CMS HPMS Memo, Part D Payment for Drugs for Beneficiaries Enrolled in Hospice—Final 2014 Guidance (Mar. 10, 2014), § CMS’ Independent Reviewer

Many commenters on the December 6th memorandum indicated the establishment of an

independent reviewer process would require rulemaking and requested we work with

stakeholders to establish standards and criteria for the reviewer to use in making coverage

determinations, reviewer qualifications and timeframes for each phase of the process. We agree

and will consider the process for future rulemaking.

Thus, there will be no process for dispute resolution for 2014. Instead, CMS expects:

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

• The hospice provider or the prescriber to promptly provide verbal communication or

written documentation from the hospice provider or prescriber in order to satisfy the

beneficiary-level hospice PA. That is, information explaining why the drug is unrelated

to the terminal illness or related conditions, or is related to the terminal illness or related

conditions and, therefore, is a responsibility of the hospice provider or beneficiary;

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

the terminal illness or related conditions and is, therefore, reimbursable under Part D and

process the claim; and

• The sponsor and hospice to negotiate the retrospective recovery of the amounts paid, if

the sponsor has paid for drugs after the effective date of the hospice election, but prior to

receipt of notification from CMS.