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Preclusion List Letter and FAQs Published

Preclusion List Letter And FAQs Published

In a November blog, we told you that the Preclusion List requirements would go into effect in early 2019. On December 14, the Centers for Medicare and Medicaid Services (CMS) issued a Frequently Asked Questions (FAQs) and the final letter plans need to send to members notifying them that they have received healthcare services or prescriptions from a precluded provider.

The FAQs clarify a few key areas. See our November blog here for details regarding the November policy memo:

  • The proposed rule covering the preclusion list, among other things, would cover 2020 and beyond. For now, the November notice will be the policy for 2019.
  • A member should be notified as soon as possible but no later than 30 days from the posting of the list and the beneficiary should have at least 60 days’ advance notice before a plan denies payment/rejects claims associated with a precluded provider. A plan may provide a beneficiary with more than 60 days’ notice but should not deny payments/reject claims earlier than 90 days after publication of the associated Preclusion List. CMS states that this will allow the beneficiary at least 60 days to find a new provider and obtain a new prescription.
  • Plans can send their own letters but should ensure that all areas of the sample letter are covered. The five percent language threshold rule applies to translation of these letters.
  • The Preclusion List file has been updated to include a preclusion date and a payment denial/claim rejection date. Important information on Preclusion List layouts and communications are posted here.
  • MA plans should notify precluded providers that they can no longer treat plan members and also notify all plan members who have received services from the precluded provider over the past 12 months as soon as possible but no later than 30 days after the date the provider has become precluded. Reasonable efforts would include copying the precluded provider on the required notice to the member. Alternatively, a plan could send a separate notice to the provider by mail or email.
  • CMS does not rule out members requesting authorizations and appealing denials for services or drugs requested by those on the preclusion list. It indicates the sample letter states that the member should seek services from other providers but then the FAQs note: “In addition, an enrollee always has the right to seek a coverage decision from the plan if there’s a question regarding coverage for an item, service or drug.” CMS has confirmed with MedHOK that coverage requests could occur, but we are clarifying details with the agency, including appeals, population of the universe and other treatment during the process.
  • Plans also need to notify non-contracted providers as well if they furnished services to members in the last 12 months (but not those with no nexus to the member, such as ER or related providers).
  • All downstream entities will need to access the Preclusion List from their health plans.
  • New members with no claim history do not need to be notified.
  • This will be a monthly process, but plans do not need to renotify members who were previously notified for a given provider. The same notification and denial periods apply to each subsequent monthly list – within 30 days to notify and at least 60 days before denial but no earlier than 90 days after a provider is added to the Preclusion List.
  • Groups may appear on the list as well as individual providers. TIN and NPI validation of groups and covered providers would need to occur.
  • The first list was made available on January 1. So, notices must go out by January 31 and denials no earlier than April 1.
  • There is also some confusion in the FAQs related to Part B drugs. It is our view that since these are covered under Part C for Medicare Advantage that the same rules apply to Part D and Part B drugs as well as other Part A and B services.

We continue to solicit input from our client plans to ensure we launch the Preclusion List solution in our UM, Medical Appeals and Pharmacy solutions.

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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