CurrentglobalhealthPolicy GH-RX-083
Part B Drug Transition Period
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Policy governing a minimum 90-day transition period for Medicare Advantage (MA) plan enrollees receiving active courses of treatment that include physician-administered Part B drugs; applies to GlobalHealth Holdings, LLC and GlobalHealth, Inc.
Policy Summary
Payerglobalhealth
PolicyPart B Drug Transition Period
Policy CodePolicy GH-RX-083
Change TypeClarified definitions and administrative updates
Effective DateJan 1, 2024
Last ReviewDec 19, 2025
Next Review DateJan 1, 2026
Key ActionDo not require prior authorization or deny coverage for an active course of treatment for new enrollees for at least 90 days.
SourceLink
POLICY UPDATE CHANGES
Updated the Organization Determination definition and added definitions for Active Course of Treatment, Course of Treatment, Prior Authorization, Reliable Evidence, Similar Fault, and MR4; replaced mention of Healthaxis with MR4; added section on the effect of prior authorization to align with CMS-4208-F.
90 daysminimum transition period
24 hoursexpedited determination timeframe
72 hoursstandard determination timeframe
Up to 90 daysmax transition fill approved
2024-01-01effective date
Part B Transition Coverage Criteria
Part B transition coverage criteria
Coverage during the transition period for new MA enrollees undergoing active treatment including physician‑administered Part B drugs:
Do not disrupt or require prior authorization for an active course of treatment for new enrollees for at least 90 days or until the course concludes, whichever comes first; services cannot be denied solely because prior authorization was not obtained or because care was furnished by an out-of-network provider, though services may be reviewed against coverage criteria when determining payment.
Eligibility: applies to new enrollees to MA coordinated care plans (including those new to Medicare or switching from Traditional Medicare) who are undergoing an active course of treatment, including physician‑administered Part B drugs.
Start date: the 90‑day transition period begins the date enrollment in the new plan becomes effective.
Post‑transition reassessment: after 90 days GlobalHealth will reassess medical necessity via prior authorization and may apply plan benefits and out‑of‑network limits as appropriate.
Documentation and approval process: if documentation confirms active treatment, the Pharmacy Administrative Coordinator will upload supporting documentation to MR4 and approve a Part B transition fill for up to a maximum of 90 days within the member's first 90 days of transition.
Effect of prior authorization or pre‑service/concurrent approval: once GlobalHealth has approved a covered item or service via prior authorization, pre‑service determination, or concurrent determination, GlobalHealth will not later deny coverage for lack of medical necessity or reopen the decision except for good cause or reliable evidence of fraud or similar fault.
Timing for expedited organization determinations: expedited organization determinations must be rendered as expeditiously as the enrollee’s condition requires, but no later than 24 hours after receipt of the request.
Regulatory & Coding References
Regulatory referencesmixed
| CMS-4201-F | Centers for Medicare & Medicaid Services (CMS) Final Rule |
| CMS-4180-F | Medicare Advantage and Part D Drug Pricing Final Rule (42 CFR Parts 422 and 423) |
| HPMS Memo: Release of Medicare Advantage and Prescription Drug Plan Appeals Guidance | HPMS memorandum (2/22/2019) |
| CMS HPMS Memo: CY 2022 Parts C & D Dismissal and Withdrawal Q's & A's | CMS HPMS memorandum (December 9, 2021) |
| CMS-4208-F | Contract Year 2026 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare cost Plan Program, and Programs of All-Inclusive Care for the Elderly (PACE) |
| 42 CFR 422.566 | Organization Determinations |
| 42 CFR 422.138(c) | Prior Authorization - Effect of prior authorization, pre-service, or concurrent approval |
| 42 CFR 422.568(b)(3) | Requests for a Part B drug |
| 42 CFR 422.572(a)(2) | Timeframe and notice requirements for expedited organization determinations - Requests for a Part B drug |
| 42 CFR 422.112(b)(8) | Continuity of Care |
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Transition period (inv-03)
Transition period length90 days
Transition period startBegins the day enrollment in the new plan becomes effective
Maximum transition fill approvedPart B transition fill may be approved for up to 90 days within the member's first 90 days
Provider Requirements and Organization Determinations
Prior Authorization
Part B transition: 90‑day no‑prior‑auth protection and organization determination timing
Do not require prior authorization or deny coverage for a new enrollee's active course of treatment — including physician‑administered Part B drugs — for at least 90 days from the plan effective date; after 90 days GlobalHealth will reassess medical necessity via prior authorization and may apply out‑of‑network limits. Expedited organization determinations must be rendered as expeditiously as the enrollee's condition requires, but no later than 24 hours after receipt of the request.
- The 90-day transition period begins the day enrollment in the new plan becomes effective. [[citation not in body; see citations field]]
- If documentation confirms active treatment, the Pharmacy Administrative Coordinator uploads it to MR4 and may approve a Part B transition fill for up to 90 days within the member's first 90 days.
- After 90 days GlobalHealth will reassess medical necessity through prior authorization and apply out‑of‑network limits per plan benefits.
- Expedited organization determinations must be rendered no later than 24 hours after receiving the request.
Defined Terms
Active Course of Treatment (inv-05)
DefinitionA course of treatment in which a patient is actively seeing the provider and following the course of treatment.
Regulatory citationReferenced at § 422.112(b)(8)(ii)(B) and applied to Part B transition eligibility
ApplicabilityUsed to determine eligibility for the 90-day transition protections for new enrollees undergoing active treatment, including physician-administered Part B drugs
Course of Treatment (inv-06)
DefinitionA prescribed order or ordered course of treatment for a specific individual with a specific condition, outlined and decided upon ahead of time with the patient and provider. A course of treatment may but is not required to be part of a treatment plan.
ContextForms the basis for transition protections when the enrollee is actively following the ordered course of treatment
Relation to prior authorizationAfter the 90-day transition, GlobalHealth may reassess medical necessity for the course of treatment via prior authorization
Expedited Organization Determination for Part B Drugs (inv-07)
Definition and purposeAn enrollee or any physician may request an expedited organization determination when waiting could place the enrollee's life, health, or ability to regain maximum function in serious jeopardy.
Required timeframeMust be rendered as expeditiously as the enrollee's condition requires, but no later than 24 hours after receiving the request.
Use caseApplies to Part B drugs when delay could seriously jeopardize the enrollee; complements standard (72-hour) determinations for non‑expedited requests.
MR4 (inv-08)
Platform referenceMR4: platform used by PBMs for clinical and utilization management; replaces prior reference to Healthaxis in this policy.
Operational usePharmacy Administrative Coordinator uploads documentation to MR4 when confirming active treatment and requesting Part B transition fills.
PurposeSupports care management, utilization management, and regulatory compliance for PBMs and risk-taking health plans.
Organization Determination (inv-09)
DefinitionAny determination made by the health plan regarding payment, coverage, refusal, reduction, or premature discontinuation of a previously authorized ongoing course of treatment, or failure to provide timely approvals/notice.
ExamplesIncludes decisions about payment for out-of-area services, emergency/post-stabilization care, services furnished by non‑plan providers, and reductions or premature discontinuation of authorized treatment.
Timing considerationFailure to provide timely approval or notice that would adversely affect the enrollee's health is also an organization determination.
Prior Authorization (inv-10)
DefinitionA utilization management requirement under which an enrollee (or their provider) must obtain approval from GlobalHealth before the plan will cover a specific service, item, or benefit.
PurposeEnsures the service meets plan coverage criteria and is medically necessary according to CMS standards.
Interaction with transition periodGlobalHealth does not require prior authorization or deny coverage for an active course of treatment for at least 90 days for new enrollees; after 90 days, prior authorization may be used to reassess medical necessity.
Reliable evidence (inv-11)
DefinitionReliable evidence means evidence that is relevant, credible, and material.
Standard for reopening decisionsGlobalHealth may reopen an approved prior authorization or determination only for good cause or if there is reliable evidence of fraud or similar fault.
Role in appeals and reviewsReliable evidence is the threshold for justifying reconsideration or reopening of prior approvals under policy provisions.
Similar fault (inv-12)
DefinitionSimilar fault means conduct to obtain, retain, convert, seek, or receive Medicare funds to which a person knows or should reasonably be expected to know they are not entitled, including failure to file a proper claim.
ScopeIncludes actions by the individual or another for whose benefit Medicare funds are obtained, retained, converted, sought, or received.
ConsequencesReliable evidence of similar fault can justify reopening or rescinding prior approvals or coverage determinations.
Policy Summary
Payerglobalhealth
PolicyPart B Drug Transition Period
Policy CodePolicy GH-RX-083
Change TypeClarified definitions and administrative updates
Effective DateJan 1, 2024
Last ReviewDec 19, 2025
Next Review DateJan 1, 2026
Key ActionDo not require prior authorization or deny coverage for an active course of treatment for new enrollees for at least 90 days.
SourceLink
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