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

or 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) 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

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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)

Contacts

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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