The Complaints Tracking Module (CTM) is a module within the Centers for Medicare & Medicaid Services (CMS) Health Plan Management System (HPMS). It tracks and processes complaints received by Medicare call centers and CMS regional offices pertaining to the Part D Medicare Prescription Drug Program received from beneficiaries and providers.
The CTM, as part of the complaint resolution process, provides the Plan Resolution functionality for the participating Part D Medicare Prescription Drug Program organizations. This functionality allows users (plan/account managers) to access, view, respond, and resolve all Part D complaint(s), submitted to their organizations. The complaints within CTM are used for various performance measures. Some of the common inquiries stored in CTM are enrollment related, access to care, payment, or customer service issued with a plan.
The plan should be the first point of contact for beneficiaries for the majority of Part D complains. It should check for timelines, establish internal controls for life threatening cases and ensure completeness in response. The prescribed time period for Plans to resolve complaints is as follows:
Some of the common reasons for raising complaints observed in the market are as follows:
In this scenario, the challenge for various market players is to design such a platform which can enable a smooth process flow for CTM. Health Technolgy also decided to take a plunge into the market and analyzed the whole process to understand the CTM from various angles. In its analysis, some of the major findings are as follows:
Majority of the medication related CTM complaints originates due to formulary issues.
A large chunk of rejected claims, related to CTM are due to Part D excluded medication.
Majority of the pharmacy claim rejection resulting from CTM complaints are due to Part-D included medications.
Majority of the Part-D included medication denials resulting to CTM complaints are included in the plan formulary.
Part-D included medication denials resulting to CTM complaints also includes protected class medication denials.
Majority of the Part-D included medication denials leading to CTM complaints are eligible for a transition supply.
Majority of formulary related CTM complaint are due to Prior Authorization restrictions.
It is observed that there has been a significant rise in CTM complaints over the last few months.
There is also a persistent occurrence of protected class medication denials.
Health Technolgy developed a solution that empowers one with the intelligence from the CTM Complaints. It created an out of the box software called CTM Pro which is sure to make the whole process simple and benefit the users in the following ways:
It will provide idea about alarming indicators.
Trend Analysis of obvious concerns can also be observed.
It will focus on major CMS concerns.
It is a tool to focus on Formulary Optimization.
It will increase CMS Compliance and Member satisfaction.
The diagram below shows the CTM Pro flowchart.
CTM Pro is a class on its own software which has some distinctive features. Some of them are:
Ability to mine related information for resolving CTM complaints.
Ability to mine similar resolved CTM complaints for future reference.
Ability to add casework, reason tag to CTM complaints to aid future CTM resolutions.
Ability to identify patterns and trends of CTM complaints.
Ability to generate indicators on nature of CTM complaints.