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Regulatory Updates
INSURANCE UPDATES

PRECLUSION LIST

CMS will make the Preclusion List available to Part D sponsors and the MA plans beginning JANUARY 1, 2019.

EFFECTIVE APRIL 1, 2019:

  • Part D sponsors will be required to reject a pharmacy claim (or deny a beneficiary request for reimbursement) for a Part D drug that is prescribed by an individual on the Preclusion List.
  • MA plans will be required to deny payment for a health care item or service furnished by an individual or entity on the Preclusion List.

 Who is on the list? 

Individuals or entities who meet the following criteria:

Are currently revoked from Medicare, are under an active reenrollment bar, and CMS has determined that the underlying conduct that led to the revocation is detrimental to the best interests of the Medicare program.

OR

 

  • Have engaged in behavior for which CMS could have revoked the individual or entity to the extent applicable if they had been enrolled in Medicare, and CMS determines that the underlying conduct that would have led to the revocation is detrimental to the best interests of the Medicare Program.

 What happens if I’m on Preclusion List?

 

  • You will receive an e-mail and letter from CMS/MAC in advance.
  • The e-mail and letter will be sent to your PECOS and NPPES.
  • The letter will contain the reason of preclusion and your applicable rights to appeal.

 

More info here.

 

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Insights
October 2018