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prescription drug event pde record overview medicare coverage gap discount program public meeting june 1, 2010

Objectives. Explain history and purposeIntroduce data elementsOutline Part D payment reconciliationReview controls, edits and data quality measures. 2. PDE History and Purpose. PDE introduced in 2006; no predecessor record format or system existedDesigned and implemented to reconcile Part D paymentsWhen feasible, the PDE incorporated data from existing NCPDP billing transactionsWhen necessary, CMS defined data elements needed for Part D payment reconciliationCMS-defined date and financia9439

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prescription drug event pde record overview medicare coverage gap discount program public meeting june 1, 2010

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    1. Prescription Drug Event (PDE) Record Overview

    2. 2

    3. PDE History and Purpose PDE introduced in 2006; no predecessor record format or system existed Designed and implemented to reconcile Part D payments When feasible, the PDE incorporated data from existing NCPDP billing transactions When necessary, CMS defined data elements needed for Part D payment reconciliation CMS-defined date and financial data elements use NCPDP format 3

    4. PDE Data Elements Contract and Beneficiary Provider Event Drug and Quantity Costs Payment Breakdowns Submission Format published at http://www.csscoperations.com/new/pdic/pde/ddps.html 4

    5. PDE is Final Action Summary of Individual Claim PDE summarizes adjudication of an individual claim Unlike other Medicare Programs, Part D Sponsor (not CMS) adjudicates claims following CMS guidance Part D sponsors must retain audit trails linking PDEs to source billing transactions Reporting is based on final action When sponsor adjusts or deletes previously saved record the most recent record submitted is designated as final action record Excludes final action deleted records 5

    6. NCPDP Data Elements Include: DATE OF SERVICE (DOS) PRESCRIPTION SERVICE REFERENCE NUMBER FILL NUMBER SERVICE PROVIDER ID and QUALIFIER (Pharmacy) PRODUCT SERVICE ID (NDC) INGREDIENT COST PAID DISPENSING FEE PAID TOTAL AMOUNT ATTRIBUTED TO SALES TAX VACCINE ADMINISTRATION FEE 6

    7. Part D Payment Reconciliation Basic benefit is basis for Part D Payment Reconciliation Payment Methodologies: Low Income Cost-Sharing Subsidy (LICS) Reinsurance Subsidy Risk-Sharing Gap Discount (effective January 1, 2011) 7

    8. Defined Standard Benefit - 2010 8

    9. Information Required for Part D Payment Reconciliation 2010 9

    10. Defined Standard Benefit 2020 10

    11. Information Required forGap Discount 11

    12. Controls 12

    13. 13

    14. Edit Categories 14

    15. Duplicate and BOL Editing 15

    16. Duplicate Editing 16

    17. Business Order Logic Editing 17

    18. Cost Balancing Edits 18

    19. Edits 690, 691 and 692 19

    20. Service Provider ID Edits 20

    21. NDC Edits 21

    22. Two Phase Data Quality Oversight 22

    23. Reporting Lag (Hypothetical Data) 23

    24. Manufacturers Perspective 24

    25. Resources 25

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