CMS disposition for IRE auto-forwards in 2022

Inovaare received the following instructions from CMS regarding how it will rule on Approved, Denied and Dismissed statuses for IRE auto-forwards:

Please note, there is an “IRE auto-forward” disposition within the CDAG Program Audit Protocol and Data Request (CMS-10717), CDAG Universe Table 4: Standard and Expedited Redeterminations (RD) Record Layout, Request Determination field.
Redeterminations the Sponsoring organization auto-forwarded to the IRE during the universe request period would be entered as ‘IRE auto-forward’ in the Request Determination field.
There are also Date forwarded to IRE and Time forwarded to IRE fields in Universe Table 4.
On Slide 42 of the Part D Coverage Determinations, Appeals, and Grievances (CDAG) Final MAPD Program Audit Protocol Training presentation, CMS noted that for untimely coverage determinations or redeterminations that are auto-forwarded to the IRE, the Sponsor may enter the date and time it closed the case file as untimely and began preparing the case file for the IRE or when the file was sent to the IRE in the Date of Determination and Time of Determination fields. These event materials are available at: https://www.cms.gov/Outreach-and-Education/Training/CTEO/Event_Archives

Sponsoring organizations should enter Denied for all ODAG/SARAG cases that were sent to the IRE, including cases that were forwarded to the IRE due to untimely decisions and auto-forwarded because of upheld decisions.

Compliance Consultation