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CMS Clarifies Treatment of AOR Requests

CMS Clarifies Treatment Of AOR Requests

Some time ago the Centers for Medicare and Medicaid (CMS) clarified to MedHOK and some health plans that Appointment of Representative (AOR) processes could be more liberal than what was outlined in Medicare Advantage Chapters 13 and 18. Because the manuals were not yet updated, some plans took a rather conservative approach to AOR policies and required the filing of an AOR form with each request for a requester who is someone other than the member or an authorized provider. But now with the proposed consolidation of the Chapters in to a clearer, streamlined sole chapter, CMS is outlining for all plans the more liberal informal guidance it has given in the past.

In 20.2 of the proposed consolidated chapter, CMS states “If the representative form is maintained and accessible by the plan, a photocopy of the signed representative form is not required to be filed with future grievances, coverage requests, or appeals made on behalf of the enrollee in order to continue representation. If the plan uses a representative form that is on file for requests, it must include a copy when sending a case file to higher level adjudicators, if applicable.” It goes on to state that the form is valid for the life of a grievance, coverage request, or appeal if the grievance, coverage request, or appeal was received within one year of the date a representative form is signed by both the enrollee and appointee.

So, the guidance is now clear:  if the CMS AOR form or an equivalent document is submitted, as long as the plan maintains the signed AOR and it is available for review when future requests come in, this is enough to satisfy requirements.

In comments to CMS on the proposed consolidation, we are seeking to clarify for current universes whether a plan should use the original AOR receipt date for the AOR receipt date element?  We are asking as the draft 2019 ODAG protocols (deferred until 2020) eliminate the AOR receipt date element and ask plans to report the AOR receipt date as the receipt date of the case. Regardless of the answer, plans will need to ensure that their systems calculate a correct due date for the case, which in this case would be from the receipt date of the case.

Marc Ryan

Marc S. Ryan serves as MedHOK’s Chief Strategy and Compliance Officer. During his career, Marc has served a number of health plans in executive-level regulatory, compliance, business development, and operations roles. He has launched and operated plans with Medicare, Medicaid, Commercial and Exchange lines of business. Marc was the Secretary of Policy and Management and State Budget Director of Connecticut, where he oversaw all aspects of state budgeting and management. In this role, Marc created the state’s Medicaid and SCHIP managed care programs and oversaw its state employee and retiree health plans. He also created the state’s long-term care continuum program. Marc was nominated by then HHS Secretary Tommy Thompson to serve on a panel of state program experts to advise CMS on aspects of Medicare Part D implementation. He also was nominated by Florida’s Medicaid Secretary to serve on the state’s Medicaid Reform advisory panel.

Marc graduated cum laude from the Edmund A. Walsh School of Foreign Service at Georgetown University with a Bachelor of Science in Foreign Service. He received a Master of Public Administration, specializing in local government management and managed healthcare, from the University of New Haven. He was inducted into Sigma Beta Delta, a national honor society for business, management, and administration.

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