Covered and Noncovered Services : Medication Therapy Management

Comprehensive Medication Review and Assessments — Documentation Requirements

The following documentation is required for CMR/A services and must be maintained by the pharmacy in the member's file:

• Member information.
• Member name
• Member identification number
• Whether or not the member resides in a nursing home
• Pharmacist name and NPI.
• Pharmacy name and NPI.
• Description of the need for the CMR/A.
• Indication if the member has other insurance. If so, indicate whether or not the member is enrolled in the other insurance's MTM program.
• Indication of how the member meets the criteria to receive a CMR/A.
• Date of the CMR/A.
• Member consent for the CMR/A, indicated by the member's signature and date.
• Indication that DAPO approval was received for the CMR/A.
• Indication if this was the initial assessment or a follow-up assessment.
• Description of what was discussed in the CMR/A.
• Face-to-face start and end time of the CMR/A.
• Total time spent providing the CMR/A, including administrative time (however, administrative time should not be billed and will not be reimbursed).
• Pharmacist signature and date on the documentation.

Pharmacies may use any format to document CMR/As, but that format must include all of the aforementioned elements. Documentation must be made available to ForwardHealth upon request. Refer to the sample of acceptable documentation for CMR/A.

ForwardHealth also requires providers to submit MTM documentation electronically using one of the following options:

• ForwardHealth-approved MTM case management software
• The ForwardHealth Portal

This electronic submission requirement is in addition to the requirement for providers to maintain on-site MTM documentation (either on paper or electronically) in the member's file. The information required to be submitted to ForwardHealth electronically is the same information required to be maintained in the member's file. Documentation for MTM services that is submitted to ForwardHealth may be used by ForwardHealth to evaluate the MTM benefit.

Comprehensive Medication Review and Assessment Approval Process

Pharmacies are required to receive DAPO approval before scheduling a CMR/A with a member. Pharmacies may contact the DAPO Center from 8:00 a.m. to 5:30 p.m., Monday through Friday, except holidays.

When calling the DAPO Center for approval to schedule the CMR/A, the following information, similar to the documentation requirements, must be provided:

• Member information
• Pharmacy and pharmacist information
• Reason for the CMR/A
• Whether or not the member is enrolled in Medicare Part D
• Member's qualifying criteria
• Whether or not member consent was obtained

The member's verbal consent is required before calling the DAPO Center to request approval to schedule a CMR/A. The member's written consent (i.e., their signature) must be obtained before performing the CMR/A. If the member is a child or has physical or cognitive impairments that preclude the member from managing their own medications, a caregiver (e.g., caretaker relative, legal guardian, power of attorney, licensed health professional) may provide verbal or written consent on the member's behalf.

Generally DAPO Center staff will approve the CMR/A request by the end of the call based on the information provided by the caller. The pharmacy then must schedule, perform, and submit the claim for the CMR/A within 60 days following the approval. If the CMR/A is not provided within 60 days of approval, a new approval may be granted for a new pharmacy. The CMR/A approval is for the initial CMR/A and the three follow-up CMR/As.

If a pharmacy calls the DAPO Center to request CMR/A approval and the information provided does not qualify, the pharmacy will be informed that the request is not approved.