CMS, Hospice Information for Medicare Part D Plans (OMB 0938-1269), § Hospice Provider

To prospectively provide “unrelated” drug information to the Part D plan:

The hospice provider can use the form to identify drugs on the beneficiary’s treatment plan that fall into

any of the four previously specified categories of prescription drugs and are unrelated to the terminal

prognosis. Initiating communication prior to a claim’s submission will provide early notice to the Part D

plan sponsor/PBM and reduce the number of claims rejected at the point of sale.

To provide information to override an A3 reject:

The hospice provider will:

• “Identify the beneficiary’s Medicare Part D plan information from the beneficiary’s Medicare Part D

card or by contacting the pharmacy provider.

• Call the beneficiary’s Medicare Part D plan to obtain the appropriate fax number or other contact

information to which the completed form should be directed.

• Complete and sign Section I.

• At the hospice’s option, complete Section II. Section II is not required to override the A3 reject.

However, it is recommended that the hospice provider complete this section and provide copies to the

beneficiary and the Medicare Part D plan to facilitate prospective/retrospective drug review

processes.

• Transmit the completed form to the beneficiary’s Medicare Part D plan.

In some instances a hospice is made aware of a hospice A3 reject for one of their beneficiaries and the drug

was prescribed by a community physician unaffiliated with the hospice. In those cases, the hospice should

coordinate with the community physician who should complete and sign the form.

To report only a change in hospice status:

The hospice provider will:

• Check the “Enrollment” or “Termination”: box

• Complete the “To:” and “From:” information segment as well as the first 6 fields in the “Patient

Information” segment.

• Complete the Hospice Admit or Discharge Date as applicable.

• Check the box in Section 1 B to indicate which document will be attached to the form (NOE or

NOTR).

• Transmit the form and attachments to the beneficiary’s Part D plan.

To report plan of care information:

The hospice provider’s completion of Section II, which provides the plan of care information, is optional as it

is not required to either override the A3 reject or communicate a change in the beneficiary’s hospice status.

However, it is recommended that copies be provided to the beneficiary and to the Part D plan sponsor.

Informing the plan sponsor of the additional medications prescribed and designating the responsible financial

party will assist the sponsor in better managing the beneficiary’s coverage and providing appropriate access

to medication.