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

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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

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Frequently Repeated Acronyms

• OOP – Out -of-Pocket
• OTrOOP – Other True Out-of-Pocket
• LICS – Low Income Cost Sharing Subsidy

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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?

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• Mr. Ben E. Ficiary

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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.

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Treatment

Institutional Provider And/Or Non-Institutional Provider MAC (formerly FIs

• r Carriers)

Enter claim into system Perform consistency and utilization edits Calculate payment Deny claims based on Medicare policy Return denied claims to provider Claim

Payment/ Denial

CWF Host

Update entitlement data Check claims for entitlement, deductible, remaining benefit, and duplicates Authorize full payment, partial payment, denial, or request additional data Claim (daily) Response

Entitlement data (Daily) Claims data (Weekly)

CMS

• Update EDB with entitlement data
• Add claims to National Claims

History Repository (NCHR)

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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

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• Mr. Ben E. Ficiary

MA-PDP or PDP enrollee

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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)

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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.

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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

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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.

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Part D Event Sources and Processing

Pharmacy Part D Plan

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

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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

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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

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Sources of Variables

• CMS Defined

˗ Drug Coverage Status ˗ Adjustment Deletion Code ˗ Catastrophic Coverage Code ˗ Gross Drug Cost [Above & Below] OOP ˗ OTrOOP Amount ˗ LICS Amount

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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.

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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.

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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.

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Part D Event Processing

• Adjustment Deletion Code
• Values
• Blank – Original PDE
• A = Adjustment
• R = Resubmitted
• All types are final action

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Resources

• Prescription Drug Event Record Layout – See

attachment

• NCPDP Reference Manual
• http://www.cms.gov/ElectronicBillingEDITrans/Do

wnloads/NCPDPflatfile.pdf

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