Plan-to-Plan Reconciliation Instructions (Phase III Updating the Contract of Record and the Plan of Record)

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1 Plan-to-Plan Recciliati Instructis (Phase III Updating the and the Plan ) The Plan-to-Plan (P2P) Recciliati Process is a process that has been implemented in phases. P2P Phase I and Phase II guidance are already in place and will ctinue to remain a part the entire P2P process. Both phases enable CMS to process many the Prescripti Drug Events (PDEs) affected by P2P and allow for P2P Financial Recciliati between affected s. Currently, when CMS processes a retroactive enrollment, the and Plan Benefit Package () will not be updated PDEs that were previously accepted into the Drug Data Processing System (DDPS). P2P Phase III establishes a process for updating the and PDEs that were already accepted and saved by CMS for covered drugs. The instructis below will explain how the enrollment changes in P2P Phase III can affect saved PDEs, the new informatial edit codes that will be generated as a result changes to and/or, and how the changes will appear Mthly Reports received from the DDPS. The following PDE references provide a framework for this P2P discussi. PDE instructis are published at: Please see for: 2006 Participant Training Guide Edits P2P Phase I and Phase II Guidance are published at: This final guidance will be published initially with the HPMS bulletins : At a later date, we will incorporate P2P Guidance in the PDE Instructis and in the PDE Participant Training Guide at the site references above. Scope: P2P Recciliati is a financial settlement process between two Part D s in which the compensates the for claims paid a beneficiary that belgs to the. Each phase P2P builds the previous phase. Phase I P2P enabled CMS to process P2P PDE data with dates service January 1 through April 30, This phase also introduced Reports 40 through 43 to the s. The Reports provide the documentati for P2P financial settlement and provide additial documentati that will be used for the annual Part D Payment Recciliati for the. P2P Phase II extended P2P processing beyd April 30, 2006 and established the initial transiti period effective end date policy for enrollment changes. P2P Phase III updates the and/or Plan prior to annual Part D Payment Recciliati so that the proper and Plan is associated with the accepted PDE data. This process will ly make correctis to the saved PDE data if there are changes to the enrollment data. If changes are made and the changes affect P2P, either by establishing a new P2P cditi or changing the status a PDE from P2P to n-p2p, the affected s will go through P2P Recciliati. If there are no changes to the enrollment data for previously accepted PDE data, the PDE data will remain unchanged and will not be a part P2P Phase III. P2P should be viewed as an going process that will occur in each Benefit Year. There will always be some instances in which a pays for covered prescripti drug costs incurred after the effective date a disenrollment. This scenario can occur when a beneficiary changes s during the mth or when there are lags associated with ctract enrollment processes

2 or with CMS informati system updates. P2P Phase I and II occur simultaneously and P2P Phase III will be de at scheduled times. P2P Phase III will be performed at least ce before each annual Part D Payment Recciliati. Authority: All compents the P2P Recciliati process were developed using the authority established under (a) the Part D regulatis. Under (a), Part D s have an obligati to coordinate benefits with entities providing other prescripti drug coverage to Part D eligible individuals. The P2P Process coordinates the correcti claim payments made by s other than the. As explained in (f), CMS recciles payment year disbursements with updated enrollment informati. P2P Phase III is the process that will update enrollment informati, for saved PDE data, prior to annual Part D Payment Recciliati. Objectives: P2P Phase III fulfills two objectives. Establishes a process for evaluating and correcting, if necessary, the and/or prior to annual Part D Payment Recciliati. Re-assigns the and/or in the event that the enrollment informati changes after the PDE was saved by CMS. Definitis: : The is submitting PDE data for which they may or may not be the at the time that they are submitting the PDE, according to beneficiary enrollment informati documented in the CMS databases. : The Plan Benefit Package () is submitting PDE data under the. : This is the that is the Part D spsor with the beneficiary enrollment as documented in CMS databases, when the PDE was accepted and saved by CMS. : This is the listed under the as documented in CMS databases, when the PDE was accepted and saved by CMS. : The new after CMS runs the P2P Phase III process and determines that there is a change in the enrollment informati that affects saved PDE data. : The new after CMS runs the P2P Phase III process and determines that there is a change in the enrollment informati that affects saved PDE data. Mthly Reports: The reports in which the financial amounts for the PDE data first appeared. If the financial amounts first appeared Report 4, the PDEs were not part P2P. If the financial amounts first appeared Reports 40 through 43, the PDEs were part P2P. Mthly Reports: The reports that now display the financial amounts for saved PDE data after the P2P Phase III update to enrollment informati. If a P2P Phase III update results in a P2P cditi, the financial amounts are documented Reports 40 through 43. If the financial amounts are documented Report 4, this means that the change in and did not result in a P2P cditi or changed from a P2P cditi to a n-p2p cditi.

3 : In the charts below that explain the P2P Phase III processing, a yes (Y) means that the field PDEs affected by P2P Phase III will be populated with the. The affected PDEs will be sent to the a special that will be distributed after the P2P Phase III process is run. A no (N) means that the field for will not be populated. : In the charts below that explain the P2P Phase III processing, a yes (Y) means that the field will be populated PDEs affected by P2P Phase III. The affected PDEs will be sent the that will be sent to the. A no (N) means that the field will not be populated. P2P Phase III Processing: P2P Phase III processing will update changes in enrollment informati that occurred after CMS accepted PDE data. P2P Phase III will allow the Drug Data Processing System (DDPS) to query the CMS Medicare Beneficiary Database (MBD) for changes to and. If this query results in changes, DDPS will update affected PDE data to reflect the changes. If this query does not result in a change, no update will occur the saved PDE data. This process will update all changes to enrollment informati; it is not limited to changes that affect P2P. This process will also update enrollment informati when the beneficiary moves from e to another within the same. CMS developed new informatial edit codes that will generate as a result the P2P Phase III update to enrollment informati. The informatial edit codes will be received by the a. The informatial edit codes will ly be sent to the and will not be sent to the. The enrollment changes to saved PDEs will result in changes that appear the Mthly Reports. The Mthly Reports will show any new payables and receivables that result from P2P Phase III. Any financial amounts resulting from this process will appear the same as any other financial amounts would appear a Mthly Report. Since the financial amounts from the P2P Phase III update will not be reported differently from any other financial amounts, the Mthly Reports should be thoroughly reviewed. The layout the Mthly Reports will not change. The and the will ly be aware changes by reviewing the Mthly Reports. All the changes resulting from P2P Phase III are explained in detail below. New Informatial Edit Codes: The will receive an informatial edit code the when enrollment changes result in a change in Part D financial dollar amounts. The change may result in either a payable or receivable. Each informatial edit code is meant to provide the with an explanati how the enrollment changes affect the saved PDE. The explanati will assist the when evaluating the Mthly Reports for changes. Informatial edit 851: The has been updated; a P2P cditi now exists. Informatial edit 852: The / is now the / ; a P2P cditi no lger exists. Informatial edit 853: has been updated. This PDE ctinues to be a n-p2p PDE. Informatial edit 854: The and have been updated. A new P2P cditi is established.

4 Informatial edit 855: The is now the but the is different from the. A P2P cditi no lger exists. : The will receive a that includes all PDEs that were sent by and accepted from the but now have a change in and/or resulting from P2P Phase III s. This file will be in the same basic format as the existing but will have a different file name so that it is not cfused with the standard. Although the basic format remains the same, e existing field will be used and a new field will be added for P2P Phase III. The existing field will be populated with, when appropriate. There will be a new field for. This field will be populated when appropriate. Up receiving a, the should update their database to reflect the changes. s 1-5 below will show when the will be populated with a PDE that displays or. The columns for and will display Y when the field is populated and N when the field is not populated. The ly example below that will not generate a is Example #6. This update does not affect P2P recciliati between the s. P2P Phase III Enrollment Changes: The following six examples will explain the potential scenarios that can occur with updating enrollment informati. Within each example, there will be two sets tables. The first table will describe the scenario and will show which updates will appear in the and the secd table will display the reports affected by the enrollment change and will show how the financial data will change between Mthly Reports using Covered Plan Paid Amount (CPP) as an example. In order to understand the changes, the examples show how the Mthly Reports will appear for the mth in which the submits the PDE and the PDE is accepted (the Submissi Mth), the mth after Submissi, and the Mth (mth in which P2P Phase III updates enrollment informati). Example 1: A 1 A 1 B 1 Y N Initially a P2P cditi did not exist when the PDE was accepted by CMS. A was submitting PDE data for a beneficiary who was enrolled in A, according to the CMS database. The P2P Phase III enrollment update changed the and. A P2P cditi now exists. Informatial edit code 851 will be sent to the. In the, the ( A) will receive the PDEs for the dates service for which the beneficiary should now be enrolled under B. The will

5 not be sent the file. The P2P cditi is established based the change so it is not necessary to send the update to A. Reports Change in CPP Report Submissi Mth Mth after Mth Submissi 4 $100 $100 $0 40 $0 $0 $ $0 $0 $ $0 $0 $ $0 $0 $100 Prior to P2P Phase III, A was the ly that had this PDE a Mthly Report. The PDE will be documented Report 4 for the mth in which the PDE was submitted and accepted and the mth after submissi. After the P2P Phase III, the PDE will appear Mthly Reports for both A and B. The Report 4 will display $0 since the PDE will be documented P2P Reports. The now owes the $100 as shown in the P2P Reports 40 through 43. Example 2: A 1 B 1 A 1 N N Initially a P2P cditi existed; A was submitting PDE data for a beneficiary that was enrolled in B. The P2P Phase III enrollment update resulted in a change in and. The informatial edit 852 will be sent to the. A P2P cditi no lger exists. The / that submitted the PDE is now the /. The and fields will not be populated the. Reports Change in CPP Report Submissi Mth Mth after Mth Submissi 4 $0 $0 $ $100 $100 $0 41 $100 $0 ($100) 42 $100 $100 $0 43 $100 $0 ($100) When the P2P cditi existed, B paid A $100, as shown in the Mthly Reports. In the Mthly Reports, the PDE will appear Report 4 for A. A will see ($100) Report 41. B will see ($100) Report 43. A negative receivable amount means that A will owe B. In this example, A owes B $100.

6 Example 3: A 1 A 1 A 2 N Y In this situati, a P2P cditi did not exist originally and does not exist after the enrollment update in P2P Phase III. This situati is still described as a possible scenario because P2P Phase III is meant to update all enrollment changes, including -ly changes. A will be sent to A to notify them the Change. An informatial edit code 853 will be sent to inform Plan A the change in. The change in will be seen the Mthly Reports. Reports Change in CPP Report Submissi Mth Mth after Mth Submissi 4 ( 1) $100 $100 $0 4 ( 2) $0 $0 $100 Although the financial informati will remain Report 4, the informati will be found under the new. Example 4: A 1 B 1 C 1 Y N In this situati, a P2P cditi existed between A and B. Once P2P Phase III updated enrollment informati, a new P2P cditi now exists between A and C. An informatial edit code 854 will be sent to the the. This file will include all PDEs for the affected Dates Service where C is the.

7 Reports Change in CPP between s A and B Report Submissi Mth Mth after Mth Submissi 40 $100 $100 $0 41 $100 $0 ($100) 42 $100 $100 $0 43 $100 $0 ($100) In the P2P cditi that was originally the Mthly Reports, B paid A $100 in CPP for this PDE. After the enrollment informati updated, the new is C. A will pay B $100. A is returning the mey that initially exchanged hands in the Mthly Reports. This is shown by negative dollar amounts Reports 41 and 43 for s A and B. Reports Change in CPP between s A and C Report Submissi Mth Mth after Mth Submissi 40 $0 $0 $ $0 $0 $ $0 $0 $ $0 $0 $100 In the new P2P cditi between A and C, C is now the. C owes A $100 in CPP for this PDE. C will be aware the P2P liability through the P2P Mthly Reports generated for the P2P Phase III update mth. This update will cause two changes the P2P Reports for A. They will see changes in the DET rows for B and C Reports 40 and 41. A owes B $100 and A will receive $100 from C. Example 5: A 1 B 1 A 2 N Y Prior to P2P Phase III, a P2P cditi existed between A and B. After the Phase III update, A was found to be the. The is different from the that originally submitted the PDE. An informatial edit code 855 will be sent to the. Only the field will be populated the.

8 Reports Change in CPP Report Submissi Mth Mth after Mth Submissi 4 $0 $0 $ $100 $100 $0 41 $100 $0 ($100) 42 $100 $100 $0 43 $100 $0 ($100) ly B paid A $100 in CPP for the PDE. Once P2P Phase III updated the enrollment informati, a P2P cditi no lger exists. A now owes B the $100 that was initially paid. This is displayed as a negative amount the P2P Mthly Reports. For A, Report 4 will now display the CPP amount under the. Example 6: A 1 B 1 B 2 N N A P2P cditi remains between A and B, ly the changes. This does not change the financial informati that was exchanged previously between A and B so A will not receive a showing this change. Reports Change in CPP Report Submissi Mth Mth after Mth Submissi 40 $100 $100 $ $100 $0 $0 42 $100 $100 $ $0 $0 $0 This update will not result in a change in financial dollar amounts the Mthly Reports. The financial amounts will now be found under the but under the.