healthcare payer

Appointment of Representative, (aka the AOR) always seems to be a topic of conversation in the healthcare payer space. Every show we attend, every customer we talk with and every industry function we attend, there are intense conversations and differing opinions on what is required by CMS. Do you only submit an AOR once? Do you need to submit a new AOR each time? Can a photo copy be used if it’s within a year of the original? Lots of questions, but no one ever seems to have a definitive answer. Most healthcare payers will default to having an AOR submitted each time to make sure they are in compliance with CMS.

However, there may be light at the end of the tunnel. In the new guidance consolidation of Medicare Advantage Chapters 13 and 18, CMS is giving us a clearer understanding of what is required. In Section 20.2 of the new guidance CMS states “If the representative form is maintained and accessible by the plan, a photocopy of the signed representative form is not required to be filed with future grievances, coverage requests, or appeals made on behalf of the enrollee in order to continue representation. If the plan uses a representative form that is on file for requests, it must include a copy when sending a case file to higher level adjudicators, if applicable.” They also state that the representative form is valid for one year from the date it is signed by both the enrollee and the appointee, unless revoked.

So there you have it and it’s crystal clear! As long as the plan maintains the signed AOR and it can be accessed and available for review when future requests come in, then we have fulfilled CMS requirements. Hopefully if this new guidance plays out it can make the AOR process a smoother one for all involved. CLICK HERE to review the guidance document.

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Submit or Not to Submit? That is the AOR question.

Appointment of Representative, (aka the AOR) always seems to be a topic of conversation in the healthcare payer space. Every show we attend, every customer we talk with and every industry function we attend, there are intense conversations and differing opinions on what is required by CMS. Do you only submit an AOR once? Do you need to submit a […]

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New CMS Guidance

  As part of an initiative to streamline the Medicare Advantage and Prescription Drug appeals and grievance processes, CMS has consolidated Chapter 13 of the Medicare Managed Care Manual and Chapter 18 of the Prescription Drug Benefit Manual into one comprehensive guidance document. They are doing this to better align and provider a more defined, straightforward and non-repetitive understanding of […]

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Your Best Teacher Is Your Last Mistake

5…4…3… 2…1 🚀, it’s time to move forward and discover the power of you! This is the message behind the 5 Second Rule by Mel Robbins. It’s a cool, powerful self-help concept I was introduced to while listening to Mel speak recently at Hyland Software’s CommunityLive event in Nashville, TN. Embracing that concept I say 5…4…3… 2…1 it’s time to […]

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How Painful is Your Contracting Process?

Does your contracting process take forever? Can it take weeks, even months to bring a contract from creation, through negotiation and finally to execution? What causes the bottlenecks and how can they be fixed? First, let’s identify some common hurdles within the contracting process. Once identified, we can implement a contracting management solution to address those issues and reduce contracting […]

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November 27, 2018

Submit or Not to Submit? That is the AOR question.

Appointment of Representative, (aka the AOR) always seems to be a topic of conversation in the healthcare payer space. Every show we attend, every customer we talk with and every industry function we attend, there are intense conversations and differing opinions on what is required by CMS. Do you only submit an AOR once? Do you need to submit a […]
October 12, 2018

New CMS Guidance

  As part of an initiative to streamline the Medicare Advantage and Prescription Drug appeals and grievance processes, CMS has consolidated Chapter 13 of the Medicare Managed Care Manual and Chapter 18 of the Prescription Drug Benefit Manual into one comprehensive guidance document. They are doing this to better align and provider a more defined, straightforward and non-repetitive understanding of […]
September 26, 2018

Your Best Teacher Is Your Last Mistake

5…4…3… 2…1 🚀, it’s time to move forward and discover the power of you! This is the message behind the 5 Second Rule by Mel Robbins. It’s a cool, powerful self-help concept I was introduced to while listening to Mel speak recently at Hyland Software’s CommunityLive event in Nashville, TN. Embracing that concept I say 5…4…3… 2…1 it’s time to […]
September 19, 2018

How Painful is Your Contracting Process?

Does your contracting process take forever? Can it take weeks, even months to bring a contract from creation, through negotiation and finally to execution? What causes the bottlenecks and how can they be fixed? First, let’s identify some common hurdles within the contracting process. Once identified, we can implement a contracting management solution to address those issues and reduce contracting […]