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Objectives. Explain history and purposeIntroduce data elementsOutline Part D payment reconciliationReview controls, edits and data quality measures. 2. PDE History and Purpose. PDE introduced in 2006; no predecessor record format or system existedDesigned and implemented to reconcile Part D paymentsWhen feasible, the PDE incorporated data from existing NCPDP billing transactionsWhen necessary, CMS defined data elements needed for Part D payment reconciliationCMS-defined date and financia9439
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1. Prescription Drug Event (PDE) Record Overview
2. 2
3. PDE History and Purpose PDE introduced in 2006; no predecessor record format or system existed
Designed and implemented to reconcile Part D payments
When feasible, the PDE incorporated data from existing NCPDP billing transactions
When necessary, CMS defined data elements needed for Part D payment reconciliation
CMS-defined date and financial data elements use NCPDP format
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4. PDE Data Elements Contract and Beneficiary
Provider
Event
Drug and Quantity
Costs
Payment Breakdowns
Submission Format published at http://www.csscoperations.com/new/pdic/pde/ddps.html
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5. PDE is Final Action Summary of Individual Claim PDE summarizes adjudication of an individual claim
Unlike other Medicare Programs, Part D Sponsor (not CMS) adjudicates claims following CMS guidance
Part D sponsors must retain audit trails linking PDEs to source billing transactions
Reporting is based on final action
When sponsor adjusts or deletes previously saved record the “most recent record submitted” is designated as final action record
Excludes final action deleted records
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6. NCPDP Data Elements Include: DATE OF SERVICE (DOS)
PRESCRIPTION SERVICE REFERENCE NUMBER
FILL NUMBER
SERVICE PROVIDER ID and QUALIFIER (Pharmacy)
PRODUCT SERVICE ID (NDC)
INGREDIENT COST PAID
DISPENSING FEE PAID
TOTAL AMOUNT ATTRIBUTED TO SALES TAX
VACCINE ADMINISTRATION FEE
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7. Part D Payment Reconciliation Basic benefit is basis for Part D Payment Reconciliation
Payment Methodologies:
Low Income Cost-Sharing Subsidy (LICS)
Reinsurance Subsidy
Risk-Sharing
Gap Discount (effective January 1, 2011) 7
8. Defined Standard Benefit - 2010 8
9. Information Required for Part D Payment Reconciliation – 2010 9
10. Defined Standard Benefit 2020 10
11. Information Required forGap Discount 11
12. Controls 12
13. 13
14. Edit Categories 14
15. Duplicate and BOL Editing 15
16. Duplicate Editing 16
17. Business Order Logic Editing 17
18. Cost Balancing Edits 18
19. Edits 690, 691 and 692 19
20. Service Provider ID Edits 20
21. NDC Edits 21
22. Two Phase Data Quality Oversight 22
23. Reporting Lag (Hypothetical Data) 23
24. Manufacturer’s Perspective 24
25. Resources 25
