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Objectives

Prescription Drug Event (PDE) Record Overview Medicare Coverage Gap Discount Program Public Meeting June 1, 2010. Objectives. Explain history and purpose Introduce data elements Outline Part D payment reconciliation Review controls, edits and data quality measures. PDE History and Purpose.

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Objectives

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  1. Prescription Drug Event (PDE) Record OverviewMedicare Coverage Gap Discount Program Public Meeting June 1, 2010

  2. Objectives • Explain history and purpose • Introduce data elements • Outline Part D payment reconciliation • Review controls, edits and data quality measures

  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

  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

  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

  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

  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)

  8. Defined Standard Benefit - 2010 Beneficiary Liability Direct Subsidy/ Medicare Pays Reinsurance Beneficiary Premium

  9. Information Required for Part D Payment Reconciliation – 2010

  10. Defined Standard Benefit 2020 Out Limit of Initial Coverage Catastrophic Threshold pocket Total Coverage Covered Drug Gap Discount Pays ~50% Spending 75% Plan Pays 80% Reinsurance Plan Pays ~25% Deductible 25% Coinsurance Total Beneficiary Out - Of - Pocket 5% Coinsurance 15% Plan Pays Medicare Pays Reinsurance Direct Subsidy/ Beneficiary Liability Beneficiary Premium Gap Discount

  11. Information Required forGap Discount

  12. Controls • Certification • Receipt and Control • Editing • Reporting • Part D Payment Reconciliation Attestations • Government Oversight • Program Integrity • CMS internal auditors • One Third (on-site) audit • OIG • Payment Error Validation • Ad Hoc PDE validation studies

  13. PDE Data Flow: Receipt and Control Plan Prescription Drug Front-End System (PDFS) • PDFS Response Report Drug Data Processing System (DDPS) • DDPS Return File • DDPS Transaction Error Summary Report Integrated Data Repository (IDR) • Cumulative Beneficiary Summary Report • P2P Reports Payment Reconciliation System (PRS)

  14. Edit Categories • Field level data validation • Duplicates and Business Order Logic (BOL) • Eligibility • LICS • Provider • Catastrophic Coverage • Cost • NDC • Non-Covered Drugs • Edits published at http://www.csscoperations.com

  15. Duplicate and BOL Editing Key Fields: Date of Service (DOS) Prescription Service Reference Number Fill Number Service Provider ID Service Provider ID Qualifier Dispensing Status Code(Discontinued 2011)

  16. Duplicate Editing Applies to Original Records only 777: Duplicate PDE record exists in DDPS data warehouse (originals only) 784: Duplicate PDE record, originally submitted by different contract 785: Duplicate PDE records exist on this file (CMS makes no assumption about sponsor intent) Duplicate logic disregards both beneficiary and contract

  17. Business Order Logic Editing • Sponsors must submit records in order • CMS makes no assumptions about sponsor intent 660: Adjustment/Deletion PDE does not match existing record 661: Cannot adjust a deleted record 662: Existing PDE has already been deleted Note: Original record may follow a Delete record

  18. Cost Balancing Edits Cost Fields: Ingredient Cost Dispensing Fee Sales Tax Vaccine Administration Fee Payment Fields: Beneficiary Liability Patient Pay Amount LICS Other TrOOP LICS PLRO Plan Liability CPP NPP Reported Gap Discount = = Covered Drugs: GDCB: Gross Drug Cost Below the Out-of-Pocket Threshold GDCA: Gross Drug Cost Above the Out-of-Pocket Threshold =

  19. Edits 690, 691 and 692 690: Sum of Cost Fields > Sum of Payment Fields +/- rounding error 692: Sum of Cost Fields < Sum of Payment Fields +/- rounding error 691: Sum of GDCB and GDCA <> Sum of Ingredient Cost Dispensing Fee Sales Tax Vaccine Administration Fee 694: Sum of Ingredient Cost, Dispensing Fee, Sales Tax and Vaccine Administration Fee = zero

  20. Service Provider ID Edits • Since May 2008, when NPI implementation completed, NPI routinely reported instead of NCPDP ID • Service Provider ID field edited against NCPDP file (updated monthly) • Ensures that provider is a pharmacy • NCPDP file contains NCPDP and associated NPI identifiers • Vaccine PDEs: CMS accepts physician NPI in lieu of entry on NCPDP file, provided that NPI, is reported in valid format

  21. NDC Edits 735: NDC code does not match a valid code on the NDC database (updated weekly) 738: NDC identifies a Part D non-covered drug, i.e., NDCs not listed with the FDA 740: NDC is DESI drug

  22. Two Phase Data Quality Oversight • Phase One: Online editing; CMS edits individual PDEs to the fullest extent possible • Phase Two: Ad Hoc studies to evaluate data quality • Studies based on saved PDEs • Data screens applied to individual records • Data screens evaluate consistency of individual record in context of all records for single beneficiary • Questions posted on PDE validation web site; sponsors evaluate and respond • Discontinue screens with high false positive rates

  23. Reporting Lag (Hypothetical Data) Percentage Month of Service Month PDE Reported

  24. Manufacturer’s Perspective • Differentiate data sources • The PDE is a final action record which summarizes multiple transactions for a single claim • Discount is not the same as rebate • Recognize that PDE data is subject to rigorous scrutiny because it must support Part D Payment Reconciliation • Reserve predictions/conclusions; year one data lags may not be representative • Remember that Part D is a capitated benefit; duplicates and increased utilization reduce sponsor revenue

  25. Resources CMS Website publishes PDE Instructions: http://www.cms.gov/DrugCoverageClaimsData/ 01_PDEGuidance.asp#TopOfPage Customer Service website publishes format, edits and training information: http://csscoperations.com/ Gap Discount guidance published via HPMS

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