Chapter 3 eligibility, enrollment and disenrollment. The chapters provide a number of examples of types of ma and part d services provided to enrollees as well as the factors to consider in determining whether a vendor is an fdr. Medicare prescription drug benefit manual and chapter 21 of the medicare managed care manual. All cms program requirements under our contract with cms apply to our delegates. The guidance as described in chapter 9 of the cms prescription drug benefit manual and chapter 21 of the medicare managed care manual will be the primary reference source for capital health plans fraud, waste and abuse initiatives. All enrollments with an effective date on or after january 1, 2021, must be processed in accordance with the revised requirements, including the new model part d enrollment form for the 2021 plan year starting october 15, 2020 and model notices, as appropriate. Chapter 21, and the prescription drug benefit manual pdbm, chapter 9. Medicare prescription drug benefit manual chapter 9 and medicare managed care manual chapter 21. These compliance program guidelines apply fully to the prescription drug benefit programs of sections 1833 and 1876 cost plans.
Medicare managed care manual chapter 21 compliance program guidelines and prescription drug benefit manual chapter 9 compliance. This training module will assist medicare parts c and d plan sponsors in satisfying the compliance training requirements of the compliance program regulations at 42 c. Medicare prescription drug benefit manual, chapter 9. This attestation form is to facilitate the oversight and monitoring for fdr compliance with cms and. If theres an fdr audit or a monitoring activity, your organization may be asked to provide both a policy that documents a process, and evidence that. Medicare parts c and d general compliance training web. Per the medicare managed care manual chapter 21 and the prescription drug benefit manual chapter 9, providence medicare advantage plans considers the below functions to be delegated when performed by an entity other than the medicare advantage plan sponsor. Chapter 4 creditable coverage period determinations and the late enrollment penalty. Medicare managed care manual chapter 21 security health plan. Medicare managed care manual chapter 21 compliance. Sponsors and their fdrs are responsible for providing. Performrx manages the pharmacy network and administers pharmacy claims and benefits for all scha members.
Chapter 9 of the medicare prescription drug benefit manualchapter 21 of the medicare managed care manual. First tier entity validates that downstream entities maintain business associate agreements when. Scha provider manual chapter 21 pharmacy services march 2017 page 3 scha grants exceptions to the formulary if the provider prescribing the drug provides documentation to performrx that the prescription drug is dispensed as written to provide maximum medical benefit to the patient. Medicare parts c and d fraud, waste, and abuse training. Chapter 9 prescription drug benefit manual, chapter 21 medicare managed care manual, compliance program guidelines.
Prescription drug benefit manual chapter 9 compliance. Prescription drug benefit manual chapter 9 compliance program guidelines chapter 21 rev. Medicare managed care manual chapter 21 compliance program guidelines and prescription drug benefit manual chapter 9 compliance program guidelines chapter 21 rev. In fact, the basics of the 7 elements outlined in ch 9 21 were actually developed almost 30 years ago. The continuing care benefit shall be extended annually if the.
Medicare advantage and the medicare prescription drug benefit programs. Prescription drug benefit manual and chapter 21 of the medicare managed care manual. Medicare parts c and d general compliance training table. Scha provider manual chapter 21 pharmacy services january 2018 page 1 chapter 21 pharmacy services south country heath alliance utilizes performrx as our pharmacy benefit manager.
Medicare prescription drug benefit manual and chapter 21 of the medicare managed care manual the downloads section of the cms compliance program policy and guidance webpage. Chapter 18 part d enrollee grievances, coverage determinations, and appeals. Changes to the medicare advantage and the medicare prescription drug benefit programs section 50. Medicare managed care manual, chapter 21 on the cms website. Chapter 9 of the medicare prescription drug benefit manual. Draft chapter 9 prescription drug benefit manual draft. For medicare advantage organizations and prescription drug plans. Please note that this manual chapter does not address or provide guidance for medicare advantage ma issues that do not relate to the medicare part d prescription drug benefit. First tier entity attestation 2017 medicare advantage. To dispense prescription drugs, a dispensing provider must meet at least one of the following. These guidelines are identical and allow organizations offering both medicare advantage ma and prescription drug plans pdp to reference one.
Chapter 21 of the medicare managed care manual cms. Medicare managed care manual chapter 21 compliance program. Fraud, waste and abuse awareness and reporting policy 11. Compliance and fraud, waste and abuse peoples health. The primary plan benefit design will dictate drug coverage. The medicare compliance program requirements apply equally to the plan sponsor, moda health, and any individualentity with which moda health contracts for services related to the medicare advantage part c and prescription drug part d program.
Please refer to the compliance policy for how to align ethical behavior with compliance requirements. Combatting medicare parts c and d fraud, waste, and abuse. Compliance program guidelines for health care professionals. While sponsors may choose to use this module to satisfy compliance training requirements, completion of this training in and of itself does not ensure that. Ma or ma organizations, programs, benefit s, contracts or. Medicare parts c and d fraud, waste, and abuse training your. This guidance update is effective for contract year20 21. Auto and facilitatedenrollment of full benefit dualeligible beneficiaries and other low income subsidy. Scha provider manual chapter 21, pharmacy services page 1. Medicare prescription drug benefit manual and chapter 21 of the medicare.
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