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

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    • 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


    Continuous monitoring allows a health plan to quickly and easily keep its finger on the pulse of the delegates’ performance to identify potential risks or issues before they become major problems. This will help ensure compliance with needed regulations through the health plan’s ability to:

    • Expedite feedback processes to mitigate operational and enterprise risks
    • Utilize streamlined reporting processes to automate reviews and highlight elements that are approaching identified tolerances
    • Track findings, recommendations and corrective action plans, as well as trends over time, to quickly compare delegates and prepare for renegotiation when the time comes

    Audit and CAP

    Auditing delegated entities is essential for maintaining good governance, managing risk and ensuring compliance within an organization. Health plans can now efficiently oversee audits and perform file reviews of their delegated entities and vendors and maintain a system-wide overview of all compliance activities:

    • Deliver real-time audit results
    • Lower audit backlog, efforts and timelines
    • Help health plans with pre- and post-delegation audits of all areas of delegation
    • Create and manage Corrective Action Plans (CAP) for all audits that produce findings

    Pre-delegation audit

    The pre-delegation audit process involves a comprehensive review of the proposed delegates’ policies, procedures, and systems, as well as an assessment of their compliance with relevant technical and operational standards. The audit may also include a review of their financial stability and management structure. Our module helps guide the process through:

    • Facility Site Review audits
    • Medical Record Review audits
    • Credentialing Audits Pre- and Annual re-certification
    • Utilization Management audits including Quality Management (QM) audits
    • Special Needs Plan (SNP) audits

    Delegation repository

    Centralized database of your various delegate or vendor information, allowing health plans to easily track and manage relationships with its FDRs.

  • Demographic information
  • Contact information
  • Responsibilities or functions assigned
  • Audit activities and past performance
  • 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:


    • 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