Determination
› Withdrawn requests/appeals/grievances are excluded
› “None” replaces “NA” or “N/A”
› TMP will be limited to Part C data

Layout Changes
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› Reduction in number of universe tables
• Combined tables with fields added to define
standard/expedited
› New universe table #7
• Comprehensive Addiction and Recovery Act (CARA)
At-Risk Determination (AR)
CDAG

2021 Layout Table 2020 Layout Table Business Impact
1: Standard and Expedited Coverage Determination (CD) 1: SCD
4: ECD
Pharmacy/PBM; UM; Delegation
Oversight
2: Standard and Expedited Coverage Determination Exception
Requests (CDER)
2: SCDER
5: ECDER
Oversight
3: Payment Coverage Determinations and Redeterminations
(PYMT_D)
3: DMRCD
7: DMRRD
Pharmacy/PBM; A&G; Delegation
Oversight
4: Standard and Expedited Redeterminations (RD) 6: SRD
8: ERD
A&G; Delegation Oversight
5: Part D Effectuations of Overturned Decisions by IRE, ALJ or
MAC (EFF_D)
9. SIAM
10: DMRRE
11: EIAM
6: Part D Standard and Expedited Grievances (GRV_D) 12: SGD
13: EGD
7: Comprehensive Addiction and Recovery Act (CARA) At-Risk
Determination (AR)
NEW Pharmacy/PBM
Layout Changes
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CDAG

Layout Changes
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CDAG
2021 Layout Table 2020 Layout Table Business Impact
1: Standard and Expedited Coverage Determination (CD) 1: SCD
4: ECD
Oversight
2: Standard and Expedited Coverage Determination Exception
Requests (CDER)
2: SCDER
5: ECDER
Oversight
3: Payment Coverage Determinations and Redeterminations
(PYMT_D)
3: DMRCD
7: DMRRD
Pharmacy/PBM; A&G; Delegation
Oversight
4: Standard and Expedited Redeterminations (RD) 6: SRD
8: ERD
5: Part D Effectuations of Overturned Decisions by IRE, ALJ or
MAC (EFF_D)
9. SIAM
10: DMRRE
11: EIAM
6: Part D Standard and Expedited Grievances (GRV_D) 12: SGD
13: EGD
7: Comprehensive Addiction and Recovery Act (CARA) At-Risk
Determination (AR)
NEW Pharmacy/PBM

Columns Added CD CDER PYMT_D RD EFF_D GRV_D
Was the request processed as Standard or Expedited? X X X X
Time the request was upgraded to expedited X
Formulary UM Type and Formulary UM Exception Type* X X X
Authorization or Claim Number X X X
Date prescriber supporting statement received X
Date effectuated in the system X
NDC X
Type of Request reversed by review entity* X
Content Changes
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CDAG

Content Changes
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CDAG
Columns Added CD CDER PYMT_D RD EFF_D GRV_D
Was the request processed as Standard or Expedited? X X X X
Time the request was upgraded to expedited X
Formulary UM Type and Formulary UM Exception Type* X X X
Authorization or Claim Number X X X
Date prescriber supporting statement received X
Date effectuated in the system X
NDC X
Type of Request reversed by review entity* X

Columns Removed CD CDER PYMT_D RD EFF_D GRV_D
Enrollment Effective Date X X X X X X
Was the beneficiary residing in a long-term care facility? X X
Was the request denied for lack of medical necessity? X X
Required AOR X X
Extension notification columns X
Resolution Description X
Content Changes
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CDAG

Content Changes
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CDAG
Columns Removed CD CDER PYMT_D RD EFF_D GRV_D
Enrollment Effective Date X X X X X X
Was the beneficiary residing in a long-term care facility? X X
Was the request denied for lack of medical necessity? X X
Required AOR X X
Extension notification columns X

Summary Changes
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ODAG
› Reduction in number of universe table
• Combined tables with fields added to define standard/expedited
• Included field to identify Part B drugs
• Combined IRE/ALJ/MAC effectuations into one universe table
› Determination values: Approved/Denied/Dismissed (except Table 2)
› Table 3 (Payment) includes NCP and enrollee claims, DMR requests/appeals – No
CP claims
› New universe table: Dual Eligible Special Needs Plans (D-SNPs) determined to be
an Applicable Integrated Plan (AIP)

2021 Layout Table 2020 Layout
Table
Business Impact
1: Standard and Expedited Pre-service Organization Determinations (OD) 1: SOD
2: EOD
4: Dismissals
UM; Delegation Oversight
2: Standard and Expedited Pre-service Reconsiderations (RECON) 5: SREC
6: EREC
4: Dismissals
3: Payment Organization Determinations and Reconsiderations (PYMT_C) 3: Claims
7: PREC
4: Dismissals
Claims; A&G; Delegation
Oversight
4: Part C Effectuations of Overturned Decisions by IRE, ALJ or MAC (EFF_C) 8: IREEFF
9: IREClaimsEFF
10: ALJMACEFF
5: Part C Standard and Expedited Grievances (GRV_C) 11: GRV_S
12: GRV_E
6: Dual Special Needs Plan-Applicable Integrated Plan Reductions, Suspensions and
Terminations (AIP)
NEW UM; A&G; Delegation Oversight
Layout Changes
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ODAG

Columns Added OD RECON PYMT_C EFF_C GRV_C
Part B Drug Request? X X
Was the request process as Standard or Expedited? X X
Time forwarded to the IRE X
Was the request processed as an OD or Recon? X
Who made the request? X
Type of reconsideration case X
Review Entity X
Was the grievance processed as Standard or Expedited X
Content Changes
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ODAG

Columns Removed OD RECON PYMT_C EFF_C GRV_C
Provider Type X X X
Diagnosis X X X
Was interest paid on the claim/reconsideration request? X X
If an extension was taken did the sponsor notify the member of the
reason(s) for the delay and of their right to file and expedited
grievance?
X X X
Date/Time service authorization entered/effectuated in the
sponsor’s system
X
Type of Request X
Date the request was dismissed X
Reason for Dismissal X
Appealed to IRE? X
Date forwarded to IRE X
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Content Changes
ODAG

Columns Removed OD RECON PYMT_C EFF_C GRV_C
Request for expedited timeframe X
Date written notification provided to IRE X
Did sponsor appeal ALJ decision to MAC? X
Date written notification provided to enrollee X
Person who made the request X
If the extension was taken because the sponsor needed more
information, did the notice include how the delay was in the best
interest of the enrollee?
X
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Content Changes
ODAG

Layout Changes
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CPE/FA
› Compliance Program Effectiveness (CPE)
• Combines FTEAM, IA and IM universes into a new universe (COA)
• Removed ECT universe
• Audit period changed from 52 weeks to 26 weeks
› Formulary Administration (FA)
• Tables and layouts remain mostly unchanged
• Two Impact Analysis requests added

2021 Layout Table CPE 2020 Layout Table Inovaare Impact Business Impact
1: Compliance Oversight Activities (COA) 1: FTEAM
3: IA
4: IM
Scrubber; Internal
Audit,
Monitoring, &
Delegated
Oversight
Delegation
Oversight;
Internal Audit;
Internal
Monitoring
2021 Layout Table FA 2020 Layout Table Inovaare Impact Business Impact
1: Rejected Claims Formulary Administration
(RCFA)
1: RCFA Scrubber Pharmacy; PBM
2: Rejected Claims Transition (RCT) 2: RCT-N
3: RCT-P
Scrubber Pharmacy; PBM
3: Prescription Drug Event (PDE) 4: PDE Scrubber Pharmacy; PBM
4. New Enrollee (NE) 5: NM Scrubber Pharmacy;
Enrollment; PBM
Layout Changes
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CPE/FA

Columns Removed
Name of FTE
FTE function and responsibilities
Auditor/Monitor Type
Identified Deficiencies
Description of Deficiencies
Corrective Action Description
Content Changes
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CPE

2021 Layout Table SNPCC 2020 Layout Table Inovaare Impact Customer Impact
1: Special Needs Plans Enrollees (SNPE) 1: SNPE Scrubber Coordinated Care;
Delegation Oversight
Layout Changes
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SNPCC
› PPME table has been removed
› An Impact Analysis may be requested for enrollees who fall outside
expected completion timeframes for initial and annual health risk
assessments when non-compliance with requirements is identified on
audit (Table 1IA and Table 2IA)

Layout Changes
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Columns Added
Most Recent Plan Change Effective Date
Date of most recent HRA
Date initial HRA (IHRA) was completed
Enrollee Risk Stratification Level at time of
audit engagement letter
Date of most recent Individualized Care Plan
(ICP)
Was an Interdisciplinary Care Team
created/identified?
Columns Removed
Enrollment Mechanism
Date sponsor received completed enrollment request
Was an initial HRA completed 90 days before or after the enrollment
effective date? (Changed to what is the date Initial HRA was
completed)
Did the sponsor conduct a HRA during the current audit period?
Date of completion for HRA conducted during current audit period
Was an ICP completed?
Cumulative Dollar Amount of Parts C and D Claims Paid
Cumulative Dollar Amount of Parts C and D Claims Denied
SNPCC

Take the road less traveled and experience all the difference
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Your Robert Frost Moment
Hope
› Generate clean universes without traditional
infrastructure
› Create CMS universes on demand in real time
Vision
› See with CMS eyes
› Detail compliance-program improvements
Options
› Build it
› Rent it
› Buy it

Actions Recommended
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› Collaborate with Operational and Compliance areas of business
› Work with your delegates
› Prepare accurate templates
› Be VERY familiar with changes
• Header terminology
• Valid data responses
› How are your universe tables produced?
› Final testing and validation

Time for
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CMS 2021 Audit Protocol Changes: Forewarned Is Forearmed

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