Appeals & Grievances—How to Measure & Improve Workflow Efficiency

In today’s managed care world, health plans must rely on complex, time-sensitive, heavily regulated, and repetitive processes to manage their Appeals & Grievances (A&G). No matter how well-designed your workflow is, there is always room for improvement. In fact, by taking a closer look at your A&G processes, you may be surprised at the challenges…

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CMS 2023 Final Notice & Updates for D-SNPs — What Should Plans Do Now?

In May, CMS published the 2023 Final Rule in the Federal Register. The rule includes many changes related to different areas, including marketing and communications, past performance, Star Ratings, network adequacy, medical loss ratio reporting, special requirements during disasters or public emergencies, and pharmacy price concessions; however, there are a number of changes related to…

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CMS Reposts CY2023 ANOC & EOC Models

On August 1, CMS reposted the revised Contract Year (CY) 2023 Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) models due to several identified issues. CMS distributed its “Model Notice Corrections” memo the following day, highlighting many of the changes. This is the first time since 2018 that CMS has provided revised models…

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Revised CMS CY23 ANOC & EOC Models — Expected Soon!

Keep an eye out for an upcoming CMS memo regarding the reposting of the CY23 ANOC & EOC models. Per CMS, the documents revealed several issues. Rather than sending a “very detailed” and lengthy corrections memo, CMS’s memo will coincide with the reposting of the models and include a summary of changes. The revised models…

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Provider Directory Accuracy—Why is it Important?

The Centers for Medicare and Medicaid Services (CMS) requires Medicare Advantage plans to post an online provider directory that is up-to-date and accurate. Beneficiaries must be able to use the online provider directory to find contracted providers they can see to receive covered services. Inaccurate provider directories pose risks to beneficiaries. Because members rely on…

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CMS Program Audit Findings & Key Preparation Tips

CMS released the 2021 Part C and Part D Program Audit and Enforcement Report on June 7, 2022. Highlights of the report indicate the average audit scores increased over the last report, stating 2020 average overall audit score of 0.15 to 2021 average overall audit score of 0.44. It’s worth noting, there were 27 plans…

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The Medicare Timeliness Monitoring Project (TMP)—What to Expect?

CMS continues to conduct an industry-wide Timeliness Monitoring Project (TMP). This project is a retrospective review of 2022 data. It allows CMS to collect data to evaluate the timeliness of processing Medicare Part C reconsiderations, using the new TMP and audit protocols in place for 2022. As a reminder, this data is used to verify…

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CMS Model Materials—Significant Changes for CY23

Wow! The CMS model materials were released weeks earlier than previous years, and we’re thankful for that! There are significant changes for CY23: most notably the reduction in length, reorganization, and reduction of tables and language. View the CY23 Models here: https://www.cms.gov/Medicare/Health-Plans/ManagedCareMarketing/MarketngModelsStandardDocumentsandEducationalMaterial CMS Model Materials Notable Changes Annual Notice of Change (ANOC)—Notable Changes (applies to…

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How to Ensure a Successful Triennial Network Adequacy Review

CMS monitors compliance with Network Adequacy Standards on a triennial basis. Every three years CMS requires a plan to upload its full-contract-level network into the Network Management Module (NMM) in Health Plan Management System (HPMS). When selecting contracts for the triennial review period, CMS pulls from the list of active contracts—primarily based on when the…

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