Supplemental Payer Transactions (Nx) Part D Plan Nx Performance Reports Guide Effective

Size: px
Start display at page:

Download "Supplemental Payer Transactions (Nx) Part D Plan Nx Performance Reports Guide Effective"

Transcription

1 Supplemental Payer Transactions (Nx) Part D Plan Nx Performance Reports Guide Effective Date: 03/09/2017

2 Table of Contents 1 BACKGROUND PURPOSE REPORT NAME & PURPOSE REPORT SCHEDULE REPORT DELIVERY INQUIRIES PROCESS FLOW AND DIAGRAM ASSUMPTIONS REPORT FIELD DEFINITIONS TRANSACTION TYPE SUMMARY REPORT CUMULATIVE UNSUCCESSFUL N DETAIL SCENARIOS SCENARIO ONE SCENARIO TWO SCENARIO THREE SCENARIO FOUR SCENARIO FIVE...11

3 1 Background Medicare Part D sponsors are required to coordinate with State Pharmaceutical Assistance Programs (SPAPs) and other providers of prescription drug coverage with respect to the payment of premiums and coverage, as well as coverage supplementing the benefits available under Part D. Entities that provide other prescription drug coverage with which Part D sponsors must coordinate include: Medicaid programs; group health plans; the Federal Employee Health Benefit Program; military coverage; the Indian Health Service (IHS); Federally qualified health centers, rural health clinics; other Part D plans; and other prescription drug coverage as CMS may specify. Requirements for Part D COB are specified in statute and codified in Federal regulations. CMS Part D COB guidance is provided in Chapter 14 of the Medicare Prescription Drug Benefit Manual available on the CMS Web site at: /Downloads/Chapter14.pdf This section does not supersede official CMS guidance, but is intended to convey a very general understanding of Part D COB requirements. Under Medicare Part D, COB also provides the mechanism for support of the tracking and calculating of beneficiaries true out-of-pocket (TrOOP) expenditures, or incurred costs as defined in the Medicare Modernization Act of 2003 (MMA) and CMS implementing regulations. Incurred costs under Part D include only costs incurred by the beneficiary for the annual deductible, or other cost-sharing prior to satisfying the out-of-pocket threshold, including the out-of-network price differential for which the individual is responsible when the emergency access requirements are met. Incurred costs are costs paid by the beneficiary, by another person on the beneficiary s behalf, by CMS on behalf of a lowincome subsidy (LIS) eligible individual, or by a qualified SPAP, the IHS or an AIDS Drug Assistance Program (ADAP) that are not reimbursed through or paid under insurance or otherwise, a group health plan, or other third party arrangement. Incurred costs must be incurred for a covered Part D drug which is a Part D drug included in the individual s Part D plan s formulary, or treated as being included as a result of a coverage determination or appeal, and obtained at a network pharmacy, unless emergency access provisions have been met. Part D sponsors must exclude costs that do not meet these requirements from a beneficiary s TrOOP. Section 1860D-2(b)(4)(D) of the Act authorizes CMS to establish procedures for the exchange of information for determining whether costs reimbursed by third parties for Part D enrollees may be included in their TrOOP and for alerting Part D sponsors about such reimbursements. The TrOOP facilitation process developed by CMS and the industry in collaboration with NCPDP allows the majority of pharmacy claims processing and benefit coordination to take place in real-time at the pharmacy point of sale. CMS Transaction Facilitator contractor, in conjunction with CMS, is responsible for establishing procedures for facilitating eligibility queries, identifying costs being reimbursed by other payers and reporting such transactions to Part D sponsors, and facilitating the transfer of TrOOPrelated data when a beneficiary changes plans during the coverage year. CMS requires that Part D sponsors coordinate benefits with supplemental payers that adhere to the CMS Data Sharing Agreement and transmit their eligibility data to CMS. Those supplemental payers that use the established on-line or batch COB process will derive the benefits associated with the creation of N transactions and their transmission to the beneficiary s Part D sponsor. Other supplemental payers that do not comply with the on-line or batch COB process forfeit COB and the benefits associated with it. CMS Part D Plan Nx Performance Report Guide Page 1

4 regulations specify the requirements for plans sponsors to coordinate benefits with both other Part D plans when a Part D sponsor other than the sponsor of record paid claims for a beneficiary during the initial transition period and with other entities providing prescription drug coverage when that entity incorrectly paid as primary. Sponsors must follow CMSestablished processes for plan-to-plan reconciliation in the former instances, and in the latter instances work directly with the other entities to achieve timely reconciliation. Responsibility for Part D sponsors to account for other providers of prescription drug coverage when a retroactive claims adjustment creates an overpayment or underpayment is addressed in the Part D regulations. Part D sponsors must coordinate benefits with SPAPs and other providers of prescription drug coverage and appropriately adjudicate claims. Compliance with this requirement entails the sponsor not only coordinate benefits with other payers at POS, but also work with beneficiaries and other payers to resolve postadjudicative payment issues arising from retroactive claims change CMS has established timeframe requirements for Part D COB. Plan sponsors must coordinate benefits with SPAPs, other entities providing prescription drug coverage beneficiaries, and others paying on the beneficiaries behalf for a period not to exceed 3 years from the date the prescription for a covered Part D drug was filled. CMS also requires that whenever a sponsor receives information that necessitates a retroactive claims adjustment, the sponsor must process the adjustment and issue refunds or recovery notices within 45 days of the sponsor s receipt of complete information regarding the adjustment. 2 Purpose The purpose of this document is to provide instruction on the use of the Part D Plan Nx Performance Reports and includes functionality of the report, examples of common scenarios that may be reported and definition of the report fields. 3 Report Names & Purpose Two types of reports will be generated bi-monthly: Nx Performance Summary and 3 plan years (if the plan was active) of Nx Cumulative Nx Reject Reports. The Nx Performance Summary report is summary level data on a Plan s performance relative to any Nx transaction received during the current year. The Nx Cumulative Reject report is a detailed report for rejected Nx transactions for a specific plan year based off the DOS. Both reports are based on Nx transactions received as of the report run date. These reports can be used monitor processing and to track compliance with CMS requirements regarding the appropriate processing of transactions that are a record of supplemental payment for coordination of benefits purposes. The reports are CMS Contract ID-based. The subject line for the s and associated file are as follows: Subject: ContractID CCYYMMDD Nx Performance Summary ContractID CCYYMMDD Nx Performance Summary.xlsx Subject: ContractID PYCCYY Nx Cumulative Reject Report ContractID PYCCYY Nx Cumulative Reject Report CCYYMMDD.txt Part D Plan Nx Performance Report Guide Page 2

5 RHP reserves the right to zip these files based on size (one or both may be zipped) 4 Report Schedule Reports will be generated bi-monthly (the 1st and 15th of every month) and will be cumulative through the report run date. For example: if the report is run on 03/15/14, the data in the report will be for N transactions received from 01/01/14 to 03/15/14 and will be reported on the detailed report by plan year. 5 Report Delivery The Part D Plan Nx Performance Report is sent via secure to addresses associated with the CMS Contract ID and the report type (Nx). The DOS on the NX determines the reporting plan year and the address associated with the plan year will received the detail report. This summary report is sent only to the current plan year address(es). This is done because the summary report may contain transactions that span multiple plan years. 6 Inquiries As this report is new, the NCPDP WG1 Supplemental Payer Reporting Task Group will be the resource to address questions and recommendations for future enhancements. The task group meets via the NCPDP Collaborative Workspace. See (lower left side) for information about joining this task group. The task group leaders and s, along with NCPDP Staff Liaison are listed in the most recent WG1 Supplemental Payer Reporting Task Group notes. If sharing information with this task group, do not send Protected Health Information (PHI). 7 Process Flow and Diagram The Part D Plan Nx Performance Reports deal specifically with the process outlined with dashed lines below: Part D Plan Nx Performance Report Guide Page 3

6 For further information on this process, please refer to the NCPDP Medicare Part D COB Document Appendix J. Diagram used with permission of NCPDP. 8 Assumptions Due to the inability of the Transaction Facilitator to know what MBI the plan has on record for the beneficiary, the transaction facilitators will send up to 6 occurrences of the MBI with effective and term dates (if applicable). The MBIs will be reported in order of the most current MBI to the oldest MBI. 9 Report Field Definitions 9.1 Transaction Type Summary Report This report is in Excel format Label Description/Business Rules Format Contract ID Part D Plan Contract ID Type Type of Nx Transaction being reported All Nx, N1, N2, or N3 Part D Plan Nx Performance Report Guide Page 4

7 Label Description/Business Rules Format All Years Date of Service Received (First through Four Quarters and YTD) Total for Type Nx Accepted This section reports all N transactions sent to the Part D plan regardless of the date of service on the N Sum of Nx transactions generated. (All Nx, N1, N2, or Sum of type Nx accepted. (All Nx, N1, N2, or Nx Accepted Rate Nx Reject Nx accepted divided by total for Nx type. (All Nx, N1, N2, or Sum of type Nx rejected. (All Nx, N1, N2, or Nx Rejected Rate Nx rejected divided by total type. (All Nx, N1, N2, or Current Year Date of Service Received (First through Four Quarters, and YTD) Total for Type Nx Accepted This section reports all N transactions sent to the Part D plan with a date of service in the current plan year. Sum of Nx transactions generated. (All Nx, N1, N2, or Sum of type Nx accepted. (All Nx, N1, N2, or Nx Accepted Rate Nx Reject Nx accepted divided by total for Nx type. (All Nx, N1, N2, or Sum of type Nx rejected. (All Nx, N1, N2, or Nx Rejected Rate Nx rejected divided by total type. (All Nx, N1, N2, or Prior Year Date of Service Received (First through Four Quarters, and YTD) Total for Type Nx Accepted This section reports all N transactions sent to the Part D plan with a date of service in the year prior to the current plan year. Sum of Nx transactions generated. (All Nx, N1, N2, or Sum of type Nx accepted. (All Nx, N1, N2, or Nx Accepted Rate Nx Reject Nx accepted divided by total for Nx type. (All Nx, N1, N2, or Sum of type Nx rejected. (All Nx, N1, N2, or Nx Rejected Rate Nx rejected divided by total type. (All Nx, N1, N2, or Part D Plan Nx Performance Report Guide Page 5

8 Label Description/Business Rules Format Three Years Prior to Current Plan Year Date of Service Received (First through Four Quarters and YTD) Total for Type Nx Accepted Row Label Sum of Nx transactions generated. (All Nx, N1, N2, or Sum of type Nx accepted. (All Nx, N1, N2, or Nx Accepted Rate Nx Reject Nx accepted divided by total for Nx type. (All Nx, N1, N2, or Sum of type Nx rejected. (All Nx, N1, N2, or Nx Rejected Rate Nx rejected divided by total type. (All Nx, N1, N2, or 9.2 Cumulative Unsuccessful N Detail This report will be in.txt format and will contain Nx rejects based on DOS for a particular plan year. Label Description/Business Rules Format Transaction Information Columns under this grouping define the information from the Nx Transaction Contract ID The contract ID for the Part D Plan. X(6) Transmission Date to Part D Plan Transaction Reference Number Date the N transaction was transmitted to the Part D Plan. Format: YYYYMMDD The Transaction ID assigned to the Nx transaction by the Transaction Facilitator. NCPDP: 880-K5 9(8) X(10) RHP Tran ID RHP Tran ID from the database. X(13) Replay Number Transaction Code Service/Provider ID Service/Provider ID Qualifier Date Of Service The number of times the Nx transaction has been replayed from the database. Type of billing transaction (N1/N2/. NCPDP: 103-A3 Service Provider ID. NCPDP: 201-B1 Service Provider ID Qualifier. NCPDP: 202-B2 Date of service NCPDP: 401-D1 9(2) X(2) X(15) X(15) 9(8) Part D Plan Nx Performance Report Guide Page 6

9 Label Description/Business Rules Format Prescription/Service Reference Number Fill Number Product/Service ID Product/Service ID Qualifier Reject Code Prescription/Service Reference Number. NCPDP: 402-D2 Fill number. NCPDP: 403-D3 Product/Service ID. NCPDP: 407-D7 Product/Service ID Qualifier. NCPDP: 436-E1 The reason for the Nx Transaction failure. If there all multiple reasons, the report shall display each reason in their own row. NCPDP: 511-FB Note: See NCPDP Reject Code list. 9(12) 9(2) X(19) X(19) X(3) Part D Information Columns under this grouping contain information relative to the Part D Plan beneficiary demographics. HICN HICN for the Part D beneficiary. Last Name Last name from eligibility file. X(40) First Name First Name from eligibility file. X(30) Part D Processor Name Part D BIN Part D PCN Part D Group Part D Cardholder ID Patient Gender Code Patient Date of Birth Part D Processor Name Note: From Processor Table Part D Plan BIN Number. NCPDP: 101-A1 Part D Plan Processor Control Number. NCPDP: 104-A4 Part D Plan Group ID. NCPDP: 301-C1 Cardholder ID for the Part D beneficiary. NCPDP: 302-C2 Gender of the Patient. NCPDP: 305-C5 Patient Date of Birth. Format: YYYYMMDD X(50) 9(6) X(15) X(20) X(1) Supplemental Information Columns under this grouping contain the supplemental demographics information for the beneficiary Part D Plan Nx Performance Report Guide Page 7

10 Label Description/Business Rules Format OHI BIN OHI PCN OHI Group OHI Cardholder ID OHI Transaction Code Supplemental BIN Number. NCPDP: 990-MG Supplemental Processor Control Number. NCPDP: 991-MH Supplemental Group ID. NCPDP: 992-MJ Supplemental Cardholder ID. NCPDP: 356-NU The OHI Transaction Code from the original claim. 9(6) X(10) X(15) X(20) X(2) Claim Receive Date Authorization Number Patient Paid Amount Submitted Additional information Plan Update Date Transaction Facilitator Update Timestamp Next Scheduled Re-try Remaining Retries Available Date claim was received by Transaction Facilitator. Format: YYYYMMDD Number assigned by the processor to identify an authorized transaction. NCPDP: 503-F3 Patient Paid Amount submitted on transaction. NCPDP: 433-DX Columns under this grouping contain information relative to the Nx processing. It may contain demographics, transaction or supplemental information that has been added since the inception of the report. These elements are added on to the end of the file in order to minimize coding efforts for the recipient. The date plan updated the Nx transaction on their system. Format: CYYYMMDD This represents the timestamp for the processing of the transaction update. Due to the possibility of multiple updates to the same transaction on a given file, the processing order will reflect the order on the request file and can be determined by the timestamp. Format: CYYYMMDDHHMMSSFF The date the Nx or Bx is scheduled for an automated retry. Format: YYYYMMDD The number automatic retries remaining. If none are remaining the field will contain a zero 0 9(8) X(20) $999, X(17) 9(2) Current MBI Medicare beneficiary identifier. MBI Effective Date Effective date of the MBI just reported. Format: CYYYMMDD Part D Plan Nx Performance Report Guide Page 8

11 Label Description/Business Rules Format MBI Termination Date MBI MBI Effective Date MBI Termination Date MBI MBI Effective Date MBI Termination Date MBI MBI Effective Date MBI Termination Date MBI MBI Effective Date MBI Termination Date MBI MBI Effective Date MBI Termination Date Termination date of the MBI just reported. This may be blank if currently active. Format: CYYYMMDD Medicare beneficiary identifier. Any MBI reported after the current MBI will be reported in order of most current to oldest. Effective date of the MBI just reported. Format: CYYYMMDD Termination date of the MBI just reported. This may be blank if currently active. Format: CYYYMMDD Medicare beneficiary identifier. Any MBI reported after the current MBI will be reported in order of most current to oldest. Effective date of the MBI just reported. Format: CYYYMMDD Termination date of the MBI just reported. This may be blank if currently active. Format: CYYYMMDD Medicare beneficiary identifier. Any MBI reported after the current MBI will be reported in order of most current to oldest. Effective date of the MBI just reported. Format: CYYYMMDD Termination date of the MBI just reported. This may be blank if currently active. Format: CYYYMMDD Medicare beneficiary identifier. Any MBI reported after the current MBI will be reported in order of most current to oldest. Effective date of the MBI just reported. Format: CYYYMMDD Termination date of the MBI just reported. This may be blank if currently active. Format: CYYYMMDD Medicare beneficiary identifier. Any MBI reported after the current MBI will be reported in order of most current to oldest. Effective date of the MBI just reported. Format: CYYYMMDD Termination date of the MBI just reported. This may be blank if currently active. Format: CYYYMMDD 10 Scenarios The following represent initial scenarios identified as examples. It is anticipated that after Part D Plan/Processors begin reviewing the data on the Part D Plan Nx Performance Report provided by the Transaction Facilitator, other scenarios may be brought forward for inclusion. Part D Plan Nx Performance Report Guide Page 9

12 10.1 Scenario One In this scenario the Part D Plan/Processor has received and rejected an N transaction on 01/14/2015. Subsequent to that the N was replayed (automated or manually requested) on 01/27/2015 and the N was accepted. The rejected N appears on the report generated 01/15/2015. The rejected N would no longer appear on the 02/01/2015 report because the replayed N was successfully processed Scenario Two In this scenario the Part D Plan/Processor has received and accepted an N1 transaction on 01/14/2015. A B2 transaction is received by the Transaction Facilitator but does not contain a Cardholder ID, so therefore an N2 transaction cannot be generated. Then a new N1 transaction is received on 01/15/2015 that is the same as the original N1 transaction. The Part D Plan/Processor rejects this N1 transaction as a duplicate. The report on 02/01/2015 will show the new N1 transaction. If this situation occurs, this probably is something the Part D Plan/Processor cannot correct and may be a valid rejection. Recommended action: Part D Plan/Processor should: Not reject the N1 transaction as duplicate Accept and update the timestamp on the N1 transaction Create an internal N2 reversal if their systems require it Otherwise there is no way to resolve the N1 reject on the report Scenario Three In this scenario the Part D Plan/Processor has received and accepted an N1 transaction on 01/14/2015. A B2 transaction is received by the Transaction Facilitator but does not contain a Cardholder ID, so therefore an N2 transaction cannot be generated. Then a new N1 transaction is received on 01/15/2015 where the patient pay amount is different but everything else is the same as the original N1 transaction. The Part D Plan/Processor rejects this N1 transaction as a duplicate. The report on 02/01/2015 will show the new N1 transaction. Recommended action: Part D Plan/Processor should: Not reject the N1 transaction as duplicate Accept and update the timestamp and patient pay amount on the N1 transaction Create an internal N2 reversal if their systems require it Otherwise there is no way to resolve the N1 reject on the report Scenario Four In this scenario the Transaction Facilitator sends an Nx transaction to the Part D Plan/Processor and does not receive a response from the Part D Plan/Processor. Depending upon the Part D Plan/Processor s system, the following situations may have occurred: The Part D Plan/Processor shows they have accepted the Nx transaction. The Part D Plan/Processor shows they have rejected the Nx transaction. The Part D Plan/Processor has no record of receipt of the Nx transaction. In all three of these situations, the Part D Plan/Processor needs to determine why a correct and timely response has not been received by the Transaction Facilitator. Once corrected, the Part D Plan/Processor will need to request a replay. Part D Plan Nx Performance Report Guide Page 10

13 10.5 Scenario Five In this scenario the Transaction Facilitator sends an N3 transaction to the Part D Plan/Processor and receives an accepted response from the Part D Plan/Processor. The assumption is that the Transaction Facilitator sent an N1 transaction originally at some point (hence the subsequent. (Note, in this scenario, it is possible that the Part D Plan/Processor cannot apply the N2 portion of the N3, however as long as the N1 portion can be accepted, then the N3 should have an accepted response returned.) If the original N1 was rejected: If the N3 is accepted, the original N1 will fall off the report. There is no further action of the Part D Plan/Processor because the N1 transaction is no longer in a rejected status. If the N3 is rejected, the N3 will appear on the report and originally rejected N1 will no longer appear on the report because the Transaction Reference Number (880-K5) is the same and the N3 represents the most current information from the supplemental payer. Part D Plan Nx Performance Report Guide Page 11

Financial Information Reporting (FIR) Daily Cumulative FIR Aging Report Guide with MBI. This report will be effective starting

Financial Information Reporting (FIR) Daily Cumulative FIR Aging Report Guide with MBI. This report will be effective starting Financial Information Reporting (FIR) Daily Cumulative FIR Aging Report Guide with MBI This report will be effective starting 3-1-2018 FIR Report Guide 6-2014 Page i Table of Contents 1 BACKGROUND... 1

More information

The Limited Income NET Program Questions and Answers for Pharmacy Providers

The Limited Income NET Program Questions and Answers for Pharmacy Providers The Limited Income NET Program Questions and Answers for Pharmacy Providers Introduction On January 1, 2012, Medicare s Limited Income Newly Eligible Transition (LI NET) Program successfully began its

More information

Frequently asked questions and answers for pharmacy providers

Frequently asked questions and answers for pharmacy providers Frequently asked questions and answers for pharmacy providers The purpose of Medicare s Limited Income Newly Eligible Transition (NET) Program is to ensure individuals with Medicare s low-income subsidy

More information

NCPDP VERSION 5.1 REQUEST PAYER SHEET

NCPDP VERSION 5.1 REQUEST PAYER SHEET NCPDP VERSION 5.1 REQUEST PAYER SHEET Payer Name: WellPoint Pharmacy Revised Date: 12/11/2005 Management Processor: WellPoint Pharmacy Switch: All Management Effective as of: 1/1/2006 Version/Release #:

More information

NCPDP Version D.0 E1 Specifications for Medicare Part D Effective Date: 03/01/2018

NCPDP Version D.0 E1 Specifications for Medicare Part D Effective Date: 03/01/2018 NCPDP Version D.0 E1 Specifications for Medicare Part D Effective Date: 03/01/2018 Note: If a "Value" contains quotation marks around it, then the value is a literal character that must be included in

More information

NCPDP Version D.0 E1 Specifications for Medicare Part D Effective Date: 05/26/2016

NCPDP Version D.0 E1 Specifications for Medicare Part D Effective Date: 05/26/2016 NCPDP Version D.0 E1 Specifications for Medicare Part D Effective Date: 05/26/2016 Note: If a "Value" contains quotation marks around it, then the value is a literal character that must be included in

More information

Upstream Reporting of Copay Assistance Issues Brief

Upstream Reporting of Copay Assistance Issues Brief Upstream Reporting of Copay Assistance Issues Brief National Council for Prescription Drug Programs 9240 East Raintree Drive Scottsdale, AZ 85260 Phone: (480) 477-1000 Fax: (480) 767-1042 e-mail: ncpdp@ncpdp.org

More information

Prescription Drug Event Record Layout

Prescription Drug Event Record Layout Prescription Drug Event Record Layout HDR RECORD 1 RECORD ID 1-3 X(3) 3 "HDR" 2 SUBMITTER ID 4-9 X(6) 6 CMS Unique ID assigned by CMS. 3 FILE ID 10-19 X(10) 10 Unique ID provided by Submitter. Same ID

More information

Martin s Point Generations Advantage Policy and Procedure Form

Martin s Point Generations Advantage Policy and Procedure Form Martin s Point Generations Advantage Policy and Procedure Form Policy #: PartD.923 Effective Date: 4/16/10 Policy Title: Part D Transition Policy Section of Manual: Medicare Prescription Drug Benefit Manual

More information

Effective

Effective NCPDP Version D.0 E1 Specifications for Medicare Part D Effective Date: 01/01/2019 Note: If a "Value" contains quotation marks around it, then the value is a literal character that must be included in

More information

Texas Vendor Drug Program Pharmacy Provider Procedure Manual

Texas Vendor Drug Program Pharmacy Provider Procedure Manual Texas Vendor Drug Program Pharmacy Provider Procedure Manual System Requirements May 2018 The Pharmacy Provider Procedure Manual (PPPM) is available online at txvendordrug.com/about/policy/manual. ` Table

More information

2012 Checklist for Community Pharmacy. Medicare Part D-Related Information

2012 Checklist for Community Pharmacy. Medicare Part D-Related Information NATIONAL COMMUNITY PHARMACISTS ASSOCIATION 2012 Checklist for Community Pharmacy Medicare Part D-Related Information Medicare Part D Valid Prescriber Identifiers For 2012, CMS will continue to permit the

More information

PURPOSE OF THE POLICY STATEMENT OF THE POLICY PROCEDURES

PURPOSE OF THE POLICY STATEMENT OF THE POLICY PROCEDURES PURPOSE OF THE POLICY The purpose of this policy is to describe Health Alliance s process for transitions and ensure that continued drug coverage is provided to new and current Part D members. The transition

More information

2019 Transition Policy

2019 Transition Policy 2019 Number: 5.8 Prescription Drug Replaces: 5.8 v.2018 Cross 5.1.2 Transition Fill Monitoring Procedure References: Purpose: To provide guidance on the transition process for new or current Plan members

More information

Subject: Indiana Health Coverage Programs (IHCP) Transition to the National Council for Prescription Drug Programs (NCPDP) Version 5.

Subject: Indiana Health Coverage Programs (IHCP) Transition to the National Council for Prescription Drug Programs (NCPDP) Version 5. P R O V I D E R B U L L E T I N B T 2 0 0 3 6 1 S E P T E M B E R 1 9, 2 0 0 3 To: All Pharmacy Providers Subject: Indiana Health Coverage Programs (IHCP) Transition to the National Council for Prescription

More information

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction.

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. NCPDP VERSION D CLAIM BILLING/CLAIM REBILL REQUEST CLAIM BILLING/CLAIM REBILL PAYER SHEET ** Start of Request (B1/B3) Payer Sheet ** GENERAL INFORMATION Payer Name: University of North Carolina Health

More information

NCPDP Electronic Prescribing Standards

NCPDP Electronic Prescribing Standards NCPDP Electronic Prescribing Standards May 2014 1 What is NCPDP? An ANSI-accredited standards development organization. Provides a forum and marketplace for a diverse membership focused on health care

More information

2018 Medicare Part D Transition Policy

2018 Medicare Part D Transition Policy Regulation/ Requirements Purpose Scope Policy 2018 Medicare Part D Transition Policy 42 CFR 423.120(b)(3) 42 CFR 423.154(a)(1)(i) 42 CFR 423.578(b) Medicare Prescription Drug Benefit Manual, Chapter 6,

More information

emedny Prospective Drug Utilization Review/ Electronic Claim Capture and Adjudication ProDUR/ECCA Standards

emedny Prospective Drug Utilization Review/ Electronic Claim Capture and Adjudication ProDUR/ECCA Standards STATE OF NEW YORK DEPARTMENT OF HEALTH emedny Prospective Drug Utilization Review/ Electronic Claim Capture and Adjudication ProDUR/ECCA Standards July 30, 2010 Version 1.33 July 2010 Computer Sciences

More information

emedny Prospective Drug Utilization Review/ Electronic Claim Capture and Adjudication ProDUR/ECCA Standards

emedny Prospective Drug Utilization Review/ Electronic Claim Capture and Adjudication ProDUR/ECCA Standards STATE OF NEW YORK DEPARTMENT OF HEALTH emedny Prospective Drug Utilization Review/ Electronic Claim Capture and Adjudication ProDUR/ECCA Standards December 06, 2005 Version 1.18 December 2005 Computer

More information

1 INSURANCE SECTION Instructions: This section contains information about the cardholder and their plan identification.

1 INSURANCE SECTION Instructions: This section contains information about the cardholder and their plan identification. 1 INSURANCE SECTION : This section contains information about the cardholder and their plan identification. 1 ID of Cardholder Required. Enter the recipient s 13 digit Medicaid ID. 2 Group ID Not Required.

More information

emedny Prospective Drug Utilization Review/ Electronic Claim Capture and Adjudication ProDUR/ECCA Standards

emedny Prospective Drug Utilization Review/ Electronic Claim Capture and Adjudication ProDUR/ECCA Standards STATE OF NEW YORK DEPARTMENT OF HEALTH emedny Prospective Drug Utilization Review/ Electronic Claim Capture and Adjudication ProDUR/ECCA Standards December 18, 2003 Version 1.7 December 2003 Computer Sciences

More information

2018 Transition Fill Policy & Procedure. Policy Title: Issue Day: Effective Dates: 01/01/2018

2018 Transition Fill Policy & Procedure. Policy Title: Issue Day: Effective Dates: 01/01/2018 Policy Title: Department: Policy Number: 2018 Transition Fill Policy & Procedure Pharmacy CH-MCR-PH-01 Issue Day: Effective Dates: 01/01/2018 Next Review Date: 04/01/2018 Revision Dates: 05/19/2016 11/14/2016

More information

Texas Vendor Drug Program. Pharmacy Provider Procedure Manual Coordination of Benefits. Effective Date. February 2018

Texas Vendor Drug Program. Pharmacy Provider Procedure Manual Coordination of Benefits. Effective Date. February 2018 Texas Vendor Drug Program Pharmacy Provider Procedure Manual Coordination of Benefits Effective Date February 2018 The Pharmacy Provider Procedure Manual (PPPM) is available online at txvendordrug.com/about/policy/manual.

More information

MEDICARE PLAN PAYMENT GROUP

MEDICARE PLAN PAYMENT GROUP DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, Maryland 21244-1850 MEDICARE PLAN PAYMENT GROUP Date: June 23, 2017 To: From: All Part

More information

Kaiser Permanente Northern California KPNC

Kaiser Permanente Northern California KPNC Kaiser Permanente Northern California KPNC BIN: 011842 State(s): Northern California Switch: emdeon Processor: Catamaran Accepting: Claim Billing and Reversals Format: NCPDP Version D.0 External Code List:

More information

MAINE GENERAL ASSISTANCE NCPDP VERSION D.Ø PAYER SHEET

MAINE GENERAL ASSISTANCE NCPDP VERSION D.Ø PAYER SHEET MAINE GENERAL ASSISTANCE NCPDP VERSION D.Ø PAYER SHEET REQUEST CLAIM BILLING/CLAIM REBILL ** Start of Request (B1/B3) Payer Sheet ** GENERAL INFORMATION Payer Name: Maine General Assistance Date: June

More information

NCPDP Version 5 Request Payer Sheet

NCPDP Version 5 Request Payer Sheet NCPDP Version 5 Request Payer Sheet NCPDP Rev.04.16.02 General Information Payer Name: 4-D Pharmacy Benefits Plan Name/Group Name: 4-D Pharmacy Benefits Processor: Argus Payer Sheet Revision Effective

More information

1. NCPDP VERSION D.0 CLAIM BILLING 1.1 REQUEST CLAIM BILLING

1. NCPDP VERSION D.0 CLAIM BILLING 1.1 REQUEST CLAIM BILLING 1. NCPDP VERSION D.0 CLAIM BILLING 1.1 REQUEST CLAIM BILLING GENERAL INFORMATION Payer Name: American Health Care Date: January 2016 Plan Name/Group Name: SEE APPENDI BIN: SEE APPENDI PCN: SEE APPENDI

More information

Prescription Drug Event (PDE) Data: Source and Processing

Prescription Drug Event (PDE) Data: Source and Processing Prescription Drug Event (PDE) Data: Source and Processing Barbara Frank, M.S., M.P.H. Director of Workshops, Outreach, & Research University of Minnesota Frequently Repeated Acronyms CMS Centers for Medicare

More information

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction.

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. NCPDP VERSION D CLAIM BILLING/CLAIM REBILL REQUEST CLAIM BILLING/CLAIM REBILL PAYER SHEET ** Start of Request (B1/B3) Payer Sheet ** GENERAL INFORMATION Payer Name: San Francisco Health Plan Date: 04/16/2013

More information

Medicare Transition POLICY AND PROCEDURES

Medicare Transition POLICY AND PROCEDURES Medicare Transition POLICY AND PROCEDURES POLICY The Plan will maintain an appropriate transition process, consistent with 42 CFR 423.120(b)(3), Chapter 6 of the Medicare Prescription Drug Benefit Manual

More information

Medicare Advantage Part D Pharmacy Policy

Medicare Advantage Part D Pharmacy Policy Page 1 of 27 DISCLAIMER NOTICE: The purpose of this policy is to provide guidance for benefit and coverage determinations only. Benefit and coverage determinations are subject to the contractual limitations

More information

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction.

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. NCPDP VERSION D CLAIM BILLING/CLAIM REBILL REQUEST CLAIM BILLING/CLAIM REBILL PAYER SHEET ** Start of Request (B1/B3) Payer Sheet ** GENERAL INFORMATION Payer Name: Community Health Choices Date: 09/21/2017

More information

Payer Sheet. Commercial Primary

Payer Sheet. Commercial Primary Payer Sheet Commercial Primary Table of Contents HIGHLIGHTS Updates, Changes & Reminders... 3 PART 1: GENERAL INFORMATION... 4 Pharmacy Help Desk Information... 4 PART 2: BILLING TRANSACTION / SEGMENTS

More information

Part D Request Claim Billing/Claim Rebill Test Data

Part D Request Claim Billing/Claim Rebill Test Data Part D Request Test Data Transaction Header Transaction Header Segment Paid Claim Resubmit Duplicate Clinical Prior Auth Rejected Reversal 1Ø1-A1 BIN Number M 603286 603286 603286 603286 603286 1Ø2-A2

More information

Payer Sheet. Commercial Other Payer Amount Paid

Payer Sheet. Commercial Other Payer Amount Paid Payer Sheet Commercial Other Payer Amount Paid Table of Contents HIGHLIGHTS Updates, Changes & Reminders... 3 PART 1: GENERAL INFORMATION... 4 Pharmacy Help Desk Information... 4 PART 2: BILLING TRANSACTION

More information

MEDICARE PART D POLICY FORMULARY: TRANSITION PROCESS Policy Number: 6-C

MEDICARE PART D POLICY FORMULARY: TRANSITION PROCESS Policy Number: 6-C MEDICARE PART D POLICY FORMULARY: TRANSITION PROCESS Policy Number: 6-C Coverage Statement This Policy is applicable to: Medco PDP, Beneficiaries, Enhanced PDPs, Client PDPs and Client MA-PDs, to the extent

More information

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction.

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. NCPDP VERSION D CLAIM BILLING/CLAIM REBILL REQUEST CLAIM BILLING/CLAIM REBILL PAYER SHEET ** Start of Request (B1/B3) Payer Sheet ** GENERAL INFORMATION Payer Name: AmeriHealth Caritas Louisiana Date:

More information

MEDICARE PLAN PAYMENT GROUP

MEDICARE PLAN PAYMENT GROUP DEPARTMENT OF HEALTH & HUMAN SERVICES Centers for Medicare & Medicaid Services 7500 Security Boulevard Baltimore, Maryland 21244-1850 MEDICARE PLAN PAYMENT GROUP Date: May 30, 2018 To: From: All Part D

More information

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction.

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. NCPDP VERSION D CLAIM BILLING/CLAIM REBILL REQUEST CLAIM BILLING/CLAIM REBILL PAYER SHEET ** Start of Request (B1/B3) Payer Sheet GENERAL INFORMATION Payer Name: NHPRI Integrity Date: 02/18/2016 Plan Name/Group

More information

Payer Sheet. Medicaid Primary Billing & Medicaid as Secondary Payer Billing Other Payer Amount Paid (OPAP)

Payer Sheet. Medicaid Primary Billing & Medicaid as Secondary Payer Billing Other Payer Amount Paid (OPAP) Payer Sheet Medicaid Primary Billing & Medicaid as Secondary Payer Billing Other Payer Amount Paid (OPAP) Table of Contents HIGHLIGHTS Updates, Changes & Reminders... 3 PART 1: GENERAL INFORMATION... 4

More information

Medicare Part D In Massachusetts: Successes and Continuing Challenges. Cindy Parks Thomas Massachusetts Health Policy Forum May 30, 2007

Medicare Part D In Massachusetts: Successes and Continuing Challenges. Cindy Parks Thomas Massachusetts Health Policy Forum May 30, 2007 Medicare Part D In Massachusetts: Successes and Continuing Challenges Cindy Parks Thomas Massachusetts Health Policy Forum May 30, 2007 2 I. Overview and Massachusetts Part D Landscape 3 Medicare Part

More information

2019 Transition Policy and Procedure

2019 Transition Policy and Procedure 2019 Transition Policy and Procedure POLICY Steward Health Choice Generations (SHCG) provides a Part D drug transition process in order to prevent enrollee medication coverage gaps. SHCG s transition process

More information

From the auditor s desk. Updating pharmacy demographics with NCPDP. Responding to daily pre-payment review requests

From the auditor s desk. Updating pharmacy demographics with NCPDP. Responding to daily pre-payment review requests Prime Perspective Quarterly Pharmacy Newsletter from Prime Therapeutics LLC June 2017: Issue 68 From the auditor s desk INSIDE From the auditor s desk...1 Medicare news/medicaid news..2 Florida news...4

More information

MEDICARE PART D PRESCRIPTION DRUG EVENTS (PDE) RECONCILIATION

MEDICARE PART D PRESCRIPTION DRUG EVENTS (PDE) RECONCILIATION MEDICARE PART D PRESCRIPTION DRUG EVENTS (PDE) RECONCILIATION 2-06-15 Presented by: Alexander Luong, Pharm.D. Candidate 2015 University of the Pacific Preceptor: Dr. Craig Stern, Pharm.D. MBA President,

More information

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction.

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. NCPDP VERSION D CLAIM BILLING/CLAIM REBILL REQUEST CLAIM BILLING/CLAIM REBILL PAYER SHEET ** Start of Request (B1/B3) Payer Sheet ** GENERAL INFORMATION Payer Name: McLaren Advantage Sapphire Date: 11/18/2014

More information

Community Care, Inc. Medicare Part-D Enrollee Transition Plans H5212 PACE and H2034 HMO-SNP 2018

Community Care, Inc. Medicare Part-D Enrollee Transition Plans H5212 PACE and H2034 HMO-SNP 2018 Title: and H2034 HMO-SNP 2018 Policy Identifier: PA - Pharmacy Effective Date: 20180101 Scope: Organization Wide Family Care PACE Partnership Waukesha Day Center HUD (Housing and Urban Development) Department:

More information

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction.

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. NCPDP VERSION D CLAIM BILLING/CLAIM REBILL REQUEST CLAIM BILLING/CLAIM REBILL PAYER SHEET ** Start of Request (B1/B3) Payer Sheet GENERAL INFORMATION Payer Name: AscellaHealth PACE Date: 11/14/2017 Plan

More information

Medicare Part D Transition Policy

Medicare Part D Transition Policy Medicare Part D Transition Policy Transition Policy for New and Current Enrollees of our Medicare Part D Prescription Drug Plan PURPOSE: Simply Healthcare Plans, Inc. must maintain an appropriate transition

More information

Payer Sheet. Medicare Part D Other Payer Patient Responsibility

Payer Sheet. Medicare Part D Other Payer Patient Responsibility Payer Sheet Medicare Part D Other Payer Patient Responsibility Table of Contents HIGHLIGHTS Updates, Changes & Reminders... 3 PART 1: GENERAL INFORMATION... 4 Pharmacy Help Desk Information... 4 PART 2:

More information

RESOURCE GUIDE Prescription Drug Event Data Training RESOURCE GUIDE. About this Guide GENERAL CONTACT INFORMATION

RESOURCE GUIDE Prescription Drug Event Data Training RESOURCE GUIDE. About this Guide GENERAL CONTACT INFORMATION 2007 Prescription Drug Event Data Training RESOURCE GUIDE RESOURCE GUIDE About this Guide This Resource Guide is intended to help prescription drug plans, providers, physicians, and third party submitters

More information

Y0076_ALL Trans Pol

Y0076_ALL Trans Pol Policy Title: Medicare Part D Transition Policy Policy Number: PCM-2018 TB Policy Owner: Antonio Petitta, Vice President Pharmacy Care Management Department(s): Pharmacy Care Management Effective Date:

More information

NCPDP Update. Review of NCPDP Task Group Efforts and Use Cases for Real-Time Benefit Inquiry Standard. May 23, 2017

NCPDP Update. Review of NCPDP Task Group Efforts and Use Cases for Real-Time Benefit Inquiry Standard. May 23, 2017 NCPDP Update Review of NCPDP Task Group Efforts and Use Cases for Real-Time Benefit Inquiry Standard May 23, 2017 Catherine C Graeff CEO, Sonora Advisory Group, LLC Active in NCPDP since 1988 - as a member,

More information

Payer Specification Sheet For Prime Therapeutics BCBS of Texas CHIP, STAR and STAR KIDS Medicaid Programs

Payer Specification Sheet For Prime Therapeutics BCBS of Texas CHIP, STAR and STAR KIDS Medicaid Programs Payer Specification Sheet For Prime Therapeutics BCBS of Texas CHIP, STAR and STAR KIDS Medicaid Programs General information Prime Therapeutics LLC September 1, 2018 Plan Name BIN PCN BCBS of Texas Medicaid

More information

Values Accountability Integrity Service Excellence Innovation Collaboration

Values Accountability Integrity Service Excellence Innovation Collaboration n04231 Medicare Part D Transition and Emergency Fill Policy Values Accountability Integrity Service Excellence Innovation Collaboration Abstract Purpose: The Medicare Part D Transition and Emergency Fill

More information

NetCard Systems P.O. Box 4517 Centennial, CO PAYER SPECIFICATION SHEET. Plan Information

NetCard Systems P.O. Box 4517 Centennial, CO PAYER SPECIFICATION SHEET. Plan Information NetCard Systems P.O. Box 4517 Centennial, CO 80112 PAYER SPECIFICATION SHEET Plan Information Payer Name: NetCard Systems Date: 12/01/12 Plan Name: NetCard Systems/Welldyne/RxWest BIN: 008878 PCN: CB8

More information

Payer Sheet. Medicare Part D Primary Billing & MSP (Medicare as Secondary Payer)

Payer Sheet. Medicare Part D Primary Billing & MSP (Medicare as Secondary Payer) Payer Sheet Medicare Part D Primary Billing & MSP (Medicare as Secondary Payer) Table of Contents HIGHLIGHTS Updates, Changes & Reminders... 3 PART 1: GENERAL INFORMATION... 4 Pharmacy Help Desk Information...

More information

Prime Perspective. From the auditor s desk. Quarterly Pharmacy Newsletter from Prime Therapeutics LLC. INSIDE From the auditor s desk...

Prime Perspective. From the auditor s desk. Quarterly Pharmacy Newsletter from Prime Therapeutics LLC. INSIDE From the auditor s desk... Prime Perspective Quarterly Pharmacy Newsletter from Prime Therapeutics LLC August 2014: Issue 61 From the auditor s desk INSIDE From the auditor s desk...1 Medicare news/medicaid news..2 Florida news...4

More information

From the auditor s desk. Billing compounds as single-ingredient claims. Submit Compound Prescription with a code of 2 in the Compound Code field.

From the auditor s desk. Billing compounds as single-ingredient claims. Submit Compound Prescription with a code of 2 in the Compound Code field. Prime Perspective Quarterly Pharmacy Newsletter from Prime Therapeutics LLC March 2018: Issue 71 From the auditor s desk INSIDE From the auditor s desk...1 Medicare news/ Medicaid news...2 Florida news...4

More information

Payer Sheet. Medicare Part D Other Payer Patient Responsibility

Payer Sheet. Medicare Part D Other Payer Patient Responsibility Payer Sheet Medicare Part D Other Payer Patient Responsibility Table of Contents HIGHLIGHTS Updates, Changes & Reminders... 3 PART 1: GENERAL INFORMATION... 4 Pharmacy Help Desk Information... 4 PART 2:

More information

TELECOMMUNICATION VERSION D AND ABOVE QUESTIONS, ANSWERS AND EDITORIAL UPDATES

TELECOMMUNICATION VERSION D AND ABOVE QUESTIONS, ANSWERS AND EDITORIAL UPDATES TELECOMMUNICATION VERSION D AND ABOVE QUESTIONS, ANSWERS AND EDITORIAL UPDATES DOCUMENTATION 08/2013 See important update in section Quantity Prescribed (46Ø-ET) National Council for Prescription Drug

More information

NetCard Systems P.O. Box 4517 Centennial, Co PAYER SPECIFICATION SHEET. Plan Information

NetCard Systems P.O. Box 4517 Centennial, Co PAYER SPECIFICATION SHEET. Plan Information NetCard Systems P.O. Box 4517 Centennial, Co 80112 PAYER SPECIFICATION SHEET Plan Information Payer Name: NetCard Systems Date: 12/31/11 Plan Name: NetCard Systems/Welldyne/RxWest BIN: 008878 PCN: CB8

More information

BIN: PCN:

BIN: PCN: NCPDP VERSION D CLAIM BILLING/CLAIM REBILL REQUEST CLAIM BILLING/CLAIM REBILL PAYER SHEET ** Start of Request (B1/B3) Payer Sheet GENERAL INFORMATION Payer Name: Vista Medicare Advantage (HMO SNP) Date:

More information

Harvard Pilgrim Health Care Pharmacy Services Policy & Criteria. Medicare Advantage Transition of Care

Harvard Pilgrim Health Care Pharmacy Services Policy & Criteria. Medicare Advantage Transition of Care SCOPE: Harvard Pilgrim Health Care Medicare Advantage enrollees, their providers, and all HPHC Pharmacy, Customer Service and Appeals & Grievances Staff. OBJECTIVE: To efficiently provide new enrollees

More information

Payer Sheet. Medicare Part D Other Payer Amount Paid

Payer Sheet. Medicare Part D Other Payer Amount Paid Payer Sheet Medicare Part D Other Payer Amount Paid Table of Contents HIGHLIGHTS Updates, Changes & Reminders PART 1: GENERAL INFORMATION Pharmacy Help Desk Information PART 2: BILLING TRANSACTION / SEGMENTS

More information

2012 Medicare Part D Transition Process for contracts H3864 & H4754:

2012 Medicare Part D Transition Process for contracts H3864 & H4754: 2012 Medicare Part D Transition Process for contracts H3864 & H4754: Essentials Rx 6, Essentials Rx 14, Essentials Rx 15, Essentials Rx 16, Premier Rx 7, Explorer Rx 1, Explorer Rx 2, and Explorer Rx 4

More information

Payer Sheet. Medicare Part D Primary Billing & MSP (Medicare as Secondary Payer)

Payer Sheet. Medicare Part D Primary Billing & MSP (Medicare as Secondary Payer) Payer Sheet Medicare Part D Primary Billing & MSP (Medicare as Secondary Payer) Table of Contents HIGHLIGHTS Updates, Changes & Reminders... 3 PART 1: GENERAL INFORMATION... 4 Pharmacy Help Desk Information...

More information

Gap Analysis for NCPDP D.0 Billing

Gap Analysis for NCPDP D.0 Billing Gap Analysis for NCPDP D.0 Billing Version 1.0 April 2010 p This information is provided by Emdeon for education and awareness use only. While Emdeon believes that all the information in this document

More information

Payer Sheet. Medicaid Primary Billing & Medicaid as Secondary Payer Billing Other Payer Amount Paid (OPAP)

Payer Sheet. Medicaid Primary Billing & Medicaid as Secondary Payer Billing Other Payer Amount Paid (OPAP) Payer Sheet Medicaid Primary Billing & Medicaid as Secondary Payer Billing Other Payer Amount Paid (OPAP) Table of Contents HIGHLIGHTS Updates, Changes & Reminders... 3 PART 1: GENERAL INFORMATION... 4

More information

TELECOMMUNICATION VERSION D AND ABOVE QUESTIONS, ANSWERS AND EDITORIAL UPDATES

TELECOMMUNICATION VERSION D AND ABOVE QUESTIONS, ANSWERS AND EDITORIAL UPDATES TELECOMMUNICATION VERSION D AND ABOVE QUESTIONS, ANSWERS AND EDITORIAL UPDATES DOCUMENTATION 12/2014 See important update in section Quantity Prescribed (460-ET) National Council for Prescription Drug

More information

SAVINGS GENERATED BY PHARMACY BENEFIT MANAGERS IN THE MEDICARE PART D PROGRAM

SAVINGS GENERATED BY PHARMACY BENEFIT MANAGERS IN THE MEDICARE PART D PROGRAM February 6, 2014 GLENN GIESE KELLY BACKES SAVINGS GENERATED BY PHARMACY BENEFIT MANAGERS IN THE MEDICARE PART D PROGRAM June 26, 2017 GLENN GIESE RANDALL FITZPATRICK KEVIN MEYER CONTENTS Findings... 1

More information

Medicare Part D Transition Policy CY 2018 HCSC Medicare Part D

Medicare Part D Transition Policy CY 2018 HCSC Medicare Part D Contract: H0107, H0927, H1666, H3251, H3822, H3979, H8133, H8634, H8554, S5715 Policy Name: Medicare Formulary Transition Purpose: This procedure describes the standard process Health Care Service Corporation

More information

The Real-Time Benefit Check Key to Closing the Gaps in Eligibility Driven Formulary. Tony Schueth Chief Executive Officer & Managing Partner

The Real-Time Benefit Check Key to Closing the Gaps in Eligibility Driven Formulary. Tony Schueth Chief Executive Officer & Managing Partner The Real-Time Benefit Check Key to Closing the Gaps in Eligibility Driven Formulary Tony Schueth Chief Executive Officer & Managing Partner Eligibility-Informed Formulary Information Flow Current Workflow

More information

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction.

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. NCPDP VERSION D CLAIM BILLING/CLAIM REBILL REQUEST CLAIM BILLING/CLAIM REBILL PAYER SHEET ** Start of Request (B1/B3) Payer Sheet ** GENERAL INFORMATION Payer Name: Doctors HealthCare Plans, Inc. Date:

More information

Harvard Pilgrim Health Care Pharmacy Services Policy & Criteria. Medicare Advantage Transition of Care

Harvard Pilgrim Health Care Pharmacy Services Policy & Criteria. Medicare Advantage Transition of Care SCOPE: Medicare Advantage enrollees, their providers, and all HPHC Pharmacy, Customer Service and Appeals & Grievances Staff. OBJECTIVE: To avoid interruption in therapy, timely access to a temporary supply

More information

Classification: Clinical Department Policy Number: Subject: Medicare Part D General Transition

Classification: Clinical Department Policy Number: Subject: Medicare Part D General Transition Classification: Clinical Department Policy Number: 3404.00 Subject: Medicare Part D General Transition Effective Date: 01/01/2019 Process Date Revised: 07/20/2018 Date Reviewed: 05/29/2018 POLICY STATEMENT:

More information

All Medicare Advantage Products with Part D Benefits

All Medicare Advantage Products with Part D Benefits SUBJECT: TYPE: DEPARTMENT: Transition Process For Medicare Part D Departmental Pharmacy Care Management EFFECTIVE: 1/2017 REVISED: APPLIES TO: All Medicare Advantage Products with Part D Benefits POLICY

More information

Training. Point of Sale

Training. Point of Sale Training Point of Sale Nicholas Sparrow, Pharm.D., BCPS Chief pharmacist, Ft. Duchesne health Center Adapted from a presentation by Ivanne L. Chiovoloni, Pharm.D., NCPS, BCPS Point of Sale Pharmacy Billing

More information

MAINE TUBERCULOSIS PROGRAM NCPDP VERSION PILOT PAYER SHEET

MAINE TUBERCULOSIS PROGRAM NCPDP VERSION PILOT PAYER SHEET AINE TUBERCULOSIS PROGRA NCPDP VERSION PILOT PAYER SHEET REQUEST CLAI BILLING/CLAI REBILL PAYER SHEET ** Start of Request (B1/B3) Payer Sheet ** GENERAL INFORATION Payer Name: aine Tuberculosis Program

More information

Payer Sheet. Commercial Other Payer Patient Responsibility

Payer Sheet. Commercial Other Payer Patient Responsibility Payer Sheet Commercial Other Payer Patient Responsibility Table of Contents HIGHLIGHTS Updates, Changes & Reminders... 3 PART 1: GENERAL INFORMATION... 4 Pharmacy Help Desk Information... 4 PART 2: BILLING

More information

2015 Medicare Low-Income Subsidy (LIS), or Extra Help

2015 Medicare Low-Income Subsidy (LIS), or Extra Help 2015 Medicare Low-Income Subsidy (LIS), or Extra Help Extra Help with Prescription Drug Costs Medicare LIS Overview Patient Eligibility and Application Process How LIS Affects Patient Responsibility for

More information

Coverage Gap Discount Program (CGDP) Introduction For Manufacturers October 28, 2010

Coverage Gap Discount Program (CGDP) Introduction For Manufacturers October 28, 2010 Coverage Gap Discount Program (CGDP) Introduction For Manufacturers October 28, 2010 Agenda Introduction and Welcome Objectives Quarterly Payment Information Flow TPA Welcome Letter Draft Report Formats

More information

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction.

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. NCPDP VERSION D CLAI BILLING/CLAI REBILL REQUEST CLAI BILLING/CLAI REBILL PAYER SHEET ** Start of Request (B1/B3) Payer Sheet ** GENERAL INFORATION Payer Name: Upper Peninsula Health Plan edicaid Date:

More information

Payer Sheet. Commercial Other Payer Amount Paid

Payer Sheet. Commercial Other Payer Amount Paid Payer Sheet Commercial Other Payer Amount Paid Table of Contents HIGHLIGHTS Updates, Changes & Reminders... 3 PART 1: GENERAL INFORMATION... 4 Pharmacy Help Desk Information... 4 PART 2: BILLING TRANSACTION

More information

X12N/005010X220A1Benefit Enrollment and Maintenance (834) and the X12N/005010X221A1 Health Care Claim Payment/Advice (835) QUESTIONS AND ANSWERS

X12N/005010X220A1Benefit Enrollment and Maintenance (834) and the X12N/005010X221A1 Health Care Claim Payment/Advice (835) QUESTIONS AND ANSWERS X12N/005010X220A1Benefit Enrollment and Maintenance (834) and the X12N/005010X221A1 Health Care Claim Payment/Advice (835) QUESTIONS AND ANSWERS Version 1.2 March 2017 National Council for Prescription

More information

Prior Authorization All non-emergent services rendered by non-contracted providers require prior authorization, unless specified otherwise.

Prior Authorization All non-emergent services rendered by non-contracted providers require prior authorization, unless specified otherwise. Prior Authorization All non-emergent services rendered by non-contracted providers require prior authorization, unless specified otherwise. Abortions, Hysterectomies and Sterilizations Ambulance Emergency

More information

Medicare Part D Task Force Statement of Purpose Revised 7/12/05

Medicare Part D Task Force Statement of Purpose Revised 7/12/05 Medicare Part D Task Force Statement of Purpose Revised 7/12/05 The purpose of the Medicare Part D Task Force is to: 1. meet the needs of Medicare eligibles who are rejected for coverage supplemental to

More information

The Kidney Health Care Program Fiscal Year 2012 Annual Report

The Kidney Health Care Program Fiscal Year 2012 Annual Report The Kidney Health Care Program Fiscal Year 2012 Annual Report Division of Family and Community Health Services Texas Department of State Health Services Legislative Authority The Kidney Health Care Act

More information

FIDA ENROLLMENT QUESTIONS AND ANSWERS (6/20/14)

FIDA ENROLLMENT QUESTIONS AND ANSWERS (6/20/14) Enrollment Files 834 Q1: When should FIDA Plans expect to receive 834 files containing FIDA members? Specifically, initial production of 834 enrollment file(s) for voluntary enrollees effective 10/1/14

More information

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction.

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. 1. NCPDP VERSION D CLAI BILLING/CLAI REBILL TEPLATE 1.1 REQUEST CLAI BILLING/CLAI REBILL PAYER SHEET TEPLATE ** Start of Request (B1/B3) Payer Sheet Template** GENERAL INFORATION Payer Name: Contra Costa

More information

CMS Proposed Rulemaking For The Medicare Advantage And Medicare Prescription Drug Programs

CMS Proposed Rulemaking For The Medicare Advantage And Medicare Prescription Drug Programs CLIENT ALERT CMS Proposed Rulemaking For The Medicare Advantage And Medicare Prescription Drug Programs Dec.08.2009 On October 22, 2009, the Centers for Medicare & Medicaid Services (CMS) issued a notice

More information

Table of Contents. Texas Vendor Drug Program Overview Requirements Envolve Communication Notices...

Table of Contents. Texas Vendor Drug Program Overview Requirements Envolve Communication Notices... Superior HealthPlan Table of Contents Texas Vendor Drug Program Overview 5 Requirements 6 Envolve Communication Notices.... 7-11 Superior HealthPlan Overview..14-23 Benefit Design.. 24 Envolve Pharmacy

More information

WINASAP: A step-by-step walkthrough. Updated: 2/21/18

WINASAP: A step-by-step walkthrough. Updated: 2/21/18 WINASAP: A step-by-step walkthrough Updated: 2/21/18 Welcome to WINASAP! WINASAP allows a submitter the ability to submit claims to Wyoming Medicaid via an electronic method, either through direct connection

More information

Payer Specification Sheet for Prime Therapeutics Medicare Part D Supplemental Clients

Payer Specification Sheet for Prime Therapeutics Medicare Part D Supplemental Clients Payer Specification Sheet for Prime Therapeutics Medicare Part D Supplemental Clients General information Prime Therapeutics LLC January 24, 2018 Plan Name BIN PCN BCBS of Florida Ø12833 FLSUP BCBS of

More information

CHAPTER 3 SECTION 1.5 DEERS FUNCTIONS TRICARE SYSTEMS MANUAL M, AUGUST 1, 2002 DEERS

CHAPTER 3 SECTION 1.5 DEERS FUNCTIONS TRICARE SYSTEMS MANUAL M, AUGUST 1, 2002 DEERS DEERS CHAPTER 3 SECTION 1.5 1.0. As the centralized data repository of Department of Defense (DoD) personnel and medical data and the National Enrollment Database (NED) for the portability of the MHS worldwide

More information

Integrated Prescription Management (IPM)/ PharmAvail Benefit Management Payor Specification Sheet

Integrated Prescription Management (IPM)/ PharmAvail Benefit Management Payor Specification Sheet Integrated Prescription anagement (IP)/ PharmAvail Benefit anagement Payor Specification Sheet BIN #: 014658, 610114 Effective Date: 03/01/2011 States: National Destination: Integrated Prescription anagement

More information

Re: Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of- Pocket Expenses [CMS-4180-P]

Re: Modernizing Part D and Medicare Advantage to Lower Drug Prices and Reduce Out-of- Pocket Expenses [CMS-4180-P] January 25, 2019 Seema Verma, Administrator Centers for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-4180-P P.O. Box 8013 Baltimore, MD 21244-8013 Re: Modernizing

More information

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction.

OTHER TRANSACTIONS SUPPORTED Payer: Please list each transaction supported with the segments, fields, and pertinent information on each transaction. NCPDP VERSION D CLAIM BILLING/CLAIM REBILL REQUEST CLAIM BILLING/CLAIM REBILL PAYER SHEET ** Start of Request (B1/B3) Payer Sheet ** GENERAL INFORMATION Payer Name: Upper Peninsula Health Plan MMP HMO

More information

POLICY STATEMENT: PROCEDURE:

POLICY STATEMENT: PROCEDURE: PAGE 1 OF 12 POLICY STATEMENT: NPS shall provide an automated process to assist beneficiaries who are transitioning from drug regimens or therapies that are not covered on the Part D Plan S are on the

More information