CMS HPMS Memo, Part D Payment for Drugs for Beneficiaries Enrolled in Hospice—Request for Comments (Dec. 6, 2013), § CMS’ Independent Reviewer

We recognize a mechanism is necessary for handling disputes between the hospice and Part D

sponsors regarding payment responsibility when the drug should be paid for and the question at

issue is whether it should be paid for by the hospice or Part D sponsor. As a result, we are

exploring incorporating an independent reviewer function as part of the appeals process under a

CMS contract. The independent reviewer’s decisions will be binding on the hospice and the Part

D sponsor. We will outline the details of the independent review process in future guidance

providing adequate notice to all affected parties.

In the interim, CMS expects:

• The hospice and Part D sponsor to coordinate their benefits;

• The hospice/prescriber to immediately provide written documentation to satisfy the Part

D PA;

• The Part D sponsor to accept and maintain the documentation that the drug is unrelated

and not waived through the hospice election and is, therefore, reimbursable under Part D

and process the claim; and

• If the sponsor disagrees with the hospice/prescriber decision, the sponsor to flag the claim

and request a retrospective determination of drug payment responsibility by the

independent reviewer once the process is implemented.