3/9/2023
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Implementing the Cost Sharing Maximums Established by the Inflation Reduction Act for Covered Insulin Products and ACIP-Recommended Vaccines for Contract Year 2023
This document is intended to communicate information about implementing cost-sharing maximums established by the Inflation Reduction Act with pharmacies and pharmacy providers.
Valid and Invalid Reject Codes for Transaction Facilitator Transmitted Part D Record of Supplemental Payment Nx Transactions
The Valid and Invalid Reject Codes for TransaPart D Record of Supplemental Payment Nx Transactions document represents a list of reject codes which are recommended as valid (applicable) or invalid (non-applicable) as they apply to processing N transactions generated by the Transaction Facilitator (RelayHealth).
Recommendations for Effective 4Rx Usage in Medicare Part D Processing
These documents were created by the industry to address a Centers for Medicare and Medicaid Services (CMS) directive entitled “Clarification of Unique BIN (or BIN/PCN) Requirements as of January 1, 2012 [§423.120(c)(4) as revised by CMS-4085-F]” which was released on November 12, 2010 that provided clarification of Unique BIN (or BIN/PCN) requirements. This directive covered the required assignment and exclusive use of unique routing and beneficiary identifiers for the Medicare Part D program. Implementing this directive consistently in the industry is the subject of the documents. The intent of these provisions is to ensure that:
- Pharmacies can routinely identify situations in which they are being reimbursed for a Medicare Part D claim.
- Payers supplemental to Medicare Part D can identify when a claim is being billed for a covered Medicare Part D beneficiary and drug so they can properly coordinate benefits.
These documents only address the matching and the consistent use of the 4Rx data to accept or reject transactions in processing. The intent of these documents is to provide:
- Clear guidance on how plans should submit 4Rx information on the MARx file to CMS when a plan or processor does not use PCN or group or only matches on a portion of those fields.
- A standard method for plans to communicate to pharmacies correct Part D 4Rx when a claim is submitted with incorrect 4Rx.
- Clarification on when to use the new benefit stage qualifiers to clearly indicate to the pharmacy and downstream payers when a claim submitted under a Part D BIN/PCN is processed under something other than Part D as allowed by CMS.
Medicare Part D Frequently Asked Questions
This document provides a consolidated reference point for questions that have been posed and warrant consistent application across the industry of Medicare Part D policy where claims or other applicable transactions, Prescription Drug Events (PDE) are involved. Please continue to review this link as the document is updated as needed.
Financial Information Reporting (FIR) Editorial Document
This document provides a consolidated reference point for questions that have been posed based on the review and implementation of the NCPDP Financial Information Reporting Standard Implementation Guide Version 1.0 and above, the Data Dictionary, and the External Code List. This document also addresses editorial changes made to these documents.
Best Available Evidence (BAE) Form
The NCPDP Medicare Part D Best Available Evidence Form (BAE) for Low Income Cost Sharing (LICS) is made available to NCPDP members and non-members to provide a uniform method for pharmacies to communicate documentation of eligibility for LICS to Part D plans on behalf of Medicare beneficiaries.
Recommendations and Guidance Documents
This document provides NCPDP recommended best practices for matching Medicare Part D Information Reporting (N) transactions to Other Health Insurance, including the CMS SPAP/ADAP Quarterly Report.
This document provides NCPDP recommended matching logic for Medicare Part D Information Reporting and corresponding claim transactions. This includes paid, rejected and reversed transactions.
This document provides guidance to the pharmacy industry by documenting a common list of
post point-of-sale adjustment scenarios and associating them to categories and actions outlined in CMS Prescription Drug Event Guidance for Post Point-of-Sale Claim Adjustments.
CMS Medicare Part D requires Part D Plan Sponsors to coordinate benefits for up to 36 months. Automated TrOOP Balance Transfer (ATBT) Process covers 17 months of the 36 month requirement. This white paper addresses a process to transfer the balances for the remaining 19 months and is called the Post Automated TrOOP Balance Transfer process.
Representatives from the prescription drug and hospice industries participating in NCPDP’s WG9 Hospice Task Group have collaborated on the development of a draft two-page form that may be used either by the hospice or prescriber to provide the information necessary to satisfy the beneficiary-level prior authorization edit, for the sponsor to make a coverage determination, or by the hospice to prospectively communicate information to the Part D sponsor. The first page of the form captures the information necessary for the prior authorization of drugs in the four categories; the second page captures information on drugs related to the terminal illness and/or related conditions and specifies whether each of these drugs is the responsibility of the hospice or beneficiary. Instructions for Use.
This document provides guidance for Medicare Part D Plans on how to transfer TrOOP and Gross Drug Spend accumulators when claims have been paid by a non-plan of record.
NCPDP has created this overview for all parties involved in managing Part D benefits for Medicare beneficiaries. The white paper provides a consolidated overview of the transactions required to properly coordinate benefits and track True Out Of Pocket (TrOOP) dollars or other out of pocket expenditures when a supplemental payer contributes to the beneficiary’s portion of the cost sharing remaining on a Medicare Part D claim.
This white paper offers a standardized process for sharing Medicare Part D beneficiary information related to point-of-sale edits and overutilization information from a previous plan of record to the new plan of record. CMS now requires sponsors to communicate and share this information to help protect beneficiaries and reduce fraud, waste and abuse.