Attachment I - KEHP Data Integration Chart - PBM RFP 2025.xlsx
XLSX spreadsheet 17 KB Posted
- Attached to
- Pharmacy Benefits Manager (PBM)
- Solicitation number
- RFP-758-2500000221-3
- Issued by
- Kentucky
About this file
This is a data integration chart for the Kentucky Employees' Health Plan (KEHP) Pharmacy Benefit Manager (PBM) contract, detailing the data exchange requirements between various vendors and stakeholders. The chart outlines detailed specifications for claims, enrollment, and financial data transfers between the PBM and multiple entities including the Data Aggregator Vendor, Medical TPA, FSA/HRA Vendor, DEI, Benefits HUB, Medication Therapy Management, Claims Auditor, and Surgical Network.
The financial specifications include weekly administrative fee payments, quarterly manufacturer rebates (required as pass-through with no PBM retention), and various invoicing schedules. Claims files are delivered on the 1st, 8th, 16th, and 24th of each month, with administrative fees following the same schedule. The document also details transition requirements between old and new PBMs, including the transfer of historical pharmacy claims, prior authorizations, and address files. Performance guarantees and associated penalties are assessed annually, with service warranties being credited on invoices with supporting documentation.
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Other files
| File | Type | Posted |
|---|---|---|
| Attachment F - Mandatory Requirements - PBM RFP 2025.xlsx | XLSX spreadsheet | |
| Attachment C - Prescriptions Filled from Nov 2023 through Oct 2024.pdf | ||
| Attahment K - BAA.pdf | ||
| Attachment O - Census Data - KEHP Rx Plan Designs 2024.xlsx | XLSX spreadsheet | |
| Attachment N - Census Data - KEHP Network Disruption Final.xlsx | XLSX spreadsheet | |
| Attachment B - Cost Form - PBM RFP 2025.xlsx | XLSX spreadsheet | |
| Final_RFP_758_2500000221_1_SO_FORM.PDF | ||
| Attachment J -DEI Billing Procedure Document.pdf | ||
| Final_RFP_758_2500000221_3_SO_FORM.PDF | ||
| Attachment M - Census Data - KEHP Formulary Disruption Final.xlsx | XLSX spreadsheet | |
| Final_RFP_758_2500000221_2_SO_FORM.PDF | ||
| Attachment H - Technical Questionnaire - PBM RFP 2025.xlsx | XLSX spreadsheet | |
| Attachment L - KEHP Pharmacy Claims Invoicing Document - PBM RFP 2025.xlsx | XLSX spreadsheet | |
| Attachment P - Census Data - KEHP Rx Plan Designs 2025.xlsx | XLSX spreadsheet |
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Text version
Pharmacy Benefit Manager (PBM)
| From | To | Frequency | What | Type | Format | Contents/Details |
| Claims/Clinical | ||||||
| PBM | Data Aggregator Vendor | Monthly | Claims File | Claims | File | Prescription drug claims for all covered lives |
Files due anytime between 1st and 15th of the month, with prior month's claims.
| PBM | Actuary | Monthly | Pharmacy Claims | Claims | File | Prescription drug claims for all covered lives. |
| PBM | Medical TPA | Weekly | Pharmacy Claims File | Claims | File | Prescription drug claims for |
a) combined deductible (accums) and max out of pocket, and
b) Disease Management.
| PBM | FSA/HRA Vendor | Unknown | Pharmacy Claims File | Claims | File | Claims for FSA & HRA card-swipe adjudication, if needed. |
| PBM | DEI | Weekly | Pharmacy Claims File | Claims | File | All KEHP pharmacy claims for which DEI must remit payment. Claims files are delivered on the 1st, 8th, 16th, and 24th of each month, with claims from prior period. |
Periods:
1st thru 7th - delivered on 8th 8th thru 15th - delivered on 16th 16th thru 23rd - delivered on 24th 24th thru 31st - delivered on 1st
| PBM | Benefit HUB | 24/7 | Pharmacy Claims | Claims | API | Pharmacy Claims (API),and one-direction Single Sign On (SSO) from the Benefits HUB to the PBM's system. |
| PBM | Medication Therapy Management | n/a | Pharmacy Claims | Claims | n/a | Medication Therapy Management has access to PBM's secure site for reviewing retiree claims. No active enrollee claims are viewed. |
Other than access to the data online, no data exchange occurs.
| PBM | Rx Claims Auditor | Unknown | Pharmacy Claims File | Claims | Unknown | Claims for pharmcy claim auditing |
| Surgical Network | PBM | Varied | Claims | Claims | Unknown | Surgery claims, consultation fees, and travel expenses for KEHP participants who elected to use Surgical Network services. |
Surgical Network sends claims and invoices to PBM for payment. PBM pays, then bills DEI for reimbursement.
| Surgical Network | DEI | Varied | Claims | Claims | Excel Report | Surgery claims, consultation fees, and travel expenses for KEHP participants who elected to use Surgical Network services. |
| Enrollment | ||||||
| Medical TPA | PBM | Daily | PASS-THROUGH: Medical Plan Enrollment File | Enrollment | File | Plan enrollment information for actives, early retirees and COBRA, for planholders and covered dependents. |
| FSA/HRA Vendor | PBM | Unknown | FSA/HRA Enrollment file | Enrollment | File | FSA/HRA Vendor provides list of planholders to PBM for whom they need claims for auto-adjudication. This ensures PBM is not sending claims to FSA/HRA Vendor for people who do not have an FSA or HRA. |
| PBM | Medical TPA | Quarterly | Vendor Sync | Enrollment | File | Enrollment and plan comparison between two vendors, for planholders and covered dependents. |
The sync process ensures pass-through set up is functioning properly, both in setting up of plans, members and dependents, and in dropping of the same.
Medical TPA and PBM will agree to an acceptible margin of error. Research is performed if discrepancy rate falls outside the margin, or YoY trend appears to be very inconsistent.
DEI receives a copy of the sync outcome and updates on any issues found and resolved during the sync.
| PBM | Medication Therapy Management | Uknown | Enrollment | Enrollment | Unknown | Retiree enrollment data. |
| PBM | Rx Claims Auditor | Unknown | Enrollment | Enrollment | Unknown | All Planholder enrollment data |
| Financial | ||||||
| PBM | DEI | Weekly | Misc Fee Report | Financial | Excel Report | Details to support charges on Admin & Claims Invoices. |
| PBM | DEI | Quarterly | Rebate Payment | Financial | ACH | Payment of manufacturer rebates PBM collected on behalf of the KEHP. All rebates are required to process as pass-through. PBM may not retain rebates. |
| PBM | DEI | Quarterly | Rebate Details - PDF & CSV | Financial | Report | Details to support Rebate Check. |
| PBM | DEI | 1st, 8th, 16th, 24th | Admin Fees Invoice | Financial | Report | Claim processing fees invoiced 1st, 8th, 16th, and 24th of each month, with fees for prior period. Periods are: |
24th-31st: 1st of month invoice 1st-7th: 8th of month invoice 8th-15th: 16th of month invoice 16th-23rd: 24th of month invoice
Some fees are monthly rather than weekly. Monthly invoicing is on the 1st of each month, with the prior month's fees.
All of these items are commonly referred to as ASO fees or Administration Fees. All billed items must be supported by either the weekly claims files or the first of month details file.
| eMARS | PBM | Weekly | Admin Fees Payment | Financial | EFT | Payment of Admin Fees. |
| PBM | DEI | Weekly | Pharmacy Claims Invoice | Financial | Invoice which accompanies weekly pharmacy claims files. | |
| eMARS | PBM | Weekly | Pharmacy Claims Payment | Financial | EFT | Payment of pharmacy claims. |
| eMARS | PBM | Varies | Surgical Network Payment | Financial | EFT | Payment of Surgical Network services. This payment is considered reimbursement for Surgical Network services PBM already paid Surgical Network for. |
| Surgical Network | PBM | Varied | Surgical Network Invoices | Financial | Unknown | Surgical Network sends claims and invoices to PBM for payment. PBM pays, then bills DEI for reimbursement. |
| Surgical Network | DEI | Varied | Surgical Network Invoices | Financial | Invoice of Surgical Network Services which require payment. This invoice is on Surgical Network's standard template and arrives alongside a claims report. DEI uses this data to reconcile and verify member eligibility, then holds the final action, i.e. payment, until the corresponding official PBM invoice arrives. | |
| PBM | DEI | Varies | Invoice of Surgical Network Services | Financial | Invoices of Surgical Network services which require payment. Surgical Network charges are officially submitted on PBM's standard invoice as the point solution agreement runs through PBM. DEI cannot pay for Surgical Network services without the formal PBM invoice. | |
| PBM | Surgical Network | TBD | Claims Payment | Financial | Unknown | Payment of Surgical Network claims |
| PBM | DEI | Annual | Performance Guarantees (PGs) | Financial | Report | Report(s) with status of each performance guarantee. |
| PBM | DEI | Annual | Performance Guarantee (PG) Penalty Payments | Financial | ACH | Penalty payments for missed PGs. |
| PBM | DEI | Varies | Service Warranties | Financial | Report | Payment of service warranties are received by DEI via credit line items on invoices. Supporting excel reports must accompany the invoice. |
| PBM | Actuary | Monthly | Pharmacy Rebates | Financial | Unknown | Prescription drug rebate reporting |
| Transition | ||||||
| Old PBM | New PBM | Pre-Go Live | Claims | Claims | File | Historical Pharmacy claims |
| Old PBM | New PBM | Pre-Go Live | Prior Auths | Claims/Clinical | File | Open Prior Auths |
| DEI | New PBM | Pre-Go Live | Address File | Enrollment | TBD | For various pre-transition and OE communications. |
| Old PBM | DEI | Post-Go Live | PBM Invoicing, Files | Varied | TBD | Last invoices and supporting files from PBM for claims, fees, and other services. |
| Old PBM | DEI | Post-Go Live | Surgical Network Invoicing, Files | Varied | TBD | Invoices and supporting files from Surgical Network for services rendered. |
CVS/CareMark - PBM
KEHP Data Integration Page &P of &N
File details come from the government source that posted it. Updated .