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CMS 365-Day Lookback Period

Medicare Advantage plans are required to conduct a 365-day lookback on the beneficiaries’ claims to ensure there are no prior administrations of the Part B drug that would otherwise exempt the patient from the step edit policy [(Source:  42 CFR §422.136(a)(1)].

The step edits imposed by Medicare Advantage plans on Part B drugs apply only to new patients, and not patients continuing prior therapy. 


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