Crosswalk (60- to 30-day Package)

September, 2014 (old version)	January, 2015 (new version)	Type of Change	Reason for Change	Burden Change
Throughout the Document-unrelated to the terminal prognosis	Unrelated to the terminal illness and related conditions	Rev	Based on comments received we are changing all references to "terminal illness and related conditions" to "terminal prognosis" to be consistent with language used in the statute.	No
Throughout the Document-"would"	"will"	Rev	As we move to finalize the instruction, we changed the instruction from proposed language "would" to "will".	No
Introduction- We have since learned that the industry has worked through the National Council of Prescription Drug Plans (NCPDP) Hospice Task Group to develop a draft form to be used for documenting Part D coverage of drugs for beneficiaries enrolled in hospice.	Subsequently, the industry has worked through the National Council of Prescription Drug Plans (NCPDP) Work Group 9 Hospice Task Group to develop a draft form to be used for documenting Part D coverage of drugs for beneficiaries enrolled in hospice.	Rev	Changed the tense of the sentence and also adds the specific work group number for clarification.	No
Introduction-A slightly modified version of the form was included with the revised guidance issued on July 18, 2014 and we are proposing that all Part D sponsors and hospices implement this version as the standard form.	A slightly modified version of the form was included with the revised guidance issued on July 18, 2014 and we encourage Part D sponsors and hospices to implement this version as a standard form.	Rev	Clarifies that CMS encourages use of the form but does that require it. CMS cannot require the form in absence of a regulatory change.	No
Purpose-These two uses are discussed below:	It may also be used for hospice providers to communicate and update the medications list from the beneficiary’s plan of care. These issue uses are discussed below.	Rev	Changed to expand instruction based on comments received.	No
Purpose-CMS July 18, 2014 guidance strongly encouraged Part D sponsors to place beneficiary-level PA requirements for their enrollees who have elected hospice care and are taking any of the four categories of prescription drugs identified by the DHHS Office of Inspector General (OIG) discussed above: analgesics, antinauseants (antiemetics), laxatives, and antianxiety drugs (anxiolytics).	CMS July 18, 2014 guidance strongly encouraged Part D sponsors to place beneficiary-level PA requirements on the four categories of prescription drugs identified by the DHHS Office of Inspector General (OIG) discussed above: analgesics, antinauseants (antiemetics), laxatives, and antianxiety drugs (anxiolytics) for plan enrollees who have elected hospice.	Rev	Changed to improve readability	No
Purpose- Hospice providers and Part D sponsors have expressed the need for a standardized form that would facilitate communication between all involved parties.	Hospice providers and Part D sponsors have expressed the need for a standardized form that would facilitate communication between all involved parties.	Rev	Changed to improve readability	No
Purpose-CMS July 18, 2014 guidance strongly encouraged Part D sponsors to place beneficiary-level PA requirements for their enrollees who have elected hospice care and are taking any of the four categories of prescription drugs identified by the DHHS Office of Inspector General (OIG) discussed above: analgesics, antinauseants (antiemetics), laxatives, and antianxiety drugs (anxiolytics). Hospice providers and Part D sponsors have expressed the need for a standardized form that would facilitate communication between all involved parties.	CMS July 18, 2014 guidance strongly encouraged Part D sponsors to place beneficiary-level PA requirements on the four categories of prescription drugs identified by the DHHS Office of Inspector General (OIG) discussed above: analgesics, antinauseants (antiemetics), laxatives, and antianxiety drugs (anxiolytics) for plan enrollees who have elected hospice. Hospice providers and Part D sponsors identified the need for a standardized form that would facilitate communication between all involved parties.	Rev	Changed to improve readability	No
Purpose-Alternatively, if this documentation is not provided in advance, the plan will be unable to determine whether the drug is related or unrelated to a beneficiary’s terminal conditions and, thus, the pharmacy will receive an A3 reject, meaning that the claim has been rejected as “unable to be processed”.	Alternatively, if this documentation is not provided prospectively, the plan will be unable to determine whether the drug is related or unrelated to a beneficiary’s terminal prognosis and, therefore, whether the drug is covered under Part D. Thus, the pharmacy will receive an A3 reject, meaning that the claim has been rejected as “This Product May Be Covered Under Hospice – Medicare A ” in combination with reject 75- Prior Authorization Required .	Rev	Changed to expand instruction based on comments received.	No
Purpose-In this case, the pharmacy will notify the beneficiary of the reject and may also notify the prescriber or the hospice. Once notified of the reject, the hospice provider or prescriber can complete and submit the form to the plan sponsor. The plan sponsor should accept it and use it to satisfy the CMS requirements and allow for normal processing of the claim. If a coverage determination is requested by the beneficiary prior to the sponsor’s receipt of the documentation, the plan sponsor must contact either the prescriber or the hospice provider to complete and submit the form. The plan sponsor should accept it and use it to satisfy the CMS requirements for removal of the A3 edit.	In this case, the pharmacy will notify the beneficiary of the reject and may also notify the prescriber or the hospice. Once notified of the reject, the hospice provider or prescriber can complete and submit the form to the plan sponsor. The plan sponsor should accept it and use it to satisfy the CMS requirements and allow for normal processing of the claim. If a coverage determination is requested by the beneficiary prior to the sponsor’s receipt of the documentation, the plan sponsor must contact either the prescriber or the hospice provider to complete and submit the form. The plan sponsor should accept it and use it to satisfy the CMS requirements for removal of the A3 edit.	Rev	Changed to expand instruction based on comments received.	No
Purpose-Part D Plan sponsors should use the information to update the beneficiary’s hospice information until the official notice is received from CMS	Part D Plan sponsors should use the information to update the beneficiary’s hospice information until the official notice is received from CMS on the daily transaction reply report (TRR). If the TRR continues to reflect a different hospice status than the one communicated by the hospice, the Part D sponsor and the hospice should attempt to reconcile the difference so that the correct status is known for each beneficiary.	Rev	Changed to expand instruction based on comments received.	No
Purpose-	Added the following section: 3) To communicate medications listed on the plan of care Medicare hospice providers are required to conduct and document a patient-specific comprehensive assessment in writing. The assessment must also include a drug profile with all of the patient’s prescription and over-the-counter (OTC) drugs, herbal remedies, and other alternative treatments that could affect drug therapy. Medication information obtained through the assessments, including whether the medications are related or unrelated to the terminal prognosis, should be provided to the Part D sponsor prospectively, before a hospice beneficiary presents a prescription for fill. The form provides a uniform way for a hospice provider to provide initial and updated drug profiles to the Part D sponsor. It is important for the Part D sponsor to be aware of all drugs which the beneficiary will be taking as well as the source of payment for each drug. As a reminder the beneficiary must assume the financial liability for a drug that is beyond what is considered reasonable and necessary. If the patient or his/her representative does not agree with the hospice plan of care and refuses to accept medications prescribed to meet the assessed needs, then the hospice is required to document this in the clinical record.	Rev	Changed to expand instruction based on comments received.	No
Users of the form and recommendations for use: Hospice Provider	Added the following section: To prospectively provide “unrelated”drug information to the Part D plan: The hospice provider can use the form to identify drugs on the beneficiary’s treatment plan that fall into any of the four previously specified categories of prescription drugs and are unrelated to the terminal prognosis. Initiating communication prior to a claim’s submission will provide early notice to the Part D plan sponsor/PBM and reduce the number of claims rejected at the point of sale.	Rev	More detailed instructions per comments received.	No
Users of the form and recommendations for use: Hospice Provider Complete Sections I and, optionally, II. Section II is not required to override the A3 reject. However, it is recommended that the hospice provider complete this section and provide copies to the beneficiary and the Medicare Part D plan to facilitate prospective/retrospective drug review processes. Fax the completed form to the beneficiary’s Medicare Part D plan.	Complete and sign Section I. At the hospice’s option, complete Section II. Section II is not required to override the A3 reject. However, it is recommended that the hospice provider complete this section and provide copies to the beneficiary and the Medicare Part D plan to facilitate prospective/retrospective drug review processes.• Transmit the completed form to the beneficiary’s Medicare Part D plan.In some instances a hospice is made aware of a hospice A3 reject for one of their beneficiaries and the drug was prescribed by a community physician unaffiliated with the hospice. In those cases, the hospice should coordinate with the community physician who should complete and sign the form.	Rev	Comments received asked for clarification of which fields need to be completed and what constitiues a completed form. We insterted additional instruction in several parts of the new form to help users of the form .	No
To report only a change in hospice status:The hospice provider would complete the “To:” and “From:” information segment as well as the first 6 fields in the “Patient Information” segment and check the “Admission or Discharge Update Only” box to alert the plan sponsor that no A3 reject override is applicable. The form submission is informational only.	The hospice provider will: • Check the “Enrollment” or “Termination”: box • Complete the “To:” and “From:” information segment as well as the first 6 fields in the “Patient Information” segment. • Complete the Hospice Admit or Discharge Date as applicable. • Check the box in Section 1 B to indicate which document will be attached to the form (NOE or NOTR). • Transmit the form and attachments to the beneficiary’s Part D plan.	Rev	Comments received asked for clarification of which fields need to be completed and what constitiues a completed form. We insterted additional instruction in several parts of the new form to help users of the form .	No
To report plan of care information:The hospice provider’s completion of Section II, which provides the plan of care information, is optional as it is not required to either override the A3 reject or communicate a change in the beneficiary’s hospice status.	The hospice provider’s completion of Section II, which provides the plan of care information, is optional as it is not required to either override the A3 reject or communicate a change in the beneficiary’s hospice status.	Rev	Improves readability	No
Prescriber To provide information to override an A3 reject: The hospice provider would: • Identify the beneficiary’s Medicare Part D plan and obtain the appropriate fax number or contact information to which the completed form should be directed. • Complete Section 1 to report for each drug that is unrelated to the terminal illness and/ related conditions. • Fax the completed form to the beneficiary’s Medicare Part D plan. Prescribers unaffiliated with the hospice provider should also: Contact the hospice provider to confirm that the medication is unrelated to the terminal illness and/or related conditions, and check the box on Page 1 under the prescriber’s signature.	Prescriber To provide information to override an A3 reject: Prescribers will: • Identify the beneficiary’s Medicare Part D plan and obtain the appropriate fax number or other contact information to which the completed form should be directed. • Complete Section 1 reporting each drug that is unrelated to the terminal prognosis. • Transmit the completed form to the beneficiary’s Medicare Part D plan. Prescribers unaffiliated with the hospice provider should also: Contact the hospice provider to confirm that the medication is unrelated to the terminal prognosis, and check the box on Page 1 under the prescriber’s signature. A signature indicates that the prescriber is aware that a medication is unrelated to the hospice prognosis. Part D sponsor may need to process more than one form for a beneficiary who is has multiple prescribers.	Rev	Comments received asked for clarification of which fields need to be completed and what constitiues a completed form. We insterted additional instruction in several parts of the new form to help users of the form .	No
Medicare Part D Plan Sponsor/PBM Upon receipt of the completed form, the Part D sponsor should override the A3 reject for the drugs listed. In addition the Part D sponsors should concurrently obtain and review the information necessary to promptly determine whether any applicable drug-specific UM requirement has been satisfied (or, alternatively, whether an exception to that UM requirement has been requested). The plan sponsor/PBM should make sure that the beneficiary’s hospice information is reflected in the sponsor’s systems until a Transaction Reply Report (TRR) is received from CMS with the election information.	Medicare Part D Plan Sponsor/PBM To prospectively satisfy PA requirements for a member enrolled in hospice: When a Part D sponsor/PBM receives prospective notification of drug information from the hospice provider indicating that a beneficiary who has elected hospice is using Part D drugs in the four categories that are unrelated to the terminal illness, the sponsor/PBM will accept the form and use it to satisfy the PA requirement. These prospective communications are not requests for coverage determinations and need not comply with coverage determination timeframes and notice requirements. This is the case regardless of how the form is transmitted to the plan sponsor/PBM. For example, even if the notification is sent through the coverage determination fax line, it would not be considered a coverage determination because it was communicated prior to the sponsor/PBM’s receipt of a claim and a hospice provider cannot request a coverage determination. To override A3 reject: When the necessary information has been provided, the sponsor/PBM will override the A3 reject for the medications listed as being unrelated to the terminal prognosis. In order for the request to be considered complete all fields in Section I must be completed EXCEPT for the following: Part A Plan sponsor Website Link Hospice Pharmacy Benefit Manager (PBM) Information if not applicable Upon receipt of the completed form, the Part D sponsor will override the A3 reject for the drugs listed. In addition the Part D sponsors will concurrently obtain and review the information necessary to promptly determine whether any applicable drug-specific UM requirement has been satisfied (or, alternatively, whether an exception to that UM requirement has been requested). To process a change in hospice status: When the necessary information has been provided, the plan sponsor/PBM will use the information submitted on and with the form as Best Available Evidence (BAE) to update the beneficiary’s hospice enrollment status. In order for the request to be considered complete the following fields in Section I must be completed: Part A Part B, Patient Name, DOB, Patient HICN# Prescriber, Name, Prescriber NPI An NOE or NOTR must be attached? The plan sponsor/PBM will ensure that the beneficiary’s hospice information is reflected in the sponsor’s systems until a Transaction Reply Report (TRR) is received from CMS with the updated election/termination information.	Rev	More detailed instructions per comments received.	No
The plan sponsor/PBM should make sure that the beneficiary’s hospice information is reflected in the sponsor’s systems until a Transaction Reply Report (TRR) is received from CMS with the election information.	To process a change in hospice status: When the necessary information has been provided, the plan sponsor/PBM shouldwill use the information submitted on and with the form as Best Available Evidence (BAE) to update the beneficiary’s hospice enrollment status. In order for the request to be considered complete the following fields in Section I must be completed: Part A Part B, Patient Name, DOB, Patient HICN# Prescriber, Name, Prescriber NPI An An indication whether an NOE or NOTR is attached The appropriate form must be attached? The plan sponsor/PBM should make will ensure that the beneficiary’s hospice information is reflected in the sponsor’s systems until a Transaction Reply Report (TRR) is received from CMS with the election updated election/termination information.	Rev	Expanded instruction	No
None	Use of plan of care information: The plan sponsor/PBM may receive a form with the Section II completed. Although completion of Section II, which provides the plan of care information, is optional (i.e., it is not required to either override the A3 reject or communicate a change in the beneficiary’s hospice status), it is encouraged. When received by the sponsor/PBM, the information regarding the additional medications prescribed and the responsible financial party will assist the sponsor in their utilization review and coordination of care activities.	Rev	More detailed instructions per comments received.	No
Pharmacy Provider	Pharmacy Provider Assist the beneficiary in accessing unrelated drugs When a Medicare Part D claim rejects with an A3 reject code, the pharmacy may contact the beneficiary’s hospice provider to provide the contact information for the Part D plan included in the supplemental messaging received with the A3 reject. If the hospice provider is unknown and other sources have been exhausted to identify the beneficiary’s hospice, the pharmacy may contact the prescriber to alert him or her of the hospice election and determine whether this prescription is under the plan of care. For “unrelated” medications, the pharmacy should request the hospice provider or prescriber to complete the Section I information for the Part D plan sponsor/PBM to override the A3 reject, and transmit to the beneficiary’s Medicare Part D plan. When a pharmacy receives a copy of a completed form from the beneficiary, the pharmacy may transmit a copy to the Part D sponsor/PBM. This may be done prospectively prior to the submission of a drug claim or in response to the pharmacy’s receipt of an A3 reject.	Rev	More detailed instructions per comments received.	No
Signature Requirements: Section 1 of the form must be signed and dated by either the hospice representative or the prescriber. Section 1 of the form must be signed and dated by either the hospice representative or the prescriber. If Section II is completed, a hospice representative and the beneficiary/representative must sign.	Signature Requirements: 1. Section 1 of the form must be signed and dated by either the hospice representative or the prescriber when the form is utilized in the following ways: a) to prospectively inform the Part D plan sponsor/PBM of drugs in the 4 categories that will likely be dispensed because they are both included in the plan of care and are unrelated to the terminal prognosis. b) to document a change in hospice status and the appropriate signed (NOE or NOTR) is attached The sponsor’s/PBM’s pharmacy help desk staff may sign the form in these two instances as well when staff complete the form based on a telephone contact with the hospice provider or prescriber. As part of the signature process, help desk staff should sign their name and include the name and contact information for the person who phoned in the information as well as the date the call was received. 2. All requests for a Hospice A3 Reject Override must be signed by the prescriber, the beneficiary or the hospice representative. 3. If Section II is completed, a hospice representative and the beneficiary/representative must sign.	Rev	More detailed instructions per comments received.	No
Limited Customization of the Format The form has been developed to provide a template for use by Part D sponsors. If the form is used, sponsors may customize it by including a plan logo and to facilitate electronic submission of the required information . No other modifications are permitted.	The form has been developed to provide a template for use by Part D sponsors. If the form is used, sponsors may customize it by including a plan logo and to facilitate electronic submission of the required information . No other modifications are permitted.	Rev	Improves readability.	No
Form-Section 1-Section I- Information to Override A3 Reject	SECTION I -HOSPICE INFORMATION TO OVERRIDE AN “HOSPICE A3 REJECT” OR TO UPDATE HOSPICE STATUS	Rev	Based on comments made name of section more inclusive of all intended use of form	No
Form-Section 1	Labeled sections "A", "B", "C", "D"and "E"	Rev	To make instruction and reference to the form easier.	No
Form-Section 1-Section "A" Purpose of the form	Inserted "proactive Rx Communication"	Rev	Inserted this purpose of the form.	No
Form-Section1- Section "A" -To: Medicare Part D Plan Information From: Hospice Provider Information	To: Medicare Part D Plan From: Hospice Provider	Rev	The word "information" is superfluous in these sentences	No
Form-Section1- Section "B" -Admit Date, Discharge Date	Hospice Admit Date Hospice Discharge Date	Rev	Based on comments included the word "hospice" to clarify which admission and discharge dates are being referenced	No
Form-Section1- Section "B" -Primary diagnosis, Secondary Diagnosis, Unrelated	Principal Diagnosis Code, Other Diagnosis Code (s), Unrelated Diagnosis Code (s)	Rev	Commentor wanted specific instruction as to whether to enter diagnosis or diagnosis code so we specify code as the field to be entered. Also specified which codes (principal, other, related, unrelated) we expect.	No
Form-Section1- Section "B" -Admission or Discharge Update Check Here	For change in hospice status update documentation is required. Please check to indicate which document is attached.	Rev	The Admission or Discharge Status is in the "A" purpose of the form above and need not be repeated so was eliminated in this section. Also, based on comments received hospices are being asked to provide the appropriate attachment to support the admission or discharge.	No
Form-Section1- Section "C" -Pharmacy Benefit Manager (PBM) Information	C. Hospice Pharmacy Benefit Manager (PBM) Information	Rev	A commentor appeared unsure which party's PBM we meant so we specified that the hospice's PBM was the one we were seeking in this field.	No
Form-Section1- Section "D" -Prior Authorization Process: Prior Authorization Process: Enter a separate line for each Analgesic, Antinauseant (antiemetic), Laxative, and Antianxiety drug (anxiolytic) Medication that is Unrelated to Terminal Illness and/or Related Conditions:	D. Prior Authorization Process: Enter a separate line for each Analgesic, Antinauseant (antiemetic), Laxative, and Antianxiety drug (anxiolytic) Medication that is Unrelated to Terminal Prognosis . Drugs outside of these four classes do not require prior authorization	Rev	Commentor suggested addition of clarification that drugs not in the 4 classes don't require a prior authorization	No
Form-Section1- Signature Block	Added "Title"	Rev	Agreed with commentor who suggested that we add a space to add the title of the signatory	No
Form-Section1- Signature Block *If the prescriber of the non-covered medication is unaffiliated with the Hospice provider, has the prescriber confirmed with the Hospice provider that the medication is unrelated to the terminal	*If the prescriber of the medication is unaffiliated with the Hospice provider, has the prescriber confirmed with the Hospice provider that the medication is unrelated to the terminal prognosis?	Rev	Eliminated "non-covered"from wording since that meaning was unclear.	No