MTM Targeted Medication Review Note (Medicare Part D)

Note Type: MTM Targeted Medication Review (TMR) Note

Date of Service: [Date of service]

Author: [Name, credentials, organization]

Beneficiary: [Full name, DOB]

Plan/Sponsor: [Plan/Sponsor] (Only include if applicable)

TMR Type: [claims-based/non-interactive / interactive follow-up / written outreach only]

Data Sources: [Part D claims / dispensing history / beneficiary interview / prescriber data / labs / hospitalization data / other]

TMR Trigger & Scope

Trigger Category: [adherence concern / high-risk medication/safety signal / therapeutic duplication / drug interaction concern / dose adjustment concern / care gap / transition of care / other]

Evidence Source: [claims alert / quality measure gap / refill history / hospitalization data / prescriber request / other]

Scope: [Scope statement] (State as a single sentence: "Targeted review limited to [medication/problem] identified by [trigger]; not a comprehensive medication review.")

Context & Target Medications

Clinical Context: [Relevant conditions linked to target medication(s); pertinent allergies with reaction type; objective constraints used in assessment such as renal function category or fall risk] (If context is unavailable, state: "Clinical context limited to claims/dispensing data; diagnoses/labs not available.")

Target Medications: [Unconfirmed regimen] (Include this label if based solely on claims)

• [Medication name (generic preferred); strength; directions or "Sig unknown (claims-based)"; last fill date; days supply; adherence estimate with method if applicable]
• (Add additional list items for each target medication or comparator)

OTC/Supplements: [not assessed / list items if assessed]

Medication Therapy Problem(s)

(If no MTPs are identified, state: "No medication therapy problems identified this cycle" and proceed to Follow-up & Reporting. Otherwise, include one MTP block for each problem identified.)

MTP #[n]: [Short Title]

Category: [Indication / Effectiveness / Safety / Adherence / Cost-Access / Monitoring / Duplication / Preventive Gap / Other] | Severity: [urgent / high / moderate / low]

Problem Statement: [One to two sentences describing the issue and its clinical significance]

Evidence:

• Subjective: [Beneficiary/caregiver report, barriers, preferences] (Only include if interactive contact occurred)
• Objective: [Refill history details, claims flags, labs or diagnoses, dosing information, utilization patterns]

Assessment: [Clinical interpretation connecting evidence to risk or impact] (Use qualified language such as "possible," "likely," or "confirmed." For adherence, use "refill history suggests gaps" rather than "noncompliant.")

Intervention Performed: [Actions taken: beneficiary education, barrier assessment, prescriber recommendation, pharmacy outreach, formulary/benefit research, other]

Recommendation: [Specific actionable request with monitoring parameters including what to monitor, by whom, and when]

Communication: [Recipient; mode; date; brief content summary]

Outcome: [Beneficiary response with any barriers identified; prescriber response if applicable; resolution status: resolved / partially resolved / pending / unable to resolve with reason]

Follow-up & Reporting

Pending Items: [List pending actions by MTP number with expected resolution timeline] (Only include if there are pending items)

Referrals: [Referral made, to whom, and reason] (Only include if applicable)

Next Planned Touchpoint: [Next quarterly TMR or earlier targeted follow-up with timing]

Outreach Attempts: [Date/time, method, and outcome for each attempt; additional attempts planned] (Only include if no beneficiary contact was achieved)

Safe Disposal Communication: [Information provided; recipient; delivery method; confirmation status] (Only include if controlled substance safe disposal was addressed this encounter)

CMS Reporting Elements:

• TMR Completed: [Yes / No]
• MTP Recommendations to Prescriber (this note): [count]
• MTP Resolutions (this note): [count / pending]
• Safe Disposal Communication (this note): [Yes / No]

Author: [Name, credentials, role, organization]

Human Review: [Reviewer name/credentials, date/time, confirmation of clinical appropriateness] (Only include if algorithm-generated TMR with pharmacist review)