DERF #: ECL #: RECEIPT DATE: 10/01/13 WG MTG REVIEW DATE(S): 11/06/13-11/08/13

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1 DAT A ELE MET REQUES T FORM (DERF)/ EXTERAL CODE LIST (ECL) ational Council for Prescription Drug Programs Please refer to instructions below before completing DERF #: ECL #: RECEIPT DATE: 10/01/13 WG MTG REVIEW DATE(S): 11/06/13-11/08/13 REFERECES OTHER SDO DATA DICTIOAR (LIST SDO, STADARD AD VERSIO): DESCRIBE THE BUSIESS EED OR PURPOSE ADDRESSED B THIS DERF/ECL SUBMISSIO (REQUIRED): FIAL DERF RESOLUTIO DERF ECL Emergency ECL Approved o Modifications Approved With Modifications Denied Pended (o further action) Withdrawn DATA ELEMET A28-ZR "ADJUDICATED PAMET TPE" - "THE TPE OF PRESCRIPTIO BEEFIT PLA THAT ADJUDICATED AD PAID THE PRIMAR AMOUT OF THE PRESCRIPTIO AS REPORTED B THE PLA I A RESPOSE." THIS IFORMATIO IS OT ALWAS COLLECTED B THE PAER OR PHARMAC BEEFIT MAAGER. AS A RESULT, A UKOW VALUE EEDS TO BE ADDED TO THE CLAIM RESPOSE. EW DATA ELEMET (DERF OL) Proposed ame (required): Size (required): Format (required): Segment for the ew Data Element (required for Telecom, XML Standard): Definition (required): Codes/Values every code/value must include a definition (Use attachments if necessary): (Maintenance and Control will determine actual code or value) Value Suggested Value Definition (required) Value Explanation (required) Reject Codes/Values standard reject codes will be assigned by Staff. List any new reject code (s) and include a definition (Use attachments if necessary): (Maintenance and Control will determine actual value) Value Suggested Value Definition (required) Value Explanation (required) Proposed XML Tag (required if data element is in an XML standard): umber of Repetitions for ew Data Element (required if repeating data element): Fill out Transaction Usage section next. CHAGE EXISTIG DATA ELEMET (ALL IFORMATIO IS REQUIRED FOR CHAGES) Field umber (Telecom): A28 ID: ZR ame: Adjudicated Payment Type XML Tag (XML Standard based)) ame: Requested change to (choose at least one): Size Format Values Definition ame Summarize Proposed Changes (Use attachments if necessary): Codes/Values every code/value change must include a definition (Use attachments if necessary): Value Suggested Value Definition (required) Value Explanation (required) 0 Payment Type Unknown Payment Type Unknown DATA ELEMET TRASACTIO USAGE Fill out Transaction Usage section next Transaction Usage - Which transaction(s) is the field used in? (check all that applies) (Use attachments if necessary): (required for Telecom or Batch Standard) Telecom or Batch Transactions Used in transaction (/)? If Used = es (), Situation must be provided. Eligibility Verification Claim Billing/Rebill/Encounter Service Billing/Rebill Predetermination of Benefits Claim Reversal Service Reversal Prior Authorization Request and Billing (Claim) Prior Authorization Request and Billing (Service) Prior Authorization Reversal (Claim) rior Authorization Reversal (Service) Prior Authorization Inquiry Prior Authorization Request Only (Claim) Revised: January 2011 Page: 1

2 Prior Authorization Request Only (Serice) Information Reporting/Rebill (Claim) Information Reporting/Rebill (Service) Information Reporting Reversal (Claim) Information Reporting Reversal (Service) Controlled Substance Reporting/Rebill (specify non-prescription or general) Controlled Substance Reporting Reversal (specify non-prescription or general) Transaction Usage - Which transaction(s) is the field used in (check all that apply)? (Use attachments if necessary): (required for XMLStandard) Transport Transactions Used in transaction (/)? If Used = es (), Situation must be provided. Error Status Verify Get Message Passwor Change SCRIPT Transactions Used in transaction (/)? If Used = es (), Situation must be provided. ew Prescription Request Refill Request/Response or Resupply Prescription Change Request/Response Prescription Fill Status otification Cancel Prescription Request/Response Medication History Request/Response Drug Administration Specialized Transactions Used in transaction (/)? If Used = es (), Situation must be provided. Census MTM TRASACTIO USAGE For standards other than Telecom, Batch, or XML, please include attachments as needed. DESCRIBE HOW THE EW/REVISED DATA ELEMET WILL BE USED: DESCRIBE ATICIPATED IMPACTS/IMPLEMETATIO COSIDERATIOS: SUBMITTER (THIS SECTIO MUST BE COMPLETED) ame: Damon Tressler Work Group submitting DERF: Task Group submitting DERF: Title: Director Company: CVS Caremark Address: 9501 E Shea Blvd. Revised: January 2011 Page: 2 Fax: damon.tressler@caremark.com City/State/Zip: Scottsdale AZ Phone: Signature: via Date: 10/1/2013 TELECOMMUICATIO STADARD OL REQUESTIG EMERGEC ECL CHAGE associated to Regulatory/Legislative Compliance If approved, the request will appear in the next ECL publication. There will be a minimum of 180 days required before the implementation of an emergency ECL change. Please see the attached Publication Release/ Implementation Dates Chart. DERF/ECL ISTRUCTIOS Reason for Emergency Change / Reference to Regulation or Legislation Date eeded By: (no earlier than 180 days from the ECL Publication) Please refer to the following instructions when completing this DERF/ECL form. Use additional attachments when necessary to provide complete information. Incomplete forms will be returned for additional information prior to processing. This form is used for multiple purposes. 1) To add/modify a data element to the Data Dictionary. 2) To add/modify a data element code to the External Code List (ECL). 3) To add/modify information in a standard or implementation guide. D E S C R I B E T H E B U S I E S S E E D O R P U R P O S E A D D R E S S E D B T H I S D E R F / E C L This section should explain, in detail, what the requester would like changed, added, or deleted and the technical and/or reasons why the modifications are necessary. The written explanation should give the readers an understanding as to what the requester is attempting to accomplish. D E S C R I B E I F O R M A T I O E E D E D F O R A D D S /CH A G E S (DERF only:) Use the EW data element section to indicate the proposed field name, the size (length, including decimals, if applicable), and the format (numeric, alpha/numeric, dollar). For a EW data element to the Telecommunications Standard, include the proposed Segment the element would be added to. Include a definition of the field. If applicable, every value/code requested must contain a definition. For the Telecommunication or Batch Standard, specify the situation in which this new field would be used. (DERF or ECL:)To change a data element, complete the CHAGE existing data element section, indicating the current data dictionary information. Check what information is changing: field size (length), format (numeric, alpha/numeric, dollar), adding or changing a value, field name or definition. Summarize all changes that are being requested. EMERGEC ECL REQUESTS via a DERF form PERTAI OL TO THE TELECOMMUICATIO STADARD. Used for regulatory and legislative changes which require the addition of a value(s) to be implemented prior to the scheduled annual implementation date of the next ECL Publication. There will be a minimum of 180 days post ECL publication required, before the implementation of an emergency ECL change. D E S C R I B E H O W T H E D AT A E L E M E T W I L L B E U SED This section needs a detailed description of how and where the data element or value change will be used in the processes governed by the specified standards. For example: If the data element is referenced in multiple standards, is the usage consistent? Will this data element or value change cause a drug claim to reject? How will the data element impact an individual s enrollment status? If the data element has a specified list of values, who will be responsible for maintaining the list? D E S C R I B E T H E I M P A C T S A D I M P L E M E T AT I O C O S I D E R AT I O I V O L V E D I R E Q U E S T I G T H AT T H I S I F O R M AT I O B E I C L U D E D I C P D P S T A D A R D S This section is intended to obtain information about the level of consideration given to the operational impacts of including this data element addition/change in the affected standard(s). Is this the most appropriate source for the data element? Are there legislative and/or legal time frames/requirements? Are there specific implementation considerations that should be documented in an implementation guide? FOR MC MAITEACE AD COTROL USE OL

3 Work Groups that may be impacted (check all appropriate boxes): WG1 Telecommunication WG11 eprescribing & Related Transactions WG2 Product Identification WG14 Long Term Care WG3 Standard Identifiers WG16 Property and Casualty/Workers Compensation WG7 Manufacturer Rebates WG17 Pharmaceutical Pedigree and Traceability WG9 Government Programs WG45 External Standards Assessment, Harmonization, and Implementation Guidance WG10 Professional Pharmacy Services MC Maintenance and Control Other Return completed form by , mail or fax: CPDP, 9240 E. Raintree Drive, Scottsdale, Arizona fax (480) phone (480) WG1 DERF/ ECL STATUS: Approved/Reviewed with no modifications This section is used by CPDP Staff Only DERF MODIFICATIOS (Actions Taken by WG(s) Review) Approved/Reviewed with modifications (complete modifications below) Pended by work group Reason: To WG1 COB TG Denied by Work Group Withdrawn by submitter Changed ECL to DERF (also check appropriate DERF status) Reason: Vote Pink ellow Green Total Approved Opposed Modifications: MC DERF/ ECL STATUS: Approved/Reviewed with no further modifications Approved/Reviewed with further modifications (complete modifications below) Vote Pink ellow Green Total Approved Opposed Modifications: the COB Task Group reviewed your DERF in light of other issues/concerns brought to that group and apparently to FAQ as well (was not on latest FAQ call). RESPOSE field required on payments: Adjudication Payment Type Add value 0 Payment Type Unknown Several Questions and Comments: 1) Value of 0 does not seem appropriate since there is a CORRESPODIG submission field Controlled Substance Reporting named A29-ZS where this payment information is logged for reporting. That list has all of the current ZR field values as well as the value 0 to indicate CASH where the claim was not billed to any processing entity. Another value would need to be assigned if this is a go HOWEVER there are a number of FURTHER concerns noted beyond the table. Revised: January 2011 Page: 3

4 A28-ZR - ADJUDICATED PAMET TPE RESPOSE Information The type of Q Claim prescription Billing/Encounter: benefit plan P or D response that Only: (ot used for R adjudicated or C response) and paid Required if needed for the primary state/federal/regulatory amount of agency programs. the See section prescription Controlled Substance as reported Reporting Information, by the plan subsection Use of in a Adjudicated Payment response. Type (A28-ZR) and Reported Payment Type (A29-ZS) for appropriate use. A29-ZS - REPORTED PAMET TPE Claim Segment info for Controlled Substance Reporting The type of prescription benefit plan that adjudicated and paid for the prescription. Q Controlled Substance Reporting (General): Required if necessary for state/federal/regulatory agency programs. See section Controlled Substance Reporting Information, subsection Use of Adjudicated Payment Type (A28-ZR) and Reported Payment Type (A29-ZS) for appropriate use. Code Description Code Description 0 Cash- money or an equivalent, as a check, paid at the time of making a purchase. 1 Medicaid- a program, financed jointly by the federal government and the states, that provides health coverage for mostly lowincome women and children as well as nursing-home care for low-income elderly. 2 Medicare-the federal program providing health insurance for people aged 65 and older and for disabled people of all ages. 3 Commercial - A prescription health insurance program provided by a for-profit, private insurance agency or company. 4 Workers Compensation-plan providing workers compensation insurance (insurance required by law from employers for the protection of employees while engaged in the employer's business). 5 Discount Program-a program that offer savings on prescription drugs to patients who are without health insurance, a traditional benefits plan, or have prescriptions that are not covered by insurance. 6 Coupon-reimbursement based on the coupon amount determined by the processor. 7 Voucher- a form authorizing a disbursement of cash or a credit against a purchase or expense. 8 Military / VA- a government-run military veteran benefit system that administers programs of veterans benefits for veterans, their families, and survivors. 99 Other-any other types not covered by definitions above. 1 Medicaid- a program, financed jointly by the federal government and the states, that provides health coverage for mostly lowincome women and children as well as nursing-home care for lowincome elderly. 2 Medicare-the federal program providing health insurance for people aged 65 and older and for disabled people of all ages. 3 Commercial - A prescription health insurance program provided by a for-profit, private insurance agency or company. 4 Workers Compensation-plan providing workers compensation insurance (insurance required by law from employers for the protection of employees while engaged in the employer's business). 5 Discount Program-a program that offer savings on prescription drugs to patients who are without health insurance, a traditional benefits plan, or have prescriptions that are not covered by insurance. 6 Coupon-reimbursement based on the coupon amount determined by the processor. 7 Voucher- a form authorizing a disbursement of cash or a credit against a purchase or expense. 8 Military / VA- a government-run military veteran benefit system that administers programs of veterans benefits for veterans, their families, and survivors. 99 Other-any other types not covered by definitions above. 2) Question came up: What is the difference between Payment Type Unknown and Other? Had a few minutes of discussion and most seemed to think that OTHER would be the value used when the claim was Medi/Medi or Medicare and EGWP wrap because none of the above values really fit since more than one entity has possibly been used in payment 3) So that led to next question: Are further values for Medi/Medi, Medicare/EGWP, etc. required? 4) Purpose of field initially was because pharmacy is being expected to provide this information to governmental agencies to whom by law they must report prescription data and who are requiring the information. 5) Today, downstream payers would like to have this information reported in Prior Payer loops to make determination if COB should be applied or not. Revised: January 2011 Page: 4

5 6) Pharmacies are often not able to ascertain in member set up the nature of the various cards/plans a member may provide to them so the responded value could help them make determination to bill a COB claim or not. 7) Version D Task Group has a sub-task group that is looking at possibly extending the field values as well as creating an Other Payer Adjudicated Payment Type that maps values from the response to a COB claim. In light of the Version D sub-task group current efforts, the COB Task Group feels that this DERF is pre-mature and should be worked further with that sub-task group. The DERF can be presented to provide visibility to issues surrounding expectations for use of the field in order to get further interest/assistance in addressing the overall concerns surrounding the issue. After a brief discussion Task Group hopes that you will opt to pend the DERF to allow for this further review. Since this is a REQUIRED Data Element in the response then the Standard needs to accommodate when this information is not known or not gathered by the Processor. Even if it is/was collected, there is an extreme amount of variety in this data element. there are many variations Here are a few examples, but Client A is a Health Plan; they bring to the PBM a TPA. It is under the Client s A umbrella. What is the Payer Type? Client A or the TPA. We could have Client B who is a Health Plan, they have a Client who is a TPA B, and the TPA s B Client is a TPA C. What is the Payer Type? We could have Client C who is a TPA, they have a Client who is a Health Plan. Type? What is the Payer The details regarding the various layers that could apply will help others understand that this is not black and white. Curious if we need to consider changing the name of the attribute to Benefit Type, eliminating the confusion that is associated to identifying the payer or payment? To address other COB business needs, Benefit Stage Indicator Count and Benefit Stage Indicator could follow. Example:(red denotes changes from current Adjudicated Payment Type values/descriptions) Benefit Type: Benefit Type Value Definition Description 1 Medicaid (FFS) a program, financed jointly by the federal government and the states, that provides health coverage for mostly low-income women and children as well as nursing-home care for low-income elderly. (may need to revise to relect FFS) 2 Medicare (B) the federal program providing health insurance for people aged 65 and older and for disabled people of all ages. 3 Commercial a prescription health insurance program provided by a for-profit, private insurance agency or company. 4 Workers Compensation plan providing workers compensation insurance (insurance required by law from employers for the protection of employees while engaged in the employer's business). 5 Discount Program a program that offer savings on prescription drugs to patients who are without health insurance, a traditional benefits plan, or have prescriptions that are not covered by insurance. D11 6 Manufacturer Coupon Program reimbursement based on the coupon amount determined by the processor. E12 7 Manufacturer Voucher Program a form authorizing a disbursement of cash or a credit against a purchase or expense. (This description may need to be updated) Revised: January 2011 Page: 5

6 8 Military / VA a government-run military veteran benefit system that administers programs of veterans benefits for veterans, their families, and survivors. 99 Other any other types not covered by definitions above. B12 9 Medicaid Managed Care 10 Manufacturer Patient Assistant Program 11 Medicare D 12 Medicare C 13 Medicare/Medicaid Demonstration 14 QHP Market Place Exchange 15 Ryan White / ADAP 16 SPAP 17 EGWP Revised: January 2011 Page: 6