For Dates of Service Before April 1, 2017

Comprehensive Medication Review and Assessments

ForwardHealth implemented the MTM benefit in conjunction with the WPQC. The MTM benefit consists of intervention-based services and 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.

Note: A separate WPQC certification is not required to perform and receive reimbursement for intervention-based services.

Conducting a Comprehensive Medication Review and Assessment

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

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 his or her drug regimen. A high-risk member meets one of the following criteria:

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:

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 he or she should take until following up with his or her 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

Commercial health insurance and Medicare Part D plans also have MTM programs. If a member is eligible for a commercial health insurance or Medicare Part D MTM program, the pharmacy provider is required to submit the claim to the member's commercial health insurance or Medicare Part D plan 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.