CMS-10492 Third Party Administrators' Submission Requirements for

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Overview

Information Tab
Self Insured Plan Information
Instructions Tab

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Sheet 1: Information Tab

		DEPARTMENT OF HEALTH AND HUMAN SERVICES
		CENTERS FOR MEDICARE & MEDICAID SERVICES
	Third Party Administrators' Submission Requirements for Claims Cost Reimbursement of Certain Preventative Services
	Third Party Administrator & Pharmacy Benefit Manager Information
	Name of Third Party Administrator (TPA) or Pharmacy Benefit Manager (PBM):
	TPA or PBM Contact Information
		Contact Name:
	Title or Organizational Role of Contact Person:
		Telephone Number:		extension:
		Email Address:
		Alternate Contact Name:
	Title or Organizational Role of Alternate Contact:
		Telephone Number:		extension:
		Email Address:
	Payment Information
		Dollar Amount of Payments for Contraceptive Services For Plan Participants & Beneficiaries Paid by a TPA			$0.00
		calculation from Self Insured Plan Info Tab
		Number of Participants and Beneficiaries in Each Self-insured Group Health Plan			0
		calculation from Self Insured Plan Info Tab
	Attestation
		On behalf of my organization, I attest that the payments for contraceptive services were made in compliance with 26CFR § 54.9815-2713A(b)(2) or 29 CFR § 2590.715-2713A(b)(2). I certify that I am authorized to attest on behalf of my organization. I certify that the information contained in this submission is true, correct, and complete to the best of my knowledge and belief, and I attest that I have taken reasonable steps to ascertain the truth, correctness and completeness of this information. I attest that my organization will promptly inform CMS if my organization becomes aware that any of the information contained in this submission is untrue, incorrect, or incomplete.
		Signature of Attestor:
		Title or Organizational Role of Attestor:
		Date signed:		ex: mm/dd/yyyy
		Email Address:
		Telephone Number:		extension:
	Please Email this form to [email protected]

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Sheet 2: Self Insured Plan Information

		DEPARTMENT OF HEALTH AND HUMAN SERVICES
		CENTERS FOR MEDICARE & MEDICAID SERVICES
	Data Elements for Third Party Administrators' Submission Requirements for Claims Cost Reimbursement of Certain Preventative Services
	Information
	Self Insured Plan HIOS ID	Date TPA or PBM Notification of Intent Sent to HHS (please use this date format - mm/dd/yyyy)	Number of Participants and Beneficiaries in Self Insured Plan Administered by the TPA or PBM	Amount of Total Contraceptive Claims Paid by the TPA or PBM
	Please Email this form to [email protected]

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Sheet 3: Instructions Tab

		DEPARTMENT OF HEALTH AND HUMAN SERVICES (HHS)
		CENTERS FOR MEDICARE & MEDICAID SERVICES (CMS)
	Third Party Administrators' Submission Requirements for Claims Cost Reimbursement of Certain Preventative Services Form Instructions
	Form Objective	This form allows third party administrators (TPAs) and pharmacy benefit managers (PBMs) to submit information on payments for contraceptive services made under contract with an eligible organization as described in 26 CFR 54.9815-2713A. Eligible organizations receive an accommodation relating to contraceptive coverage so that they are not required to provide, arrange, or make payment for these services. As is described in 26 CFR 54.9815-2713A(b)(3), CMS will use the amounts reported in this form to adjust FFM user fees for FFM issuers that have entered into an agreement with a TPA or PBM that is arranging for contraceptive services to be provided to participants and beneficiaries in self-insured plans of organizations that receive the accommodation. This form is designed for TPAs and PBMs only. Issuers submitting information on payments for contraceptive services should use the version of this form specific to issuers.
	Submission Guidelines	Email this form to [email protected] 45 CFR 156.50(d)(2)(iii) requires a participating TPA seeking an FFM user fee adjustment to submit payment amounts for contraceptive services to CMS in the year following the calendar year in which the contraceptive services were provided. 45 CFR 156.50(d)(2)(iii)(A) through (E) specifies that TPAs must submit: • Identifying information for each TPA, • Identifying information for each self-insured group plan for which the TPA is seeking an adjustment, • The total number of beneficiaries and participants in each self-insured group plan, • The total dollar amount of payments for contraceptive services, and • An attestation that the payments for contraceptive services were made in compliance with federal law.
	This section lists each data element required for the form and detailed instructions on how to populate each data field in the workbook.
	Column Name	Column and Cell #	Instructions
	Information Tab
	Third Party Administrator (TPA) and Pharmacy Benefit Manager (PBM) Information
	Name of TPA or PBM	C11	Enter the business name of the TPA or PBM submitting the form.
	Third Party Administrator (TPA) Contact Information
	TPA User Fee Adjustment Contact Name	D17	Enter the name of the person CMS can contact if CMS identifies a discrepancy or has a question about the TPA's submission.
	Title or Organizational Role of Contact Person	D18	Enter the title or organizational role of the TPA user fee adjustment contact identified above.
	Telephone Number/Extension	D19 and E19	Enter the telephone number of the TPA contact person and include an extension, if applicable.
	Email Address	D20	Enter the email address of the TPA contact person.
	Alternate TPA User Fee Adjustment Contact Name	D23	Enter the name of an additional contact available to answer questions about the TPA's submission.
	Title or Organizational Role of Contact Person	D24	Enter the title or organizational role of the alternate TPA user fee adjustment contact identified in DE23
	Telephone Number/Extension	D25 and E25	Enter the telephone number of the alternate TPA contact person and include an extension, if applicable.
	Email Address	D26	Enter the email address of the alternate TPA contact person.
	Payment Information
	Dollar Amount of Payments for Contraceptive Services for Plan Participants & Beneficiaries Paid By a TPA	F30	Do not populate this field; this field auto populates with the sum of all amounts in Column E in the Self Insured Plan Information sheet. This amount reflects the total dollar amount of payments made by a TPA during the applicable calendar year.
	Number of Participants and Beneficiaries in Each Self Insured Plan	F34	Do not populate this field, this field auto populates with the sum of all amounts in Column D of in the Self Insured Plan Information Sheet. This number represents the total number of covered lives of participants and beneficiaries in self-insured plans for which the TPA or PBM arranged for the provision of contraceptive services during the applicable calendar year.
	Attestation
	Attestation Text	C39	This attestation certifies that: • The reported payments for contraceptive services were made in compliance with federal law [26 CFR § 54.9815-2713A(b)(2) or 29 CFR § 2590.715-2713A(b)(2)], • The attester is authorized to attest on behalf of the organization, • The attester certifies that the information contained in the submission is true, correct, and complete to the best of the attester's knowledge or belief, • The attester has taken reasonable steps to ascertain the truth, correctness, and completeness of the reported information, and • The organization will promptly inform CMS if the organization becomes aware that any information submitted on the form is untrue, incorrect, or incomplete. Read the text of the attestation carefully before signing.
	Signature of Attester	D41	Signature of the person responsible for attesting to the stipulations presented in the attestation statement.
	Title or Organizational Role of Attester	D42	Enter the title of the attester.
	Date Signed	D43	Enter the date the attestation was signed in eight-digit, mm/dd/yyyy format.
	Email Address	D44	Enter the email address of the attester.
	Telephone Number/Extension	D45 and E45	Enter the telephone number of the attester and include an extension, if applicable.
	Self Insured Plan Information Tab
	Self Insured Plan HIOS ID	B10 – B47	Enter the five-digit Health Insurance Oversight System (HIOS) ID for each self insured plan for which the TPA intends to seek an adjustment.
	Date of TPA or PBM Notification of Intent Sent to HHS (please use this date format - mm/dd/yyyy)	C10 – C47	Enter the date the TPA/PBM sent a notification to CMS indicating its intent to enter into an arrangement with a participating FFM issuer seeking an adjustment to the FFM user fee. Enter the date the TPA/PBM notified HHS of their intent to seek a user fee adjustment in eight-digit, mm/dd/yyyy format. HHS has issued clarifying guidance indicating that TPAs/ PBMs must notify HHS of their intent for an issuer to seek a user fee adjustment on their behalf by [Insert 30 days after finalization of the PRA]. The notification of intent letter is available on the CCIIO website. TPAs/PBMs should complete the letter and email it to [email protected]
	Number of Participants and Beneficiaries In Self Insured Plan Administered by the TPA or PBM	D10 – D47	Enter the total number of covered lives for participants and beneficiaries in the self insured plan for which the TPA/PBM administered or arranged for the provisions of contraceptive services in the year preceding the current calendar year. This number will reflect the total covered life enrollment in the self insured plan administered by the TPA/PBM as of December 31 of the year preceding the current calendar year. This number will count all participants and beneficiaries in the self insured plan administered by the TPA/PBM, irrespective of whether or not the plan participant or beneficiary utilized contraceptive services.
	Amount of Total Contraceptive Claims Paid by the TPA or PBM	E10 – E47	The total dollar amount for contraceptive claims, as defined at §147.130(a)(1)(iv), incurred by plan participants and beneficiaries as of December 31 in the year preceding the current calendar year. The dollar value of claims incurred by this date are counted in the total, even if the claims were not paid by December 31st. The total dollar amount equals the payment for contraceptive services that the TPA or PBM payments made directly, or the payment amount that the TPA or PBM arranged for an issuer or other entity to make on its behalf.