Prescription Drug Event
(PDE) Record Overview
Medicare Coverage Gap Discount Program
Public Meeting
June 1, 2010
Objectives
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•
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Explain history and purpose
Introduce data elements
Outline Part D payment reconciliation
Review controls, edits and data quality measures
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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
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PDE Data Elements
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•
•
•
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Contract and Beneficiary
Provider
Event
Drug and Quantity
Costs
Payment Breakdowns
Submission Format published at
http://www.csscoperations.com/new/pdic/pde/ddps.html
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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
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NCPDP Data Elements Include:
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•
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•
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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
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Part D Payment Reconciliation
• Basic benefit is basis for Part D Payment
Reconciliation
• Payment Methodologies:
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•
•
•
Low Income Cost-Sharing Subsidy (LICS)
Reinsurance Subsidy
Risk-Sharing
Gap Discount (effective January 1, 2011)
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Defined Standard Benefit - 2010
Beneficiary Liability
Direct Subsidy/
Beneficiary Premium
Medicare Pays Reinsurance
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Information Required for Part D
Payment Reconciliation – 2010
Part D enrollment
Contract of Record, DOS
Part D Covered Drug
Low Income Cost-Sharing Subsidy
Status
Drug Coverage Status Code = C
Low Income Cost-Sharing Subsidy (LICS) >
0
Cost in Catastrophic Benefit Phase
(Reinsurance Cost)
Catastrophic Coverage Code = C
Gross Covered Drug Cost Above the Out-ofPocket Threshold (GDCA)
TrOOP status of OHI Payer, if any: Other
TrOOP or Patient Liability Reduction due to
Other Payer (PLRO)
Basic benefit portion of Plan payment Covered Part D Cost (CPP)
Non-Covered Plan Paid Amount (NPP)
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Defined Standard Benefit 2020
Catastrophic
Coverage
Total
Covered
Drug
Spending
Deductible
75% Plan
Pays
Gap Discount
Pays ~50%
80% Reinsurance
Plan Pays
~25%
25% Coinsurance
Total Beneficiary
Out -Of-Pocket
15% Plan Pays 5% Coinsurance
Beneficiary Liability
Direct Subsidy/
Beneficiary Premium
Medicare Pays Reinsurance
Gap Discount
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Information Required for
Gap Discount
Applicable beneficiary
Low Income Cost-Sharing Subsidy Status2010
Applicable drug
Identified from Product Service ID (NDC) 2010
Applicable discount
50% of negotiated Price that falls in the Coverage
Gap:
Costs: Ingredient, Dispensing Fee, Sales Tax,
Vaccine Admin Fee2010
2010
Covered Part D Cost (CPP)
2010
Non-Covered Plan Paid Amount (NPP)
2011
Reported Gap Discount
2011
Total Gross Covered Drug Cost Accumulator
2011
Out-of-Pocket (TrOOP) Accumulator
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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
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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)
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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
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Duplicate and BOL Editing
Record Type
Adjustment Deletion Code Value
Original
blank
Adjustment
A88
Deletion
D
Key Fields:
Date of Service (DOS)
Prescription Service Reference Number
Fill Number
Service Provider ID
Service Provider ID Qualifier
Dispensing Status Code(Discontinued 2011)
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Duplicate Editing
Applies to Original Records only
777:
784:
785:
Duplicate PDE record exists in DDPS data
warehouse (originals only)
Duplicate PDE record, originally submitted
by different contract
Duplicate PDE records exist on this file
(CMS makes no assumption about sponsor
intent)
Duplicate logic disregards both beneficiary and
contract
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Business Order Logic Editing
•Sponsors must submit records in order
•CMS makes no assumptions about sponsor
intent
660:
661:
662:
Adjustment/Deletion PDE does not match
existing record
Cannot adjust a deleted record
Existing PDE has already been deleted
Note: Original record may follow a Delete record
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Cost Balancing Edits
Cost Fields:
=
=
Ingredient Cost
Dispensing Fee
Sales Tax
Vaccine Administration Fee
Payment Fields:
Beneficiary Liability
Covered Drugs:
GDCB: Gross Drug Cost Below
the Out-of-Pocket Threshold
GDCA: Gross Drug Cost Above
the Out-of-Pocket Threshold
Patient Pay Amount
LICS
Other TrOOP
LICS
PLRO
Plan Liability
=
CPP
NPP
Reported Gap Discount
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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
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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
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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
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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
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Reporting Lag (Hypothetical Data)
100
90
80
Percentage
70
60
50
40
30
20
10
0
Month of Service
Month PDE Reported
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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
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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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