April 2016 Issue 9 Training Changes In This Issue

April 2016 – Issue 9Training changesEffective 1/1/2016, Centers for Medicare &Medicaid Services (CMS) requires that FDRs useCMS’s training courses to meet the FDR trainingrequirements.Two ways to completeYour employees and Downstream Entities assignedto provide administrative and/or health careservices for our Medicare plans can access CMS’strainings in one of two ways:1. Complete the modules on the MedicareLearning network (MLN) website. The generalcompliance course is called Medicare Parts Cand D General Compliance Training, and theFWA training is called Combating MedicareParts C and D Fraud, Waste and Abuse (FWA)Training. They can both be completed on theMLN, after registration.2. Download or print CMS’s general compliancetraining and FWA training and incorporatethem into your training materials/system. Youcan’t change the content of the CMS trainingmodules to ensure the integrity andcompleteness of the training.Regardless of the method used, training must becompleted: Within 90 days of hire or the effective date ofcontracting At least annually thereafterSP-0046-16In this issue Training changesAudit protocol updatesPrior to hire screeningsBan of Advanced Beneficiary Notices(ABN) for Medicare Advantage (MA)Quick links Aetna's FDR Guide (updated 2/2016) Medicare Managed Care Manual Medicare Prescription Drug Benefit Manual Aetna’s Code of Conduct (updated 10/2015) CMS’s General Compliance Training CMS’s FWA Training Exclusion Lists:oOIG's List of Excluded Individualsand Entities (LEIE)oGSA's System for AwardManagement(SAM)Aetna maintains a comprehensive MedicareCompliance Program. It includes communicationwith Aetna Medicare FDRs. Dedicated to Aetna’sMedicare Compliance Program is John Wells,Medicare Compliance Officer. He’s based inMaryland. You can send questions or concerns forJohn and/or his Medicare compliance subjectmatter experts to MedicareFDR@aetna.com.

Keep recordsWe confirm your compliance with theserequirements as part of our annual attestationprocess. But you should also maintain evidence oftraining completion. Evidence of completion may bein the form of certificates from the MLN,attestations, or training logs. If you use training logsor reports as evidence of completion, they mustinclude: Employee names Dates of employment Dates of completion Passing scores (if captured)FWA Training exceptionThe only exception to this training requirement is ifyou are “deemed” to have met the FWAcertification requirements through enrollment intoMedicare Parts A or B of the Medicare program orthough accreditation as a supplier of DurableMedical Equipment, Prosthetics, Orthotics andSupplies (DMEPOS). Those parties deemed to havemet the FWA training through enrollment into theCMS Medicare Program must still completegeneral compliance training.CMS’s audit protocolupdatesCMS performs regular program audits on plansponsors, like Aetna, that offer Medicare Part Cand D plans. These audits ensure that we deliverbenefits according to the terms of our contract.They also confirm that we evaluate compliancewith core program requirements.On October 19, CMS released their 2015 and 2016audit protocols. This release was followed by aclarification document issued on January 19.Major universe changesBelow is a summary of the major changes betweenthe 2015 and 2015/2016 universes. This list is notcomplete. You can refer to the 2015/2016 AuditProtocol documents and CMS Audit ProtocolAnnouncement, and CMS Audit ProtocolAddendum Memo for a full description of changes.First Tiers, Downstream and RelatedEntitiesFirst Tier Entity is any party that enters into a writtenarrangement, acceptable to CMS, with a MedicareAdvantage Organization or Part D plan sponsor or applicantto provide administrative services or healthcare services toa Medicare eligible individual under the MedicareAdvantage program or Part D program.Downstream Entity is any party that enters into a writtenarrangement, acceptable to CMS, with persons or entitiesinvolved with the Medicare Advantage benefit or Part Dbenefit, below the level of the arrangement between aMedicare Advantage Organization or applicant or a Part Dplan sponsor or applicant and a first tier entity. Thesewritten arrangements continue down to the level of theultimate provider of both health and administrativeservices.Related Entity means any entity that is related to aMedicare Advantage Organization or Part D sponsor bycommon ownership or control and:Performs some of the Medicare Advantage Organization orPart D plan sponsor’s management functions under contractor delegation; orFurnishes services to Medicare enrollees under an oral orwritten agreement; orLeases real property or sells materials to the MedicareAdvantage Organization or Part D plan sponsor at a cost ofmore than 2,500 during a contract period.CMS now requires that all universes be submittedin .xlsx or .csv format. Additionally, the date andtime formatting has changed.Organization Determination Appeals andGrievances (ODAG) universesMany fields were added or removed from tables1,2,5-10, and 3. In addition, the following changesshould be noted: The Health Insurance Claim Number (HICN)has been removed from all tables. International Classification of Diseases(ICD) codes are requested for all diagnosisfields.All universesThis newsletter is provided solely for your information and is not intended as legal advice. If you have any questions concerning theapplication or interpretation of any law mentioned in this newsletter, please contact your attorney

‘Person who made the request’ has beenadded to many of the tables.Coverage Determinations Appeals and GrievancesuniversesMany fields were added and removed from tables3,5-7, and 11-13. In addition, the following changesshould be noted for the ODAG universes: New universe pull instructions wereprovided as part of the CDAG 2015/2016Audit Protocol document introduction. Dismissed, Withdrawn, and N/A have beenadded as acceptable responses to the‘Request Disposition’ field. N/A has been listed as an acceptableresponse to the ‘NDC 11’ field.Other universesMany fields were added and removed from theCompliance Program Effectiveness (CPE) universetables. There were also multiple additions andremovals to the Formulary Administration Table 3.Review the protocolsThere have been many changes made to theuniverse tables. Become familiar with them byreviewing the individual tables.You can refer to the 2015/2016 Audit Protocoldocuments, CMS Audit Protocol Announcement,and the memo released January 19, titled“Addendum to the 2015/2016 Program AuditProtocols” for more information.Prior to hire screeningsFDRs must complete exclusion list screenings priorto hire and monthly thereafter for all employeesand downstream entities.Upon hireMany FDRs confuse “upon hire” with “prior to hire,”but they are not the same. CMS requires thescreening be conducted prior to hire. When weaudit your screening process, we will look forevidence that the screening occurred before thehire date.Screening at the same time or “upon hire” does notmeet the requirement. We often see FDRs that tryto do screening on an employee’s first day, but thatdoes not satisfy the requirement. You must ensurethat you know whether an employee ordownstream entity is excluded before they arehired or contracted to provide Medicare servicesLet us know if you have any questions. Just send anemail to MedicareFDR@aetna.com.Ban of AdvancedBeneficiary Notices(ABN) for MedicareAdvantage (MA)Provider organizations should be aware that anAdvanced Beneficiary Notice of Non-Coverage(ABN) is not a valid form of denial notification for anMA member. ABNs, sometimes referred to as“waivers,” are used in the original Medicareprogram. However, you can’t use them for patientsenrolled in Aetna’s MA plans as CMS prohibits useof ABNs.As a provider who has elected to participate in theMedicare program, you need to understand whichservices are covered by original Medicare and whichare not. Aetna’s Medicare Advantage plans arerequired to cover everything that original Medicarecovers, and in some instances may providecoverage that is more generous or otherwise goesbeyond what is covered under original Medicare.As an Aetna Medicare contracted provider, you areexpected to understand what is covered underAetna’s Medicare Advantage plans. CMS mandatesthat providers who are contracted with a MedicareAdvantage plan, such as Aetna, are not permitted tohold a Medicare Advantage member financiallyresponsible for payment of a service not coveredunder the member’s Medicare Advantage planunless that member has received a pre-serviceOrganization Determination (OD) notice of denialfrom Aetna before such services are rendered. Ifthe member does not have a pre-serviceThis newsletter is provided solely for your information and is not intended as legal advice. If you have any questions concerning theapplication or interpretation of any law mentioned in this newsletter, please contact your attorney