PACESupplementalQuestions - Track change version

Instructions:

• Enter responses to each question in the PACE Supplemental Questions tab of this document.
• PACE organizations may also upload grievance and service determination request policies pertaining to the questions in the PACE Supplemental Questions
tab.
• Responses must reflect practices, policies, and procedures in place during the data collection period. The data collection period begins 6 months prior to the
date of the audit engagement letter and ends on the date of the audit engagement letter. For example, an audit engagement letter is issued on March 4,
2026. The audit review period for this audit is September 4, 2025, through March 4, 2026.

Due Date:

This document must be completed and submitted to HPMS within 5 business days following the issuance of the audit engagement letter.

Question #
1

Question

Response

List the emergency medications (name, dosage and quantity) that your organization keeps
readily available on site at all times.
Note: List drug name as written on the product label. Do not include medications that are
stored in a cabinet, cart, room, etc. for convenience but are not specifically for emergency
situations. This list of emergency drugs may be provided as a separate attachment labeled
"emergency medications".

2

Identify the name of each medical record system used by the PACE organization including,
but not limited to, systems used to document progress notes, medications orders, orders for
all other services, the provision of all services, assessments, care plans, home care, lab and
diagnostic test results, hospital and ER records, imported documentation, etc.

3

Can CMS access all of the organization’s medical records systems using a web-based portal
or will auditors need to utilize specialized software, a VPN, or other methods to connect
remotely to the systems?

4

What information is needed in order to provide auditors with access to your systems?

5

Other than establishing usernames and passwords for each system, is any additional
authentication required? For example, will auditors need to complete two-factor
authentication using a text message or an authentication application?

6

Does your organization use a committee to advise the IDT on decision making?

7

Does your organization have any policies that place limits on the amount, duration,
frequency, or other restrictions to receiving any of the following items or services:
a. Glasses/replacement glasses
b. Hearing aids/replacement hearing aids
c. Home care services (including services at night, on the weekends, or holidays)?
d. Respite care
e. Specialist consultations
f. Nursing facility services
g. Hospital or ER services
h. Dental services
i. DME
j. Personal alert systems
k. Medications
If you answer yes to any of the above items, please explain the policy or restriction. You may
submit the policies directly into HPMS in lieu of an explanation (use the "Supplemental" file
type to upload).

8

Do you collect/require a copay or coinsurance for any services? If so, please list the services
and copay/coinsurance amount.

9

Does your organization utilize a Pharmacy Benefits Manager and, if so, please explain the
services they provide?

10

Does your organization have a Pharmacy & Therapeutics (P&T) committee? If yes, please
explain the responsibilities of the P&T committee?

11

Can participants obtain prescriptions or orders written from any prescriber including
specialists? This includes prescriptions or orders for medications, DME, or any other
care/services applicable. If no, explain the process of reviewing recommendations for
prescriptions or orders from other prescribers and how the PACE organization determines if
the recommendation should be provided.

12

How does your organization identify drugs that are covered under Medicare Part D?

13

Are there any drugs that must undergo prior authorization before dispensing?
Prior authorization means that the participant must meet some form of criteria prior to
approval, for example, the participant must have a specific diagnosis or the participant cannot
be using illegal substances prior to receiving approval for the requested drug.

14

Are there any drugs that require step therapy?
This includes any program that requires a certain drug to be used first, before a different drug
can be dispensed.

15

Are there any drugs with quantity limits?
Quantity limits are often used in cases where FDA-approved prescribing instructions state
that only a certain number of doses should be used in a certain time period.

16

Does your organization maintain a list of preferred drugs that your providers refer to when
considering which medication to prescribe? What factors go into identifying a drug as
preferred for prescribing purposes?

17

What cost containment or utilization management programs do you utilize for Part D drugs?

Pending OMB Approval (0938-New)