COVID-19 Emergency Flexibilities for Medicare (Part C/D) Appeals
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Describes temporary operational flexibilities Imperial/EnvisionRx will apply to processing Medicare Advantage (Part C) and Part D appeals during the COVID-19 public health emergency; affects plan/TPA appeals staff and delegated entities handling Medicare appeals for enrolled members.
No material clinical or coverage changes in this revision.
Appeals Processing Flexibilities
Appeals processing flexibilities and constraints
EnvisionRx will apply CMS flexibilities and specific operational recommendations when processing delegated Part D (and where applicable Part C) appeals during the declared public health emergency.
Flexibilities (apply when applicable)
- Extend filing timeframe beyond 60 calendar days for adverse decisions dated March 1, 2020 or later
- Waive timeliness for requests for additional information needed to adjudicate the appeal
- Process appeals submitted by a person claiming to be the enrollee's representative as if received from the enrollee; provide notification of the decision to the enrollee even if representative documentation is incomplete
- Process appeal requests that lack required elements using available information and utilize good-cause flexibilities
Constraints specific to Part D
- Part D adjudication timeframes cannot be extended (standard: 7 days; expedited: 72 hours)
- Outreach to obtain additional information will continue to be made within the required Part D timeframes
Procedural / Coding References
| No codes listed |
Operational Flexibilities and Provider Directions
Operational flexibilities for appeals processing
Apply CMS COVID-19 flexibilities when processing delegated Medicare appeals: extend filing timeframes, waive timeliness for requests for additional information, process appeals with incomplete representative forms while communicating only to the beneficiary, process requests missing required elements using available information, and apply good-cause flexibilities as appropriate for the duration of the HHS public health emergency.
- Extension to file an appeal beyond standard timeframes
- Waive timeliness for requests for additional information
- Process appeals with incomplete Appointment of Representative forms and communicate decisions to the enrollee
- Process appeals missing required elements using available information
- Treat good-cause flexibilities as satisfied where applicable
Extension to file appeals for adverse decisions dated March 1, 2020 or later
EnvisionRx will extend the standard 60-calendar-day filing timeframe for appeals for adverse decisions dated March 1, 2020 or later, allowing members additional time to request an appeal for those decisions.
- Applies to adverse initial determination notices dated March 1, 2020 or later
- Extends filing timeframe beyond the normal 60-calendar-day limit for those decisions
Process appeals submitted by claimed representatives without valid AOR
If an appeal is submitted by someone claiming to be the enrollee's representative but lacking a valid Appointment of Representative (AOR), EnvisionRx will process the appeal as if received from the enrollee and will provide notification of the decision to the enrollee.
- Do not delay review pending receipt of representative documentation for Part D delegated appeals during the emergency
- Communicate decisions to the enrollee even when representative forms are incomplete
Part D adjudication timeframes remain fixed; outreach continues
Part D adjudication timeframes (7 days standard, 72 hours expedited) cannot be extended; outreach to obtain additional information must continue and determinations must be completed within these required timeframes.
- Part D standard: 7 calendar days; expedited: 72 hours
- No extensions permitted for Part D adjudication timeframes—continue outreach within the required period
Key Terms and Timeframes
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