March 2, 2011
COVERAGE GAP DISCOUNT PROGRAM – USER GROUP
Manufacturers Webinar
1
COVERAGE GAP DISCOUNT PROGRAM – USER GROUP
Agenda
•
•
•
•
•
Invoice Correction Process
Payment Confirmation Process
Frequently Asked Questions
Dispute Process
Questions and Answers
2
COVERAGE GAP DISCOUNT PROGRAM – USER GROUP
Announcements
• Connectivity reminder from TPA
• When sending emails to the TPA please
include the P Number in the subject line
of the email
3
COVERAGE GAP DISCOUNT PROGRAM – USER GROUP
Webinar Schedule
•
•
•
•
April 6th, 2011
May 4th, 2011
June 1st, 2011
July 6th, 2011
4:00-5:00 p.m. ET
4:00-5:00 p.m. ET
4:00-5:00 p.m. ET
4:00-5:00 p.m. ET
4
COVERAGE GAP DISCOUNT PROGRAM – USER GROUP
Accomplishments
• Released EFT template
o 2/8/2011
• Updated Manufacturer's Report layout
o 2/23/2011
• Distributed Test Files
o 2/22/2011
5
COVERAGE GAP DISCOUNT PROGRAM – USER GROUP
Future TPA Tasks
• Distribute EFT Files
• Collect manufacturer payor name as it
will appear on Sponsor’s statements.
6
COVERAGE GAP DISCOUNT PROGRAM – USER GROUP
Invoice Correction Process (Draft)
•
Manufacturers wishing to correct an invoice may do so only if they have been
invoiced for NDCs with labeler codes not covered by their CGDP Manufacturer
Agreements. CMS publishes the “Participating Manufacturer Labeler Codes” at
http://www.cms.gov/PrescriptionDrugCovGenIn/05_Pharma.asp#TopOfPage which
documents the current list of labeler codes covered by each Manufacturer.
Manufacturers submit their labeler codes at the time they sign the CGDP
Manufacturer Agreement and maintain current labeler codes on an ongoing basis
as described in “Medicare Coverage Gap Discount Program Guidance” CMS
published on December 17, 2011. CMS uses “Participating Manufacturer Labeler
Codes” to create the quarterly CGDP Invoice report. The quarterly report invoices
Manufacturers for Labeler codes assigned to them as of the first business day
following the end of the quarter.
•
To request an invoice correction the Manufacturer shall complete the information
on the following slide and submit the invoice correction request to the TPA within
five (5) days of the date the TPA distributes the CGDP Quarterly Invoice. The TPA
will respond within 3 business days. If the TPA confirms the invoice correction, the
manufacturer shall not be responsible for paying NDCs with labeler codes invoiced
incorrectly. Instead the Manufacturer shall pay all other labeler codes in the
invoice. The TPA will follow up with Part D sponsors and other affected
Manufacturers to reissue invoices and confirm payment.
7
COVERAGE GAP DISCOUNT PROGRAM – USER GROUP
Invoice Correction Process (Draft)
• Individual submitting Invoice Correction Request:
• Manufacturer (name and P#)
• Contact information:
Email address
Telephone number
Address
• Submission date (date invoice correction form submitted):
• Date TPA distributed Quarterly Invoice Report
• Report ID
• Labeler Code(s) in question
• Total dollars invoiced for Labeler Code(s) in question
8
COVERAGE GAP DISCOUNT PROGRAM – USER GROUP
Manufacturer Payment Confirmation
Report Overview
o Step 1: Manufacturers receive Invoice Report from TPA in their
Outbound folder.
– Manufacturers will be invoiced on a quarterly basis.
o Step2: According to the terms in the Manufacturers’
Agreement, Part D Manufacturers will have 38 days to pay
Sponsors in full.
– The TPA will facilitate the funds transfer between the Manufacturers
and Sponsors by providing Sponsor EFT information
o Step 3: Manufacturers are required to send a confirmation of
payment to the TPA. There is a five day window after payment
is made to the sponsor.
– Invoice report is a versatile format. With minimal change,
Manufacturers convert the Invoice Report to the Confirmation of
Payment report.
9
COVERAGE GAP DISCOUNT PROGRAM – USER GROUP
Manufacturer Confirmation Payment Report
Creation Steps
Steps to create Confirmation of Payment Report from Invoice Report:
1. Add File date to Manufacturer Header Record (TPAMH):
Field 8- Date Confirmation Report will be returned
2.
3.
4.
5.
Manufacturers have a Contract Trailer Record for each contract they
must pay. On each Contract Trailer (TPACT) populate:
Field 12 - DATE OF PAYMENT
Field 13 - PAYMENT AMOUNT
On the Manufacturers P Number Trailer (TPAMT) populate:
Field 12 - DATE OF PAYMENT
Field 13 - PAYMENT AMOUNT
At this time the Confirmation Report will need to change from
“10MIV” to “10MPC” in field 6 of the TPAMH, field 6 of the
TPACH, field 6 of the TPACT and field 6 of the TPAMT records.
Rename the file as follows R.#######.RPT.MANUF_CONFIRM
The ####### is a sequential number the Manufacturer received on their
Manufacturers Invoice Report.
6.
7.
Save the file as either a flat file or a text file. You can use a text
editor like Wordpad, Notepad or Textpad to create the text file.
10
Send the new file to your Inbound folder.
COVERAGE GAP DISCOUNT PROGRAM – USER GROUP
Manufacturer Payment
Confirmation File Layout
Legend:
Record Type Code
Record Description
Notes
TPAMH
Manufacturer P Number Header
Used to provide TPA overall Payment completion
TPACH
Contract Header
LBLR
Manufacturer Total at the Labeler Level
TPACT
Contract Trailer
Used to provide TPA Payment Confirmation to Contract
TPAMT
Manufacturer P Number Trailer
Used to provide TPA overall Payment completion
Manufacturer Payment Confirmation Report
TPAMH
Return for TPA Payment Confirmation
TPACH
LBLR
LBLR
TPACT
Return for TPA Payment Confirmation
TPACH
LBLR
TPACT
TPAMT
Return for TPA Payment Confirmation
Return for Overall Payment Confirmation
COVERAGE GAP DISCOUNT PROGRAM – USER GROUP
Manufacturer Payment Confirmation:
P Number Header and Contract Header
TPAMH
FIELD NAME
Field NO
1
RECORD TYPE CODE
POSITION
1-5
PICTURE LENGTH
X(5)
5
"TPAMH"
DEFINITION / VALUES
2
REPORT ID
6 - 11
9(6)
6
Year/Quarter item was placed on the invoice. Format is: "YYYYQQ".
QQ represented as "01"-"13".
3
4
5
6
7
SEQUENCE NO
DDPS SYSTEM DATE
DDPS SYSTEM TIME
FILE ID
MANUFACTURER P NUMBER
12 - 18
19 - 26
27 - 32
33 - 37
38 - 42
9(7)
9(8)
9(6)
X(5)
X(5)
7
8
6
5
5
An incrementing batch sequence number that starts at 0000001.
‘CCYYMMDD’ = DDPS File creation date.
‘HHMMSS’ = DDPS File creation time.
10MPC - Manufacturer Payment Confirmation
The CMS assigned manufacturer P-Number
8
9
FILE DATE
FILLER
43 - 50
51 - 200
9(8)
X(150)
8
150
Date the Manufacturer sends the Confirmation of Payment Report to the
TPA. (To be filled in when returning file to TPA for payment
confirmation. )
Spaces
TPACH
FIELD NAME
FIELD NO
1
RECORD TYPE CODE
POSITION PICTURE LENGTH
1-5
X(5)
5
"TPACH"
2
3
4
5
6
REPORT ID
SEQUENCE NO
DDPS SYSTEM DATE
DDPS SYSTEM TIME
FILE ID
6 - 11
12 - 18
19 - 26
27 - 32
33 - 37
9(6)
9(7)
9(8)
9(6)
X(5)
6
7
8
6
5
7
8
SUBMITTING CONTRACT NUMBER
FILLER
38 - 42
43 - 200
X(5)
X(158)
5
158
DEFINITION / VALUE
Year/Quarter item was placed on the invoice. Format is: "YYYYQQ".
represented as "01"-"13".
An incrementing batch sequence number that starts at 0000001.
‘CCYYMMDD’ = DDPS File creation date.
‘HHMMSS’ = DDPS File creation time.
10MPC - Manufacturer Payment Confirmation
QQ
The contract that submitted the Gap Discount PDEs
Spaces
12
COVERAGE GAP DISCOUNT PROGRAM – USER GROUP
Manufacturer Payment Confirmation:
Contract Trailer
TPACT
FIELD NAME
FIELD NO
1
RECORD TYPE CODE
POSITION PICTURE LENGTH
1-5
X(5)
5
"TPACT"
DEFINITION / VALUES
2
REPORT ID
6 - 11
9(6)
6
3
4
5
6
7
8
SEQUENCE NO
DDPS SYSTEM DATE
DDPS SYSTEM TIME
FILE ID
SUBMITTING CONTRACT NUMBER
DETAIL RECORD COUNT
12 - 18
19 - 26
27 - 32
33 - 37
38 - 42
43 - 49
9(7)
9(8)
9(6)
X(5)
X(5)
9(7)
7
8
6
5
5
7
Year/Quarter item was placed on the invoice. Format is:
"YYYYQQ". QQ represented as "01"-"13".
An incrementing batch sequence number that starts at
0000001.
‘CCYYMMDD’ = DDPS File creation date.
‘HHMMSS’ = DDPS File creation time.
10MPC - Manufacturer Payment Confirmation
The contract that submitted the Gap Discount PDEs
The number of Labeler records for this Contract.
9
TOTAL REPORTED GAP DISCOUNT PREVIOUS
AMOUNT
50 - 63
S9(12)V99
14
Reported Gap Discount that was reported on preceding Data
Report
10
TOTAL REPORTED GAP DISCOUNT CURRENT
AMOUNT
64 - 77
S9(12)V99
14
New Gap Discount amounts invoiced this quarter.
11
TOTAL GAP DISCOUNT AMOUNT THIS PERIOD
78 - 91
S9(12)V99
14
Net payment amount this quarter,calculated as the "current
amount" minus the "previous amount"
12
DATE OF PAYMENT
92 - 99
9(8)
8
Date payment was paid. If payments were made on multiple
days, use final payment date
13
PAYMENT AMOUNT
14
Amount of payment made. If payments were made on multiple
days, use the sum of all payments.
15
72
A descriptive identifier that should be used by the manufacturer
as the Individual Identification Number on the EFT Payment
that is made to Contracts. Contracts should be able to identify
the payment from the manufacturers on their banking records
using this number. Format is:
"CG" + Year/Quarter (i.e. "YYQQ") + Manufacturer P Number
missing the P (i.e."8888") + Contract Number (i.e. "H1234")
Example: "CGYYQQ8888H1234"
Spaces
14
15
EFT INDIVIDUAL IDENTIFICATION NUMBER
FILLER
100 - 113 S9(12)V99
114 - 128
129 - 200
X(15)
X(72)
13
COVERAGE GAP DISCOUNT PROGRAM – USER GROUP
Manufacturer Payment Confirmation:
P Number Trailer
TPAMT
FIELD NO
FIELD NAME
DEFINITION / VALUES
POSITION PICTURE LENGTH
1
RECORD TYPE CODE
1-5
X(5)
5
"TPAMT"
2
REPORT ID
6 - 11
9(6)
6
Year/Quarter item was placed on the invoice. Format is:
"YYYYQQ". QQ represented as "01"-"13".
3
SEQUENCE NO
12 - 18
9(7)
7
An incrementing batch sequence number that starts at 0000001.
4
DDPS SYSTEM DATE
19 - 26
9(8)
8
‘CCYYMMDD’ = DDPS File creation date.
5
DDPS SYSTEM TIME
27 - 32
9(6)
6
‘HHMMSS’ = DDPS File creation time.
6
FILE ID
33 - 37
X(5)
5
10MPC - Manufacturer Payment Confirmation
7
MANUFACTURER P NUMBER
38 - 42
X(5)
5
The CMS assigned manufacturer P-Number
8
DETAIL RECORD COUNT
43 - 49
9(7)
7
The number of Contracts this Manufacture will pay (i.e. count of
TPACT records.)
9
TOTAL REPORTED GAP DISCOUNT PREVIOUS AMOUNT
50 - 63
S9(12)V99
14
Reported Gap Discount that was reported on preceding Data
Report
10
TOTAL REPORTED GAP DISCOUNT CURRENT AMOUNT
64 - 77
S9(12)V99
14
New Gap Discount amounts invoiced this quarter.
11
TOTAL GAP DISCOUNT AMOUNT THIS PERIOD
78 - 91
S9(12)V99
14
Net payment amount this quarter,calculated as the "current
amount" minus the "previous amount"
8
Date of last payment for this invoice. If payments were made on
multiple days, use final payment date. (To be filled in when
returning file to TPA for payment confirmation.)
12
DATE OF PAYMENT
92 - 99
9(8)
13
PAYMENT AMOUNT
100 - 113 S9(12)V99
14
Total amount of payments made for this invoice. (To be filled in
when returning file to TPA for payment confirmation.)
14
FILLER
114 - 200
87
Spaces
X(87)
14
COVERAGE GAP DISCOUNT PROGRAM – USER GROUP
Frequently Asked Questions
• Invoice Data
• EFT
• Labeler Code
• Third Party Vendor Roles
15
COVERAGE GAP DISCOUNT PROGRAM – USER GROUP
Dispute Process – Overview (Draft)
• Dispute Reports: Proposed model is similar to payment
confirmation report model (File formats to be developed.)
o Manufacturer uses Manufacturer Data report to create the
Dispute Submission file
o TPA uses Dispute Submission Report to create Dispute Reply
Report
Dispute Timeline for 1st Quarter CGDP Reports
TPA distributes CGDP quarterly reports
April 30, 2011
Manufacturer submits disputes to TPA
(report distribution date + 60 days)
June 29, 2011
TPA sends dispute reply report
(report distribution date + 120 days)
August 29, 2011
16
COVERAGE GAP DISCOUNT PROGRAM – USER GROUP
Dispute Process Approach (Draft)
• For each CGPD record disputed, Manufacturer submits
o Dispute Reason Code; examples
– DUP – duplicate
– OTH - other
o Data specific for individual Dispute Reason Code
o Optional text field with additional information to further
explain the dispute
o Optional comment record to further explain the dispute(s).
Each comment record has a unique identifier which the
manufacturer associates with each dispute described in the
comment record.
• TPA replies with dispute reply code(s).
17
COVERAGE GAP DISCOUNT PROGRAM – USER GROUP
Sample Dispute: Duplicate gap discount record
(Draft)
Dispute Submission Report
Dispute Reason Code: DUP
Data to support dispute: Detail Reference Number
Text field: optional
Comment record - optional
unique identifier (required if comment record is submitted.)
Dispute Reply Report
Dispute reply code:
18