A19-J.12- PWS TECHNICAL EXHIBIT 4- STAFF PORTAL DATA ELEMENTS (2).docx
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- Attached to
- PHARMACY BENEFITS MANAGEMENT SERVICES (PBM) Federal contract opportunity
- Solicitation number
- 1605C3-24-R-00011
About this file
This document is a Technical Exhibit that outlines the required data elements for a Staff Portal as part of a Pharmacy Benefits Management (PBM) Services contract. The exhibit lists 68 data elements that the PBM must be able to display in the staff portal, including case information, claimant details, medication details, pricing information, and various indicators and codes.
The related federal contract opportunity is for PBM Services on behalf of the U.S. Department of Labor (DOL), Office of Workers' Compensation Programs (OWCP). The solicitation is for a single-award, fixed-price contract. Questions regarding the Request for Proposal (RFP) must be submitted by October 21, 2024, and the due date for proposals will be provided in a later amendment.
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Text version
Technical Exhibit 4 – Staff Portal Specification – Required Data Elements
The PBM must have the capability to display the following data elements within the OWCP staff portal (requirement XXXX), but not limited to the following:
1. Case Number
2. Claimant Name
3. DOB
4. SSN
5. Employing agency (FECA only)
6. Assigned Claims Examiner Name
7. Medical Benefit Examiner Name
8. Case Eligibility Details
a. Date of Injury (FECA), Entitlement Date (BLNG), Case Acceptance Date (ENRG)
b. Accepted Condition Details - ICD codes, Description, Effective Date and End Date
c. Offset Indicator (where applicable)
d. Transplant Indicator (where applicable)
e. Date of Death (Termination Date when applicable)
f. Case Status (Current Claim Status, Previous Claim Status and effective dates (FECA))
g. CA-15 start/end dates (where applicable)
h. CA-16 start/end dates (where applicable)
i. Short Form Closure Balance (where applicable)
j. MBO Offset Date (where applicable)
k. Final Adjudication Date (where applicable)
l. Medical Offset Indicator (where applicable)
m. Primary Lung Flag Indicator (where applicable)
n. Claim Record No (where applicable)
o. Claimant Type
9. Reference Number
10. Medication Name of the product dispensed
11. NDC
12. Transaction Status (Denied, Paid or Reversed)
13. Rx #
14. Filled method- Retail, Mail Order, or Paper Bill
15. Program Name
16. Reject Codes (displays on Denied status transactions, 1-3 reject codes displayed)
17. DUR Alert
18. Paid Amount
19. Brand or Generic Indicator
20. Transaction Control Number (TCN)
21. TCN to Credit
22. EOB (if applicable)
23. Reference Number
24. Prescriber DEA
25. Prescriber NPI
26. Prescriber Name
27. Prescriber Taxonomy
28. Prescriber Address
29. Prescriber Phone Num
30. Pharmacy Address
31. Pharmacy Name
32. Pharmacy NCPDP
33. Pharmacy Phone/Fax
34. Dispensed Date
35. Paid Date
36. Check Number
37. Reject Codes
38. AWP Amount
39. AWP Eff. Date
40. Individual MED (Morphine Equivalent Dose
41. Cumulative MED (Morphine Equivalent Dose)
42. Compound Indicator
43. Authorization Number (PA Sequence Number)
44. Authorization Effective Date
45. Authorization Expiration Date
46. Case Status (per program eligibility business specs)
47. GPI or GCN
48. Drug Class
49. MONY Code
50. FDA Application (NDA/ANDA)
51. Quantity
52. Strength
53. Day Supply
54. OPIOID, TOPICAL, COMPOUND Indicators
55. Formulary Indicator
56. Formulary Name
57. Dosage Form
58. DAW Code
59. Paper, Network, Mail, Claimant Submitted
60. Electronic/Point-of-Sale, Self-Pay, Paper Bill
61. Out of Network, Network, Third-Party Biller
62. Reason for Professional Service Code
63. Professional Service Code
64. Return of Professional Service Code
65. Result of Professional Service Code
66. Fill #
67. Date Written
68. Savings Amount
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