Appendix G_020226.pdf

This document is a process flowchart depicting the Real-time Supplemental Payment N Transaction Process, which appears to be a healthcare claims adjudication and payment workflow.

The process begins when a pharmacy submits a claim to a Part D Plan, which returns its response. The system then determines whether the claim qualifies as supplemental by checking if it is directed to a supplemental payer. If yes, the pharmacy submits the claim to the Supplemental Payer, which accepts the claim and transmits it to a Transaction Facilitator. The Pharmacy's Switch then forwards the initial supplemental claim request and payment transaction to the Transaction Facilitator, which attempts to match supplemental claim information (BIN, PCN, Cardholder ID) to CMS's supplemental claim eligibility file.

If a match is found, the Transaction Facilitator identifies the associated Part D Plan and checks whether a matching Part D Plan exists. When located, the facilitator creates an N transaction and sends it to the Part D Plan for acceptance. If the Part D Plan accepts the N transaction and applies coverages like TrOOP or PLRO, the process continues with follow-up actions as needed. Rejected claims proceed based on specific reject codes. The workflow includes multiple decision points regarding BIN/PCN or SPAP/ADAP list verification and availability of additional follow-ups. Claims that cannot be matched or verified result in no N transaction generation, or the N record of supplemental payment is not applied.