CMS Pub. 100-18, ch. 14, § 50.14.6

A number of issues associated with Part D, such as incidents involving multiple payers,

payer order, and retroactive eligibility, create challenges for coordinating benefits among

Part D sponsors and other providers of prescription drug coverage. When all payer

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information is available at the point-of-sale, pharmacies typically serve as the intermediary,

facilitating coordination between Part D sponsors and other payers.

However, when the information necessary to identify the correct primary payer for Part D

drugs provided to Medicare beneficiaries enrolled in Part D sponsors is incomplete or

lacking, through no fault of the pharmacy, a pharmacy may bill the State and other payers

instead of a beneficiary’s Part D sponsor.

CMS may address many of these situations through a special, one-time reconciliation

process. However, some of these situations may require resolution through claims reversal

and rebilling. In their role of facilitating coordination between Part D sponsors and payers,

some pharmacies may agree to reverse incorrect claims and bill the proper Part D sponsor.

CMS believes that in those circumstances in which the pharmacy is not at fault, it would be

inappropriate for Part D sponsors to impose the conventional 30-90 day timely filing limits

rather than a less restrictive timeframe, since this industry standard generally applies only

when the pharmacy is in a position to correctly bill but fails to do so. CMS believes that this

process is also appropriate for use in the Point of Sale Facilitated Enrollment process when

incorrect health insurance claim numbers (HICNs or MBIs) were used.

Beginning in 2007, in lieu of a requirement for a 180-day timeframe, which was

implemented to accommodate the identification and resolution of coordination of benefits

issues requiring claims reversal and rebilling to appropriate payers when Medicare Part D

was introduced in 2006, CMS requires sponsors to establish at least a 90-day claims filing

timeframe and to make appropriate allowances for COB claims on a case-by-case basis. It is

important to note also that plans may be liable for claims from the prior year that are

received after March 31st. While in these instances contractual provisions regarding timely

claims filing may limit claims from network pharmacies, non-network pharmacies and

beneficiaries must still have the opportunity to submit claims for reimbursement.

With the inclusion in the claim segment of the transaction standard for retail pharmacy drug

claims of field number 357-NV, Part D sponsors may use certain delay reason codes in the

external code list, to specify the reason for the delay in claims submission, in order to

differentiate COB-related delays from other types of delays.

50.15 – Using the Best Available Information when making B vs D Coverage

Determinations

(Issued: 04-02-18, Effective Date; 01 -01-2019, Implementation Date: 01-01-19)

In the 2019 Final Call letter CMS announced the launch of a web portal called Additional

Beneficiary Information Initiatives (ABII, pronounced ‘Abby”). As of September, 2018 the

system is being populated with Medicare -covered transplant data derived from Medicare

fee-for -service claims. CMS is exploring using the ABII portal to convey other COB-related

data to Part D plans. Part D plans needing access to ABII should consult the August 14,

2018 HPMS memo titled “Access to the Additional Beneficiary Information Initiatives

(ABII) Web Portal”.

50.15 .1 – Immunosuppressants Used to Prevent Transplant Rejection

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Part D plans use ABII to access Medicare-covered transplant data derived from Medicare

fee-for -service claims. The following guidance establishes CMS’ expectations for how Part

D plans should perform due diligence to ensure that Part D does not pay for drugs that

should be paid under Part B. In all cases, Part D sponsors should document the basis for

their determinations to cover immunosuppressants and make such documentation available

upon audit.

1. No Prior Part D Claims History for Immunosuppressants

a) The plan has received information from CMS (e.g. via MARx or ABII) indicating that

Medicare covere d the enrollee’s transplant or, in the case of a Medicare Advantage

enrollee, the MA Plan has medical claims history of a covered transplant regardless of

previously received information from a prescriber on whether or not the transplant was

covered by Med icare.

In this situation, plans are expected to rely on the CMS information (or in the case of an MA

plan, its own medical claims history) and cannot cover immunosuppressants under Part D

even if information is also provided by the prescriber that indicat es that the transplant was

not Medicare covered.

b) The plan has NOT received information from CMS (via MARx or ABII) indicating that

Medicare covered the transplant for the enrollee; in the case of a Medicare Advantage

enrollee, the MA Plan does not hav e medical claims showing a history of a covered

transplant; and the plan has not previously received information from a prescriber that the

transplant was covered by Medicare.

In this situation, CMS expects plans to default to covering the immunosuppressa nts under

Part D and no longer expects plans to reach out to prescribers to inquire about Medicare

coverage of the transplant. Such outreach is burdensome for plans and prescribers, and has

been shown to be unreliable for accurately determining if Medicare covered a transplant.

Nevertheless, the plan should approach this coverage decision using the best available

information; if the plan has previously reached out to the 257

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prescriber and received information indicating that the that the transplant was c overed by

Medicare (in full or in part), the Part D plan may not cover immunosuprressants under D.

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2. Prior Part D Claims History AND MARx or ABII currently indicates that Medicare

covered the transplant:

A plan might have covered the drugs under Part D previously because either:

• MARx information was updated after the Part D sponsor relied on prior information

from the prescriber that the transplant was NOT covered/ paid by Medicare; or

• The Part D sponsor had relied solely on information from the prescriber that the

transplant was NOT covered/paid by Medicare without regard to MARx.

Under either scenario, the Part D sponsor must now rely on the MARx information going

forward and notify the enrollee that the plan can no longer cover the immunosuppressant(s)

because it is covered under Medicare Part B. No changes need to be made to prior Part D

claims.

3. Prior Part D Claims History, no MARx indicator or MA plan medical claims history of a

covered transpl ant BUT the Part D sponsor receives information from CMS that the

transplant was covered by Medicare (e.g. Part D sponsor receives the information from

CMS as part of a CMS Program Integrity audit or through ABII).

Under this scenario, the Part D sponsor must now rely on the CMS information going

forward and provide notice to the enrollee that the plan will no longer cover the

immunosuppressant(s) under Part D because it is covered under Medicare Part B. No

changes need to be made to prior Part D claims.

50.16.2 – Inhalation Durable Medical Equipment (DME) Supply Drugs

Medicare Part B covers certain inhalation drugs, such as Albuterol and Levalbuterol

nebulizer solutions, as supplies under the DME benefit. The DME benefit, however, is not

available to beneficiaries residing in long -term care facilities (i.e. Nursing Facilities and

Intermediate Care Facilities for Individuals with Intellectual Disabilities). Consequently, if

the beneficiary is not on a Part A stay in one of these facilities, these inhalation drugs can

be covered under Medicare Part D. CMS permits Part D sponsors to rely on a patient

residence code of “3” or “9” on a pharmacy claim for determining when such inhalation

drugs may be covered under Part D. Moreover, we expect that sponsors wil l only pay claim s

for these products when the pharmacy claim includes these specified patient residence codes

regardless of any prior coverage determination based upon a prescriber statement

indicating that the beneficiary resides in a long-term care facil ity (i.e. the prescriber

statement and patient residence code must be aligned).