J.6 Assumptions.DOC

Attachment J.6 attachment j.6 Assumptions

· CMS will:

· Provide complete benefit information for Medicare beneficiaries to PDP’s and Eligibility vendors

· Reporting Transactions Standardized

· e.g., On adjustments or reversals the Part D plans will receive the same information that was provided on the secondary or tertiary modified N1 transaction

· Non PDP payers will:

· Provide to CMS a RxBIN, RxPCN, RxGRP, RxID to support creation of enrollment file

· Batch

· If unique RxBIN and RxPCN are not RxBIN/RxGRP

· Non real-time billing claims (batch or paper) will be submitted through TrOOP Facilitation process using Standardized Information Reporting, Information Reporting Reversal, and Information Reporting Re-bill transactions (i.e. NCPDP modified N1, N2 and N3 (optional) transaction format)

· Real-time claims not routed through TrOOP Facilitation Process:

· Create and send Information Reporting, Information Report Reversal, and Information Reporting Rebill transactions to TrOOP Facilitation process, If a unique RxBIN, RxPCN, RxGRP is not established and provided to CMS.

· General:

· All Payers will:

· Resolve rejects generated as a result of incorrect information provided by payer

· The TrOOP Facilitation Process supports:

· Information Reporting, Information Reporting Reversals, and Information Reporting Re-bill transactions (N1, N2, and N3 (optional) transactions.

· Certification with each payer interface

· Eligibility Process supports:

· Standard Eligibility Request, Response, and Messaging

· The NCPDP v5.1 N1 transaction will be modified to include data elements in the Data Element Request Form (DERF) submitted to NCPDP.

· NCPDP and ANSI will manage the uniqueness of the RxBIN/RxPCN that will be used in the header of a Medicare Supplemental Claim

· Pharmacies will place the unique RxBIN and PCN in the headers of Medicare Supplemental Claims they send

TrOOP Facilitation SOW