Covered and Noncovered Services : Medication Therapy Management

Comprehensive Medication Review and Assessments

ForwardHealth implemented the MTM benefit in conjunction with the WPQC. The MTM benefit consists of CMR/As.

The CMR/A services are voluntary medication reviews for members performed by a pharmacist. CMR/As may include one or more of the following analytical, consultative, educational, and monitoring services, provided by a pharmacist to help members get the best results from medications through enhancing consumer understanding of medication therapy, increasing adherence to medications, controlling costs, and preventing drug complications, conflicts, and interactions.

An initial face-to-face CMR/A identifies, resolves, and prevents medication-related problems, including adverse drug events, or can include performing medication reconciliation for a member discharged from a hospital or long-term care setting.

A follow up CMR/A monitors and evaluates the member's response to therapy, including safety and effectiveness of target medications.

Certification Requirements for Providing Comprehensive Medication Review and Assessments

To perform and be reimbursed for CMR/As, the pharmacists and the pharmacy at which a pharmacist is performing the CMR/A are required to be certified by an approved MTM program. Currently, the only approved MTM certification program is offered by the WPQC. The PSW manages the WPQC training and certification process, and has established rates for WPQC certification.

Conducting a Comprehensive Medication Review and Assessment

The CMR/A services may include the following value-added professional services provided by a pharmacist:

• Obtaining the necessary assessments of the member's health status.
• Formulating a medication treatment plan for the member.
• Providing an updated personal medication record and medication action plan for the member following each CMR/A visit.
• Providing information, support services, and resources designed to enhance member adherence with the therapeutic regimen.
• Providing verbal education and training designed to enhance the member's understanding and appropriate use of the medication.
• Documenting the care delivered and communicating essential information to the member's primary care providers.
• Referring to an appropriate health care provider, if necessary.
• Coordinating and integrating medication management services within the broader health care system.
• Notifying appropriate prescribers of each comprehensive care review and assessment service provided and sending a copy of the personal medication record and medication action plan. If authorizations to change specific medications are needed, the specific prescriber will be notified.

Qualifying Criteria for Members

A CMR/A service may be provided to a member who is at a high risk of experiencing medical complications due to their drug regimen. A high-risk member meets one of the following criteria:

• The member takes four or more prescription medications to treat or prevent two or more chronic conditions, one of which must be hypertension, asthma, chronic kidney disease, congestive heart failure, dyslipidemia, COPD, or depression.
• The member has diabetes.
• The member requires coordination of care due to multiple prescribers.
• The member has been discharged from a hospital or long-term care setting within the past 14 days; these services are referred to as transition of care CMR/A services.
• The member has health literacy issues as determined by the pharmacist.
• The member has been referred for the MTM services by the prescriber.

Members residing in a nursing home are not eligible for CMR/As.

If the member meets at least one of the aforementioned criteria, the pharmacy must call the DAPO Center to request approval to provide CMR/A services. The CMR/A approval covers the initial and up to three follow-up CMR/As.

Comprehensive Medication Review and Assessment Process

The following is a step-by-step process for providing a CMR/A:

• The pharmacist identifies an opportunity or receives a prescriber referral to perform a CMR/A.
• The pharmacy contacts the member about the CMR/A opportunity and the member accepts services.
• The pharmacy calls the DAPO Center to request approval to schedule a CMR/A.
• If approved, the pharmacist schedules an appointment with the member to perform the CMR/A.
• The pharmacist performs the CMR/A, which may include the following:
• Meeting with the member
• Consulting with the prescriber if needed
• Documenting the intervention
• The pharmacy submits a professional claim for the CMR/A.

Conducting Transition of Care Comprehensive Medication Review and Assessment Services

ForwardHealth expects the pharmacist to complete the following steps when rendering transition of care CMR/A services:

1. Obtain a complete list of the prescription and over-the-counter medications, vitamins, and supplements the member was taking prior to admission to the hospital or long-term care setting. (If the pharmacist performing the service does not have a complete pre-admission medication list, the pharmacist should contact the member's pharmacy/pharmacies to obtain this information. An admission history obtained from an Electronic Medical Record does not fulfill this step requirement.)
2. Obtain the discharge medication orders and compare to the pre-admission medication list.
3. Upon conclusion of the CMR/A service, provide an updated medication list to the member that calls attention to changes made to the member's pre-admission medication regimen.
4. Provide a MAP to the member that reminds the member of action items they should take until following up with their primary care provider. The final MAP should be provided to the member within 14 days of consultation.
5. Maintain documentation in the member's file of the transition of care CMR/A services provided and submit required documentation electronically to ForwardHealth.
6. Attempt to contact the member after the visit to ensure and reinforce understanding of the post-discharge medication regimen.

Note: Providers are reminded that PA from the DAPO Center is required in order to be reimbursed for providing transition of care CMR/A services.

Coordination of Benefits

Other health insurance sources also have MTM programs. If a member is eligible for another health insurance MTM program, the pharmacy provider is required to submit the claim to the member's other health insurance before submitting the claim to ForwardHealth.

Pharmacies are responsible for MTM COB. ForwardHealth is the payer of last resort.

The 1500 Health Insurance Claim Form Completion Instructions contain information regarding documenting other insurance information.