CMS-10630 PACE Supplemental Questionnaire

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Overview

Instructions
PACE Supplemental Questions

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Sheet 1: Instructions

Instructions:	• Enter responses to each question in the PACE Supplemental Questions tab of this document. • PACE organizations may also upload grievance and service determination request policies pertaining to the questions in the PACE Supplemental Questions tab. • Responses must reflect practices, policies, and procedures in place during the data collection period. The data collection 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, 2023. The audit review period for this audit is September 3, 2022, through March 3, 2023.
Due Date:	This document must be completed and submitted to HPMS within 5 business days following the issuance of the audit engagement letter.

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Sheet 2: PACE Supplemental Questions

Question #	Question	Response
1	Please explain how your organization defines and processes grievances.
2	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	Please provide instructions for CMS to be granted access to your organization’s electronic medical record system.
5	Does your organization have any policies that place limits on the amount, duration, frequency, or other restrictions to receiving any of the following items or services: a. Glasses/replacement glasses b. Hearing aids/replacement hearing aids c. Home care services (including services at night, on the weekends, or holidays)? d. Respite care 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).
6	Does your organization utilize a Pharmacy Benefits Manager and, if so, please explain the services they provide?
7	Does your organization have a Pharmacy & Therapeutics (P&T) committee? If yes, please explain the responsibilities of the P&T committee?
8	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	How does your organization identify drugs that are covered under Medicare Part D?
10	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.
11	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.
12	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.
13	Does your organization maintain a list of preferred drugs that your providers refer to when considering which medication to prescribe? What factors go into identifying a drug as preferred for prescribing purposes?
14	What cost containment or utilization management programs do you utilize for Part D drugs?