This announcement summarizes the updates to the
Dispute Resolution file layout to reflect multiple benefit years. The TPA uses the Dispute Submission file to create the Dispute Resolution Report so the updates that were made to the Dispute Submission file to account for the inclusion of multiple years on the invoice carryover to the Dispute Resolution file layout. These updates will allow manufacturers to receive one report per quarter containing the determinations on disputes submitted from multiple benefit years.
On the header and trailer records of the Dispute Resolution file, the TPAMH and the TPAMT records, in Field # 3 the Current Reporting Period field replaces the Report ID field. The Current Reporting Period field refers to the calendar year and quarter that the invoice was issued. Because this field is specific to the calendar year, the value reported for the quarter cannot exceed “04” (Quarter 4).
On the DETDR record, the Prior Low Income Discount Flag (formerly field #17) has been removed, in accordance with the change to our low volume policy. The DETDR also includes two new fields, Previous Reporting Period (field # 17) and Current Reporting Period (field #18). The Current Reporting Period carries over from the TPAMH record and identifies the calendar year and quarter that the invoice was issued. If the PDE on the current invoice represents an adjustment to a previously invoiced PDE, the Previous Reporting Period identifies the calendar year and quarter the original PDE was invoiced. Previous Reporting Period is also calendar year specific and for this reason, the quarter cannot exceed Quarter 4. The addition of the Previous and Current Reporting Period fields shifts all of the fields that follow by 11 positions, including the Dispute Disposition, Dispute Resolution Code, and Dispute Resolution text fields.
Lastly, on the TPAMT record, the following fields have all been expanded in length from seven to eight positions: the Total Detail Record Count (field #8), the Total Detail Record Count – Upheld (field #9), the Total Detail Record Count – Denied (field #10), Total Detail Record Count – Denied, Rejected on Error (field #11), and Total Detail Record Count – Denied, Received After 60 Days (field #12). The expansion of these fields reduces the filler field at the end of the record by five positions.