CMS-10191 ODAG Supplemental Questions

ODAG_SupplementalQuestions

Question #

1
2

Question
Are Organization Determinations made by your organization or a first tier or downstream
related entity (FDR)?
How many staff at each entity are dedicated to ODAG for your organization?

3

Does this staff perform only ODAG review for your organization or do they do other work
also?

4

If staff performs other work, how much of their time is spent on work for your organization?
And who supervises this work?

5

Are Reconsiderations made by your organization or by a FDR? If different than Organization
Determinations, explain how information is shared between the two entities.

6

Is there a policy which indicates what requirements must be met before a pre-service request
is approved (e.g., ER services, outpatient hospital, inpatient hospital, urgent care, etc.) ? Y/N

7
8
9

If response to #6 is yes, please attach the portion of your policy that specifically address this
question.
Do you have a policy for approval time frames? Y/N
If response to #8 is yes, please attach the portion of your policy that specifically address this
question.
Please explain your mailroom policies and/or procedures as related to beneficiary notification.

10

11

Are grievances handled by your organization or a FDR? What is the process once a grievance
is received by either entity?

12

Which entity, Sponsor or FDR, is responsible for incoming ODAG calls on evenings,
weekends, and holidays?

13

If the Sponsor handles calls on evenings, weekends and holidays, are all inquiries (e.g., Part C
ODAG and Part D CDAG) handled at the same call center? Or are there specific staff that
handles only ODAG requests?

14

If a FDR handles calls on evenings, weekends and holidays, is the call-in number dedicated to
just business for the Sponsor?

15

If a potential organization determination (OD) is discussed during a grievance call, what is the
Sponsor's SOP for handling the OD?

16

Please provide a description of how your organization handles POS transactions for Part B
drugs? Include how your organization classifies these transactions (i.e., classified as a preservice OD, etc)?

17

If you are processing POS transactions for Part B drugs as organization determinations, are
you following the OD guidance in Chapter 13? If not, please describe the process/ internal
procedures you use to handle these transactions (i.e., what notification is given, etc)?

18

When processing these transactions do you follow the notification guidelines in Chapter 13
for (claims or pre-service ODs)? If "yes," enter notification fields as you normally would. If
"no," do you send any notification? (If "no," fields should be marked NA.)

Response