CMS-10630 PACE Supplemental Questionnaire

Instructions:

• Enter responses to each question in the PACE Supplemental Questions tab of this document.
• PACE organizations may also upload grievance and service delivery request policies pertaining to the questions in the PACE Supplemental
Questions tab.
• Responses must reflect practices, policies, and procedures in place during the audit review period. The audit review period begins 6 months
prior to the date of the audit engagement letter and ends on the date of the audit engagement letter. For example, an audit engagement
letter is issued on March 3, 2019. The audit review period for this audit is September 3, 2018, through March 3, 2019.

Due Date:

This document must be completed and submitted to HPMS within 5 business days following the issuance of the audit engagement letter.

PACE Supplemental Questions

Question #
1

2

Question
Please explain how your organization defines and processes grievances.

List the emergency medications (name, dosage and quantity) that your organization keeps
readily available on site at all times.
Note: List drug name as written on the product label. Do not include medications that are
stored in a cabinet, cart, room, etc. for convenience but are not specifically for emergency
situations. This list of emergency drugs may be provided as a separate attachment labeled
"emergency medications".

3

Include the name(s) of your organization’s electronic medical record system, if applicable.

4

Does your organization have the ability to provide remote access to medical records? If so,
please provide instructions for CMS to be granted access.

5

Please describe when your organization deems a service delivery request as received by the
IDT. Please attach the portion of the policy or procedure that discusses receipt of a service
delivery request.

6

Does your organization have any policies that place limits on the amount, duration, or
frequency of the following items or services:
a. Glasses/replacement glasses
b. Hearing aides/replacement hearing aides
c. Home care services (including services at night, on the weekends, or holidays)?
d. Respite
e. Specialist consultations
f. Nursing facility services
g. Hospital or ER services
h. Dental services
i. DME
j. Personal alert systems
k. Medications
If you answer yes to any of the above items, please explain the policy or restriction. You
may submit the policies directly into HPMS in lieu of an explanation (use the
"Supplemental" file type to upload).

7

Does your organization utilize a PBM and, if so, please explain the services they provide?

8

Does your organization have a P&T committee? If yes, please explain the responsibilities of
the P&T committee?
Can participants obtain prescriptions or orders written from any prescriber including
specialists? This includes prescriptions or orders for medications, DME, or any other
care/services applicable. If no, explain the process of reviewing recommendations for
prescriptions or orders from other prescribers and how the PACE organization determines
if the recommendation should be provided.

9

10

How does your organization identify drugs that are covered under Medicare Part D?

11

Are there any drugs that must undergo prior authorization before dispensing?
Prior authorization means that the participant must meet some form of criteria prior to
approval, for example, the participant must have a specific diagnosis or the participant
cannot be using illegal substances prior to receiving approval for the requested drug.

12

Are there any drugs that require step therapy?
This includes any program that requires a certain drug to be used first, before a different
drug can be dispensed.

13

Are there any drugs with quantity limits?
Quantity limits are often used in cases where FDA-approved prescribing instructions state
that only a certain number of doses should be used in a certain time period.

14
15
16

Are there any drugs that are considered preferred or drugs that participants are steered
towards?
What cost containment or utilization management programs do you utilize for Part D
drugs?
Are there any participants who have opioid restrictions? If yes, please provide a general
explanation of what the restrictions entail (e.g., describe your opioid restriction policies or
types of restrictions used).

OMB No: 0938-1327 (Expires: 03/31/2020)

Response