- Establish CMS Casework Communication Email box & Update Contacts in HPMS
Establish an Email Box --
Per instructions provided in the January 11, 2006 User Group call, CMS is strongly encouraging your organization to immediately establish a CMS casework communication email box. We believe that the email box will provide a communication channel that will allow your organization and CMS to better manage the total casework load. This email box should be functional no later than this weekend, January 14, 2006. Instructions for providing to HPMS the email box address and the name of the person from your organization responsible for managing its contents are provided below.
Your organization can expect to receive at least two types of beneficiary specific information, which will be encrypted or password protected:
a) downloads of contract-specific complaint files that come into 1-800-Medicare, and
b) beneficiary cases from the CMS regional offices concerning problems at the point of sale which are impeding the beneficiary from getting their prescription or paying too much, and an intervention from the plan is necessary to bring the case to closure.
1) The files your organization will receive in the email box will contain Prescription Drug Program complaint records as captured daily by the CMS 1-800-Medicare Helpline CSRs. The file will be in a comma delimited format (.csv) for ease of use, and to allow for additional sorting as needed. When selected, the file will open by default into Microsoft Excel.
The file will contain information about the beneficiary, the complaint, several informational flags and optional plan and pharmacy information. If a beneficiary did not provide a piece of information, that field will be blank. Fields of particular interest and their location within the file are:
+ LIS Eligible (Limited Income Subsidy) - Column F (Values: Yes, No, Unknown, or NA)
+ Critical Flag - Column E (Values: Yes, No - Based on question: Is the beneficiary completely out of medication and unable to get their prescription filled?
+ Complaint Category - Column I (Multiple Values)
+ Complaint Type - Column J (Multiple Values based on Category)
+ Complaint Summary - Column O (Based on CSR captured text from Beneficiary)
+ Reason Card Didn't Work at Pharmacy - Column AB (Freeform text from Beneficiary)
Plan Name, Plan Contract Number, Plan Member Number, and PBP Number are optional fields that were provided by the Beneficiary based on information that was available to them at the time of the call.
It is our expectation that your organization will use the LIS information in the interim until your files are updated through the regular transaction reports. Using this file, your organization should check the LIS status and if your organization's data does not have the person identified as LIS eligible, use this information. Information in this file will not differentiate levels of cost sharing so your organization would default to the $2 / $5 co pay level.
2) It is our expectation that your organization is doing everything possible to prevent issues from turning into complaints made to 1-800-MEDICARE and the CMS regional offices. CMS has and will continue to develop and provide guidance and other information to your organization to facilitate rapid resolution of issues occurring at the point of sale.
For complaints that require casework that CMS submits in your organization's email box, your organization must ensure that the contents of this email box are downloaded and addressed routinely throughout each day. In operating the email box, your organization will need to respond to messages sent from the CMS regional office caseworkers indicating what action is being taken to resolve the issue. From CMS' perspective the case will not be closed until your organization completely resolves it and communicates that to the caseworker. In responding to the caseworker, your organization should provide in the subject line the case number if it is provided to your organization. All beneficiary health information must be password protected in email.
Your organization should be actively identifying and triaging to the front of your own casework urgent issues that need immediate resolution, e.g., a person needs medications urgently.
Your organization should also be looking for patterns among the complaints and your organization's own performance monitoring metrics to ensure systemic issues are quickly identified and resolved.
Emergency Contact & Pharmacy Technical Support Contacts in HPMS --
Your organization's designated contacts as listed in HPMS (e.g., emergency contact and pharmacy technical desk support contact) must be available to CMS caseworkers during the hours in which your pharmacy network operates. That includes weekends and holidays. For most networks there are at least some pharmacy chains open 24 / 7. Your organization's pharmacy technical desk support contact must also be available to the pharmacists in your network during these open hours. Your organization would be out of compliance with CMS guidance if a pharmacist in your network can not gain access to your plan to immediately resolve transition and formulary issues.
You are strongly encouraged to check in HPMS these contacts and their contact information to ensure these numbers are up to date. We will provide this contact information to all of our caseworkers on Friday afternoon, January 13, 2006. Instructions for entering this information into HPMS are provided below.
Part D Appeals Contact in HPMS --
CMS has received many requests, particularly from the LTC pharmacy community and from the physician community, about how to contact the Part D plans on formulary exceptions and appeals issues. Your organization provided a Part D appeals contact in HPMS. Please be advised that we will be sharing this number with the provider community on Friday, January 13, 2006. Please check to ensure that the appropriate contact for the provider community is in HPMS. Instructions for entering this information into HPMS are provided below.
Instructions for Providing Email Box and Contact Information to HPMS --
Please use the following navigation path in HPMS to enter your CMS casework communication contact and to update your existing contacts: HPMS Homepage > Contract Management > Contract Management > Select a Contract Number > Contact Information. If you require technical assistance, please contact the HPMS Help Desk at either 1-800-220-2028 or firstname.lastname@example.org.