Prescription Drug Event (PDE) Data: Source and Processing

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1 Prescription Drug Event (PDE) Data: Source and Processing Barbara Frank, M.S., M.P.H. Director of Workshops, Outreach, & Research University of Minnesota

2 Frequently Repeated Acronyms CMS Centers for Medicare and Medicaid Services CCW Chronic Condition Warehouse PDE Part D Event PDP Stand-alone Prescription Drug Plan feefor-service MA-PD Medicare Advantage Prescription Drug Plan FFS Fee-for-Service 2

3 Frequently Repeated Acronyms MAC Medicare Administrative Contractor FI Fiscal Intermediary EDB Enrollment Database NCHR National Claims History Repository NCPDP - National Council for Prescription Drug Programs DDPS - Drug Data Processing System PDFS - Prescription Drug Front End System IDR Integrated Data Repository SAF Standard Analytical File 3

4 Frequently Repeated Acronyms OOP Out -of-pocket OTrOOP Other True Out-of-Pocket LICS Low Income Cost Sharing Subsidy 4

5 Overview of CMS PDE Data What is an event (versus a claim)? How are data processed? What data system does CMS maintain for the event data? What are the sources of the data in the files? What Part D Event File variables are available to researchers? 5

6 Mr. Ben E. Ficiary 6

7 Review: What is a Claim? Claims are bills submitted for services provided to the Medicare enrollees like Ben the FFS Medicare beneficiary. Claims are reimbursed per claim by Medicare based on the service billed. 7

8 Treatment Institutional Provider And/Or Non-Institutional Provider Claim Payment/ Denial CWF Host Update entitlement data Check claims for entitlement, deductible, remaining benefit, and duplicates Authorize full payment, partial payment, denial, or request additional data Claim (daily) Response MAC (formerly FIs or Carriers) Enter claim into system Perform consistency and utilization edits Calculate payment Entitlement data (Daily) Claims data (Weekly) CMS Update EDB with entitlement data Add claims to National Claims History Repository (NCHR) Deny claims based on Medicare policy Return denied claims to provider 8

9 What is an Event? Event Detail: PDE record is not the same as the pharmacy claim and so differs from point-ofservice Post-transaction adjustments between plan and pharmacy Plan-to-plan adjustments for misenrollees Plan-to-CMS adjustments for some demonstration projects 9

10 Mr. Ben E. Ficiary MA-PDP or PDP enrollee 10

11 Part D Event Sources and Processing Beneficiary prescription goes to pharmacy Pharmacy requests beneficiary Part D cardholder information for which Plan beneficiary is enrolled Pharmacy contacts Part D Plan for information regarding payment Pharmacy finalizes transaction for beneficiary (fills/dispenses prescription) Pharmacy submits electronic transaction (claim) back to Plan (using National Council for Prescription Drug Programs-NCPDP electronic format 99% of time) 11

12 Part D Event Sources and Processing Plans submit events/transactions (all variables) to CMS. The PDE records enter the CMS Drug Data Processing System (DDPS) through the Prescription Drug Front End System (PDFS) in a CMS defined record format. (See PDE Record Layout) The PDFS initially performs format and face validity checks. Once the file has passed front-end checks, it moves through the DDPS where detail level edits are performed. The Drug Data Processing System (DDPS) is the information system that collects, validates, and stores PDE data received from plans or their designee. 12

13 Part D Event Processing From DDPS, event flows into Integrated Data Repository (IDR) on a daily basis CMS creates Standard Analytical File (SAF) which contains only final action events from PDE data in IDR Part D Event SAF downloaded by Buccaneer/CCW from CMS 13

14 Part D Event Processing Buccaneer/CCW begins processing file to encrypt necessary variables and add derived variables. CCW creates the CCW Encrypted Part D Event ID which is an unique identifier for each record in the PDE file. 14

15 Part D Event Sources and Processing Pharmacy Buccaneer/CCW creates CCW Part D Event File Contacts Plan Submits Claim (NCPDP) Part D Plan Submits Bi-weekly or Monthly Integrated Data Repository (IDR) CMS through Prescription Drug Front End System (PDFS) into Drug Data Processing System (DDPS) Editor 15

16 Sources of Variables Depending on year of data requested, there are data elements in the PDE record 15 data elements from the NCPDP billing transaction 5 data elements from the NCPDP billing response transaction 17 data elements defined by CMS for purposes of administering Part D 16

17 Sources of Variables NCPDP Defined Patient Date of Birth (not edited by CMS) Patient Gender Code (not edited by CMS) Date of Service Product Service ID Fill Number Dispensing Status and Dispense as Written Compound Code Provider & Prescriber IDs Quantity Dispensed Days Supply Patient Pay Amount 17

18 Sources of Variables CMS Defined Drug Coverage Status Adjustment Deletion Code Catastrophic Coverage Code Gross Drug Cost [Above & Below] OOP OTrOOP Amount LICS Amount 18

19 Part D Event Processing When and where do adjustments occur? With Pharmacy: If beneficiary does not pick up prescription, pharmacy will return to shelf and send a deletion transaction notice to Plan. Pharmacies typically allow 2 weeks for pick up. Plan can delete transaction before submitting to CMS (if in time) or send a deletion transaction to CMS. PDE Event record will not be found in PDE data file as there are no deletion records in CCW PDE data file. 19

20 Part D Event Processing When and where do adjustments occur? Plans have several months after CY to submit electronic transactions to CMS. However, most will submit on a bi-weekly or at the minimum required monthly basis. Adjustment events can be submitted during this time. 20

21 Part D Event Processing When and where do adjustments occur? Plans may have submitted a transaction when after the fact, another plan was responsible for that prescription coverage. For example, an LIS beneficiary changes plans and the enrollment information does not catch up until after a pharmacy has filled a prescription for that beneficiary. This type of adjustment will lead to misenrollee PDE record in file. 21

22 Part D Event Processing Adjustment Deletion Code Values Blank Original PDE A = Adjustment R = Resubmitted All types are final action 22

23 Resources Prescription Drug Event Record Layout See attachment NCPDP Reference Manual wnloads/ncpdpflatfile.pdf 23

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