Appendix D_020226.pdf

Medicare Part D Eligibility Verification Transaction (E1)

What is an E1 Transaction?

An E1 transaction is a Medicare Part D Eligibility Verification transaction intended to provide the status of a beneficiary's Medicare Part D plan covering the individual, along with details regarding primary and supplemental coverage if applicable.

The transaction comprises of a request and a response. The pharmacy submits a request transaction that contains beneficiary demographic information, (see bulleted list below), that is sent in the E1 Request to the Part D Transaction Facilitator (PDTransFac). In the request the pharmacy submits the following beneficiary demographic information:

• Cardholder ID

• Full Last Name

• Full First Name (optional)

• First Initial of First Name

• Date of Birth

• ZIP/Postal Code

If a Part D beneficiary match is found in the CMS Eligibility Database, the beneficiary's Part D plan information is returned along with any other health insurance coverage in the response to the pharmacy.

If a Part A or Part B beneficiary match is found, an indicator value of "A" or "B" is returned in the response to the pharmacy.

If there is no match found in the CMS Eligibility Database, a reject response with a coinciding message is returned in the response.

When should the pharmacy submit an E1?

There are number of situations when a pharmacy may need to submit an E1:

• A prescription is called into a pharmacy, the pharmacy has not filled a prescription for the patient before, and the patient would qualify for Medicare.

• The pharmacy has filled prescriptions for the patient before and they have been covered by a commercial plan or by Medicare Part A, B, or D. However, those claims are not rejecting for the member as "not covered." If the patient is eligible for Medicare, the pharmacy should submit an E1 to see if there is other coverage.

• The pharmacy is told by a patient that has Medicare Part D that they have other coverage, but the patient does not have the coverage information. By submitting an E1, if the other coverage is on file with CMS, the E1 will return the 4Rx (BIN, PCN, Group ID, Cardholder ID), for the other health insurance so that the pharmacy can submit a Coordination of Benefits (COB) supplemental claim.

• If the patient comes to pick up a prescription and cannot provide evidence of Medicare enrollment, the pharmacy can submit an E1 to get plan information and other health insurance coverage.

How does the Pharmacy submit an E1?

Pharmacies generally use information from their patient profiles/demographics to submit a real-time query (E1). If you are unsure of how to submit an E1 transaction, you should contact your corporate office and/or software vendor.

The PDTransFac returns information about whether the patient is eligible for Part A, Part B, or Part D and accurate patient information needed to submit the claim.

What are the results when I submit an E1?

1. Pharmacy submits the E1 request transaction from the pharmacy system.

2. The switch (routes transactions to the PDTransFac that the pharmacy has contracted to handle transactions (i.e., claim billing) will forward the E1 request to the PDTransFac.

3. The PDTransFac uses the E1 request to match the data contained within the request to the CMS Eligibility file.

4. The PDTransFac returns the E1 Response to the switch.

5. The switch returns the E1 Response to the pharmacy system.

6. The Pharmacy uses the information contained in the E1 Response to create the billing claim for the patient. If a beneficiary cannot be found or there is no coverage for the beneficiary, the pharmacy will need to contact the beneficiary directly for proof of coverage.

Current & future payer sheets can be found in Appendix E.

Financial Information Reporting Transactions (FIR)

What is a FIR Transaction?

FIR transactions are designed to facilitate the real-time transfer of beneficiary information and TrOOP and Drugs Spend dollars accumulated between all Part D plans the beneficiary may have had during a calendar year.

FIR transactions are NCPDP transactions.

There are three types of FIR transactions:

F1-Financial Information Reporting Inquiry

This transaction is sent to the very first plan for the beneficiary in a calendar year.

F2- Financial Information Reporting Update

This transaction is sent to the last plan on record during the calendar year as of the date of the FIR transaction. This is also called the current plan of record for the beneficiary.

F3- Financial Information Reporting Exchange

This transaction is sent to any additional plans between the first plan of record for the calendar year and the last or current plan of record for the calendar year. This transaction contains accumulators from any prior plans and allows for the plan(s) receiving the F3 to report their accumulators in addition to those reported by others in their response to this transaction.

Every time a beneficiary changes plans in a calendar year, there will be at minimum two FIR transaction types (F1 and F2) generated; however if the beneficiary has more than two plans in a calendar year, there will be three transaction types (F1, F2 and F3).

The entire process of sending FIR transactions to each of the beneficiary's plans is called a Sequence. Each FIR transaction is sent sequentially from the oldest (first plan in a calendar year) to the most current plan. Each Sequence will contain at minimum an F1 and an F2, but may also include an F3 if more than two plans exist for a beneficiary in a calendar year.

What is the FIR Transaction Process?

The Part D Transaction Facilitator (PDTransFac) receives a nightly eligibility data file from CMS that indicates a new Part D plan for a patient.

The PDTransFac determines if the new plan will become effective in the future or is already effective. If the plan is already effective, the PDTransFac sends an F1 to the first plan for the calendar year.

If the plan will become effective in the future, the PDTransFac schedules the delivery of the F1 to the first plan for the calendar year one day before the plan becomes effective.

If the response to the F1 is a rejection, the Sequence stops. The rejection is reported on the rejecting plan's Daily Cumulative Exception Report. Until the rejection is resolved, the beneficiary's accumulators will not be transferred to any plans after the first plan in the calendar year.

If the F1 is accepted, the PDTransFac will send a FIR transaction to the next plan in line. If there is only one additional plan, that transaction will be an F2. If there is more than one additional plan, the transaction will be an F3. Specifically:

There is only one additional plan.

The PDTransFac sends an F2 transaction. This transaction contains the accumulators from the prior plan. If the F2 is accepted, the plan receiving the F2 will update the beneficiary's accumulators with information provided by the prior plan.

There is more than one additional plan

The PDTransFac sends all additional plans except the plan that caused the FIR sequence to be initiated (the most current plan of record), an F3 transaction. This transaction contains accumulators from all plans prior to the plan receiving the F3.

If the F3 is accepted, the plan receiving the F3 will respond to the F3. The response will either mirror back what prior plans have reported (if receiving plan does not have a any dollars to report for the month) or will contain the sum of prior plans and current plan accumulators (if prior plans had dollars to report and receiving plan has dollars to report in the same month). Additionally, the Part D plan should update their systems to reflect any dollars provided from prior plans.

Each additional plan except the plan that caused the FIR sequence to be initiated (the most current plan of record) will receive an F3.

If there are no additional plans other than the most current plan of record the PDTransFac will send an F2 containing all prior plan dollars to the most current plan of record.

What causes a FIR to be triggered?

Any beneficiary that has a change in Contract ID during a plan year will initiate a new FIR series.

Any beneficiary that has a change in PBPID with a change in either BIN, PCN or both will initiate a new FIR series.

Any beneficiary for which a proxy add was requested, by any plan that may have paid claims on behalf of the beneficiary, will always initiate a new series.

Any beneficiary for which a proxy edit was requested will trigger a FIR Sequence if a series is already under way. However if there is not an active series for the beneficiary a new series will be initiated.

A retrigger request, from any plan the beneficiary may have had during the plan year, will initiate a new sequence.

A beneficiary that has a FIR series "in flight" that also has a 4Rx or DOB change will generate a one time, on demand, FIR sequence on the day prior to the effective date of the change or the date of receipt of the change (whichever is later) if a FIR sequence is not already in queue on that day.

How often are the FIR Sequences sent?

Many events can occur that result in a change to the way a claim originally processed.

These events may occur even after the beneficiary has left (dis-enrolled) a plan. For example, a plan may receive a retroactive change to the Low-Income Cost Sharing that requires claims to be adjusted. Other examples may be the receipt of latent supplemental payer information (N transactions), paper claims submitted by the beneficiary, reversal or non-coverage of claims previously paid, and end-of-year reconciliation. All of these can impact the beneficiary's accumulators. To account for these changes, the PDTransFac automatically submits FIR sequences multiple times, as defined in the schedule below, to all plans to communicate any changes to the beneficiary's accumulators.

FIR sequences are sent based on the following schedule, which is called a Series unless a new event (e.g. beneficiary moves to another plan) restarts the Series at which time the schedule restarts based on that new event. The specific timing of each sequence in a series is listed below:

1 day prior to effective date if eligibility is received prior to effective date

Effective date (or receive date if received after effective date)

Day 2 (1 from effective date or receive date)

Day 4 (3 days from effective or receive date)

Day 8

Day 10

Day 12

Day 14

Day 21

Day 28

Day 73

Day 118

Remainder of the triggers follow the mass trigger schedule below:

Mass Trigger Schedule:

Current Year

1st Tuesday of December

Prior Year

2nd Tuesday of February

2nd Tuesday of March

2nd Tuesday of May

2nd Tuesday of July

2nd Tuesday of September

2nd Tuesday December

Two Years Prior

3rd Tuesday of January

3rd Tuesday of April

3rd Tuesday of July

3rd Tuesday of October

Three Years Prior

4th Tuesday of February

4th Tuesday of May

4th Tuesday of August

4th Tuesday of November

If a Part D Plan continues to experience changes to the beneficiary's prior plan year accumulators between March 31st and May 31st, the plan can request the PDTransFac to initiate a FIR sequence.

For additional information on FIR timing and examples, please consult FIR Timing Examples which can also be found under the Related Documents section of this page.

For accumulator balance changes that occur after May 31st following a plan year, CMS and the industry worked together to define a set timeframe (which is roughly quarterly) to retrigger prior plan year FIRs. This process is called the Mass Retrigger process and only beneficiaries that had FIR transactions in a prior plan year will be retrigger during the mass event. Plans may not request a manual retrigger once FIRS have reached the Mass Retrigger stage. See a schedule of Mass Retrigger dates (Appendix E).

Supplemental Payment Information Transaction (Nx)

Providing Part D Plans a Record of Supplemental Payer's Payments

The Medicare Part D Prescription Drug Program was enacted on January 1, 2006 as part of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). The Medicare Part D program was implemented, in part, to help subsidize the cost of the overall prescription drugs of an aging population by ensuring access to affordable drugs.

Part D Sponsors are required to coordinate benefits with State Pharmaceutical Assistance Programs (SPAPs), AIDS Drug Assistance Programs (ADAPs), charities and other providers of prescription drug coverage (such as commercial insurance). If these entities provide coverage supplemental to Part D and participate in the eligibility data exchange with CMS, Part D Plans are required to coordinate benefits for a period not to exceed 36 months from the date of fill for a covered Part D drug.

CMS requires Part D Sponsors to coordinate benefits with supplemental payers when:

• Supplemental payers send electronic eligibility data for Part D eligible beneficiaries that are in their plan to CMS.

• The 4Rx on the claim paid by the supplemental plan matches the 4Rx on the eligibility information the supplemental payer has sent to CMS.

• The Part D Sponsor has paid for the Part D drug and the supplemental payment transaction information (N transaction) can be matched to the Other Health Insurance information on record and the covered Part D Claim.

When coordinating benefits, only supplemental coverage of Part D covered drugs must follow Coordination of Benefits Rules as only Part D covered drugs count towards the beneficiary's TrOOP accumulation. A Part D covered drug is one that is covered by the Part D Plan under the plan's formulary, through a transition period, or via an exception, appeal, or grievance, and must be purchased at a Part D in-network pharmacy (unless the Part D Sponsor has permitted an override for a non-network pharmacy). The drug must meet the CMS definition of a Part D drug.

Coordinating benefits with supplemental payers ensures that the Part D beneficiary's TrOOP is correctly stated, and that supplemental plans that have contributed to the beneficiary's cost share are considered when adjustments are made by the Part D Plan, and when determining refunds based on payment order. This means that if a refund is due, the supplemental payer will be refunded prior to any refund going to the beneficiary.

To effectively coordinate benefits there are processes, rules and requirements for both the Part D Plans and the supplemental payers. The links to the right on this page provide documentation specific to Part D Plans.

In a nutshell, the process of providing Part D Plans with a record of a Supplemental Payers coverage for purposes of coordination of benefits is documented in a high-level flow chart (Appendix F).

Hospice Nx

The Hospice Part D pilot program established a process to transmit hospice election information via the electronic 837i standard to the PDTransFac. The PDTransFac transmits these elections via the NCPDP information reporting transaction standard (Nx) to the Medicare Part D plans. The goal of the program is to significantly reduce the time elapsed between when the NOE is submitted and when the Medicare Part D plan receives the NOE.

The pilot provides the notice of hospice election to the Medicare Part D sponsors in a timely manner. Medicare Part D sponsors are able to utilize hospice election status for purposes of drug coverage determinations, with the intent of minimizing latent subrogations.

During the first phase of the pilot, the PDTransFac will use the Nx transaction to provide a record of Hospice elections to the Medicare Part D sponsor. The Nx transaction will be used to track enrollment in hospice, specific to the hospice provider, in the event that a coordination of benefits is required. Medicare Part D sponsors will be able to process the Hospice Nx Transactions in real-time.