Download your free Universe Management Case Study

Download now
IRE auto-forwards rule by CMS in 2022 IRE auto-forwards rule by CMS in 2022

    Your Name *

    Your Email *

    Download Files

    Reporting

    • The State Regulatory Guidance (All Plan letters) responsibilities include, but are not limited to:
      1. DHCS All Plan Letter (APL) and Policy Letter (PL) Applicable Notices
      2. DHCS All Plan Letter (APL) and Policy Letter (PL) - Non-Applicable Notices
      3. Submits proof of APL and PL compliance documents to DHCS
    • The Organization Risk Assessment responsibilities include, but are not limited to:
      1. Review of new potential risks with assigned accountable business owners
      2. Provide final data set to senior executive team for implementation of agreed upon interventions
    • The Regulatory Audit Process responsibilities include, but are not limited to:
      1. Creation of audit folders
      2. Tracking of documents/universe and requests received from the auditor and distributed to the business owners
      3. Audit Readiness Questionnaires
    • The Regulatory Routine Reporting responsibilities include, but are not limited to:
      1. Maintaining calendar for all regulatory compliance
      2. Tracking timeliness of business owner’s submissions and attestation

    Monitoring

    • The Enterprise Monitoring and Oversight workstream responsibilities include, but are not limited to:
      1. CMS Program Audit universe scrubber (for all universes)
    • The Federal Regulatory Guidance (CMS HPMS memos) responsibilities include, but are not limited to:
      1. Tracking of regulatory guidance changes (2017 Medicare Marketing Guidance Changes)
      2. Maintenance of the 2018 Call Letter Grid that illustrates deliverables by business units

    Audit and CAP

    • The Internal Audit workstream responsibilities include, but are not limited to:
      1. Review of prior and current year ORA risks
      2. Initiates Management Action Plans (MAP) for all audits that produce findings

    Pre-delegation audit

    Pre-Delegation Audit, Healthcare Delivery Organization (HDO) Credentialing, HDO Initial Credentialing, HDO Re-credentialing and Re-credentialing.

    • Facility Site Review audits, specifically audit of medical facilities/sites
    • Medical Record Review audits, specifically audit of medical records
    • Utilization Management audits include:
      1. UM audits
      2. Quality Management (QM) audits
      3. Special Needs Plan (SNP) audits
      4. Service Denial audits

    Pre-delegation audit

    Credentialing, Facility Site Review (FSR), Medical Record Review (MRR) and Utilization Management (UM).

    • Credentialing audits include:
      1. Adverse Action Monitoring
      2. Annual Credentialing
      3. Credentialing Initial File
      4. Credentialing

    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:

    CDAG

    • 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

    ODAG/SARAG

    • 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