CMS Revises the 2019 A&G Guidance

By Jen Sousa, Vice President

In February 2019, CMS released the long-awaited updates to Chapter 13 of the Medicare Managed Care Manual and Chapter 18 of the Medicare Prescription Drug Benefit Manual. These changes were released as combined Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance. CMS has recently updated and revised this guidance, effective January 1, 2020.  Fortunately, CMS updated the guidance directly rather than issuing updates and clarifications via HPMS memos. We all know it’s hard to keep up with the changes through HPMS memos!

The most significant change is that CMS is applying Part D processing timeframes for coverage determinations and appeals to reviews for Part B drugs handled under Part C. This means that the following timeframes apply to Part B drugs:

  • Standard organization determination for Part B drugs: 72 hours
  • Expedited organization determination for Part B drugs: 24 hours
  • Standard reconsideration for Part B drugs: 7 calendar days
  • Expedited reconsideration for Part B drugs: 72 hours

As is the case for Part D drug reviews, plans cannot extend the timeframe for conducting an organization determination or reconsideration for Part B drugs. The easiest way to operationalize this change is to treat Part B drugs just as you would Part D drugs from a timeframe perspective.

Most of the other changes to the guidance are moving or reorganizing the language, which does not result in a true change. Below is a summary of the substantive changes to the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance:

  • Section 10.5.2: CMS added grievances to the types of requests that plans must accept 24 hours a day, 7 days a week. Most plans do this already, but this was officially added as a requirement.
  • Section 40.5.3: CMS clarifies that if a Part D exception request involves benefits not yet received, the start of the timeframe may be tolled, rather than is As we all know, “may” is usually treated as a “must” by CMS, so it was interesting to see CMS make this change.
  • Section 40.5.4: CMS provided much needed structure on processing timeframes when a request is tolled for a prescriber supporting statement. Under previous guidance, CMS used a “reasonable timeframe” standard and suggested that it not exceed 14 calendar days. In the updated guidance, CMS’s language is absolute and states that the plan must notify the enrollee (and the prescribing physician or other prescriber involved, as appropriate) of its decision no later than 72 hours (or 24 hours in the case of an expedited decision) after receipt of the prescriber’s supporting statement or 14 calendar days after receipt of the request, whichever occurs first. If the supporting statement is not received by the end of the 14 calendar days, then the plan sponsor must notify the enrollee (and prescriber, as appropriate) of its decision no later than 72 hours (24 for expedited cases) from the end of the 14 calendar days from receipt of the exception request.

Need assistance?  Call Shelley Segal at 562 334-7980 or Julie Mason at 415-596-5277.  Medicare Compliance Solutions can answer your questions, assist with implementation, review your policies and procedures, or conduct mock audits to assess your compliance with CMS requirements.  Don’t wait until it’s too late!


Jen Sousa, Vice PresidentJen Sousa

Jennifer Sousa is a seasoned compliance professional with 20 years of Medicare Advantage experience. She began her career with a large national plan, handling call center operations and appeals and grievances for their Medicare line of business. She then moved on to a 15-year career for a large state plan, serving as its Chief Compliance Officer and Medicare Compliance Officer. She joined the Medicare Compliance Solutions team in 2015.

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