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Transition (audit element)
FA audit element that checks new and continuing enrollees eligible for a transition fill get the full transition benefit and proper notices.
CMS samples up to 15 rejected claims for continuing enrollees (cross-year formulary changes, such as deletions) and up to 15 for new enrollees (formulary administration during transition). Reviewers check that eligible enrollees get the full transition benefit based on their enrollment and disenrollment dates, that long term care enrollees get emergency supplies while an exception or prior authorization is processed, and that enrollees and prescribers get appropriate, timely and accurate transition fill notices.
Source: FA protocol, Audit Elements Tested, compliance standards 2.1-2.2, PDF pp. 7-8.