Prescription Drug Event (PDE) Data: Source and Processing Barbara - PowerPoint PPT Presentation

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 and Medicaid Services  CCW – Chronic Condition Warehouse  PDE – Part D Event  PDP – Stand-alone Prescription Drug Plan – fee- for-service  MA-PD – Medicare Advantage Prescription Drug Plan  FFS – Fee-for-Service 2

Frequently Repeated Acronyms  MAC – Medicare Administrative Contractor  FI – Fiscal Intermediary  EDB – Enrollment Database  NCHR – National Claims History Repository  NCPDP - National Council for Prescription Drug Programs  DDPS - Drug Data Processing System  PDFS - Prescription Drug Front End System  IDR – Integrated Data Repository  SAF – Standard Analytical File 3

Frequently Repeated Acronyms  OOP – Out -of-Pocket  OTrOOP – Other True Out-of-Pocket  LICS – Low Income Cost Sharing Subsidy 4

Overview of CMS PDE Data  What is an event (versus a claim)?  How are data processed?  What data system does CMS maintain for the event data?  What are the sources of the data in the files?  What Part D Event File variables are available to researchers? 5

Mr. Ben E. Ficiary 6

Review: What is a Claim?  Claims are bills submitted for services provided to the Medicare enrollees like Ben the FFS Medicare beneficiary.  Claims are reimbursed per claim by Medicare based on the service billed. 7

Treatment Institutional Provider And/Or Non-Institutional Provider Payment/ Claim Denial CWF Host MAC (formerly FIs Update entitlement data or Carriers) Claim (daily) Check claims for entitlement, deductible, remaining benefit, Enter claim into system and duplicates Perform consistency Authorize full payment, Response and utilization edits partial payment, denial, or request additional data Calculate payment Deny claims based on Entitlement data Claims data Medicare policy (Weekly) (Daily) Return denied claims to provider CMS • Update EDB with entitlement data • Add claims to National Claims History Repository (NCHR) 8

What is an Event?  Event Detail: PDE record is not the same as the pharmacy claim and so differs from point-of- service ˗ Post-transaction adjustments between plan and pharmacy ˗ Plan-to-plan adjustments for misenrollees ˗ Plan-to-CMS adjustments for some demonstration projects 9

Mr. Ben E. Ficiary MA-PDP or PDP enrollee 10

Part D Event Sources and Processing  Beneficiary prescription goes to pharmacy  Pharmacy requests beneficiary Part D cardholder information for which Plan beneficiary is enrolled  Pharmacy contacts Part D Plan for information regarding payment  Pharmacy finalizes transaction for beneficiary (fills/dispenses prescription)  Pharmacy submits electronic transaction (claim) back to Plan (using National Council for Prescription Drug Programs-NCPDP electronic format 99% of time) 11

Part D Event Sources and Processing  Plans submit events/transactions (all variables) to CMS. The PDE records enter the CMS Drug Data Processing System (DDPS) through the Prescription Drug Front End System (PDFS) in a CMS defined record format. (See PDE Record Layout)  The PDFS initially performs format and face validity checks. Once the file has passed front-end checks, it moves through the DDPS where detail level edits are performed.  The Drug Data Processing System (DDPS) is the information system that collects, validates, and stores PDE data received from plans or their designee. 12

Part D Event Processing  From DDPS, event flows into Integrated Data Repository (IDR) on a daily basis  CMS creates “Standard Analytical File” (SAF) which contains only final action “events” from PDE data in IDR  Part D Event “SAF” downloaded by Buccaneer/CCW from CMS 13

Part D Event Processing  Buccaneer/CCW begins processing file to encrypt necessary variables and add derived variables.  CCW creates the CCW Encrypted Part D Event ID which is an unique identifier for each record in the PDE file. 14

Part D Event Sources and Processing Pharmacy Submits Conta tact cts s Claim Plan (NCPDP) Buccaneer/CCW creates CCW Part D Event File Part D Plan Submits Bi-weekly or Monthly Integrated Data CMS through Prescription Drug Front End Repository System (PDFS) into Drug Data Processing (IDR) System (DDPS) Editor 15

Sources of Variables  Depending on year of data requested, there are 37-41 data elements in the PDE record ˗ 15 data elements from the NCPDP billing transaction ˗ 5 data elements from the NCPDP billing response transaction ˗ 17 data elements defined by CMS for purposes of administering Part D 16

Sources of Variables  NCPDP Defined ˗ Patient Date of Birth (not edited by CMS) ˗ Patient Gender Code (not edited by CMS) ˗ Date of Service ˗ Product Service ID ˗ Fill Number ˗ Dispensing Status and Dispense as Written ˗ Compound Code ˗ Provider & Prescriber IDs ˗ Quantity Dispensed ˗ Days Supply ˗ Patient Pay Amount 17

Sources of Variables  CMS Defined ˗ Drug Coverage Status ˗ Adjustment Deletion Code ˗ Catastrophic Coverage Code ˗ Gross Drug Cost [Above & Below] OOP ˗ OTrOOP Amount ˗ LICS Amount 18

Part D Event Processing  When and where do adjustments occur? ˗ With Pharmacy: If beneficiary does not pick up prescription, pharmacy will return to shelf and send a deletion transaction notice to Plan. Pharmacies typically allow 2 weeks for pick up. Plan can delete transaction before submitting to CMS (if in time) or send a deletion transaction to CMS. ˗ PDE Event record will not be found in PDE data file as there are no deletion records in CCW PDE data file. 19

Part D Event Processing  When and where do adjustments occur? ˗ Plans have several months after CY to submit electronic transactions to CMS. However, most will submit on a bi-weekly or at the minimum required monthly basis. Adjustment events can be submitted during this time. 20

Part D Event Processing  When and where do adjustments occur? ˗ Plans may have submitted a transaction when after the fact, another plan was responsible for that prescription coverage. For example, an LIS beneficiary changes plans and the enrollment information does not catch up until after a pharmacy has filled a prescription for that beneficiary. ˗ This type of adjustment will lead to misenrollee PDE record in file. 21

Part D Event Processing  Adjustment Deletion Code  Values  Blank – Original PDE  A = Adjustment  R = Resubmitted  All types are final action 22

Resources  Prescription Drug Event Record Layout – See attachment  NCPDP Reference Manual  http://www.cms.gov/ElectronicBillingEDITrans/Do wnloads/NCPDPflatfile.pdf 23