Sanctioned provider claims for Part D

[chantell.reagan]

One of our users posed a question, specific to Medicare Part D:

How are plans dealing with the sanctioned provider prescription claims for Part D members? For those plans that are rejecting these claims at the point of sale, are they requiring members to get a new prescription from a different provider before the claim can be processed or are they overriding the edit to allow the pharmacist to provide an interim supply (i.e. 15, 30days) while the patient chooses another provider?

[chantell.reagan]

It has been challenging to find a specific response to this question. While we are continuing to search for answers from the people who are currently dealing with these operational issues, I wanted to make a quick point. Having worked with the Medicare Part D benefit for 2 years, I would think that in the case of unsanctioned providers, plans should be able to provide an emergency supply, for a few days, similar to the 96-hour supply mandated by CMS for other authorization issues.

[S. Butler]

Hello, can you define "sanctioned provider". As I have found there seems to be several differing opinions on the definition.

[diana.papshev]

In this context a sanctioned provider would be anyone who is listed by the General Service Administrator (GSA) and/or the Office of the Inspector General (OIG) as an excluded prescriber (ie, excluded from participating in any government subsidized programs).

[S. Butler]

Per the FWA information I reviewed. Any sanctioned provider claim could not be billed to CMS. The Health Plan could pay for 15 days or so as an interim, and would best serve the patient, but submitting the claim on a PDE file for example, might "red flag" for a potential fraud, waste and abuse review.