Updates to the Sponsor Invoice and Payment File Layouts (Multiple Benefit Years) - Begins Quarter 1 2012
Updates to the Sponsor Invoice and Payment File Layouts to Accommodate the Inclusion of Multiple Benefit Years on a Single Invoice
Beginning with the invoices distributed in April 2012, there will be data from multiple benefit years invoiced at each quarterly cycle. At this time, there will be PDE data invoiced from Q1 2012, as well as from Q5 2011.
Because Prescription Drug Event records (PDEs) can be submitted up to three years following the date of service, updates have been made to several file layouts in order to accommodate the inclusion of multiple benefit years on a single invoice.
The new layouts, which go into effect with the Q1 2012 invoice distributed in April, will allow manufacturers to make a single EFT payment to each Part D contract that is the sum of the invoice amounts across multiple benefit years. The following file layouts are impacted:
Attachment 1: Contract Summary Report
Attachment 2: Contract Data Report
Attachment 3: Contract Payment Confirmation Report
Attachment 4: Contract Payment Confirmation Report Response File
This document summarizes the changes to each file in greater detail. Any questions regarding these changes should be directed to the TPA.
Changes to the Contract Summary Report:
Because the PTOT record is no longer the basis for building the payment confirmation, the EFT Individual Identification Number has been removed. Added to the PTOT record are the Total Reported Gap Discount Previous Amount and the Total Reported Gap Discount Current Amount. As in the previous version of this report, the Report ID field on the PTOT record is benefit year specific. This means that for each P number where there were invoiced gap discount amounts in multiple benefit years, there will be a PTOT record on the Contract Summary Report for each P number and benefit year/quarter combination.
The file structure of the Contract Summary Report adds additional record types called the TPAMH and the TPAMT. The purpose of this header and trailer pair is to contain and summarize multiple PTOT records that are benefit year specific and belong to a single manufacturer. The TPAMT record is now the basis for sponsors to confirm payment from each manufacturer. Because of this, the EFT Individual Identification Number has been added to the TPAMT. Both the TPAMH and the TPAMT have a field called Current Reporting Period. The Current Reporting Period will be populated with the calendar year and quarter for which the invoice was created. Because this is based on the calendar year, the reported quarter will not exceed Q4. This is in contrast to the Report ID field on the PTOT record which is benefit year specific and therefore the reported quarter could be up to Q17 to accommodate the three year PDE submission acceptance window following the end of a benefit year.
The TPACT record on the Contract Summary Report informs sponsors of the grand total due from all manufacturers across all benefit years for the current reporting period. It too includes the Current Reporting Period field. The TPACT record is now the basis for the trailer record on the Sponsor Payment Confirmation Report.
Changes to the Contract Data Report:
On the Contract Data Report, the DETCD record provides PDE level information for all PDEs invoiced in a quarter. Due to the change in policy regarding invoicing low volume claims (see HPMS memo dated January 27, 2012 titled “Medicare Coverage Gap Discount Program—Update on Low-Volume Claims”), the Prior Low Volume Discount Flag field has been removed from the DETCD record. Added to the DETCD record is the Previous Reporting Period field.
While the fields Reported Gap Discount Previous Amount, Reported Gap Discount Current Amount and Gap Discount Amount This Period remain on the DETCD record, due to the number of questions we have received, further explanation of these fields is warranted. When an invoiced PDE represents an adjustment of a PDE that was previously invoiced, the most recent previously invoiced amount that appeared in the “Reported Gap Discount Current Amount” on the previous invoice will be displayed in the field called Reported Gap Discount Previous Amount on the current invoice. The Reported Gap Discount Current Amount field represents the dollars from the Reported Gap Discount Amount on the most recently received version of the PDE as of the current invoice period. The total amount due for this invoice is calculated as Reported Gap Discount Current Amount minus Reported Gap Discount Previous Amount and is reported in the field titled Gap Discount Amount this Period.
On the trailer records of the Contract Data Report (and, incidentally, on the PTOT, TPAMT and TPACT records of the Contract Summary Report), the Total Reported Gap Discount Previous Amount field includes the sum of all dollars reported in this field on the Contract Data Report detail records. This means that only PDEs invoiced this quarter that represent an adjustment to a previously invoiced PDE will contribute to this field as reported on the above mentioned records.
The BYRH and BYRT header and trailer records have been added to the Contract Data Report in order to summarize the invoiced PDEs by benefit year.
The Detail Record Count on all trailer records (TPAMT and TPACT) has been expanded by one position to an eight byte field. This shifts all fields following the Detail Record Count over by one position in the record and decreases the Filler space by one position.
Additionally on the TPAMH/TPAMT and TPACH/TPACT records, the Current Reporting Period has replaced the Report ID.
No Changes to the Coverage Gap Tracking Report:
The Tracking Report will remain benefit year specific. Sponsors will receive two tracking reports with invoices issued in April of 2012, one Tracking Report reflecting PDEs with DOS in 2011, and a second Tracking Report that includes PDEs with DOS in 2012. In order to distinguish between the two, the TPA will add the appropriate Report ID to the end of the file name. Tracking Reports distributed in April will be named:
R#######.RPT.SPON_TRACKING_201201
R#######.RPT.SPON_TRACKING_201105
Changes to the Contract Payment Confirmation Report:
Due to the new level of summarization added to the Sponsor Summary Report file layout that is necessary to add invoiced amounts from multiple benefit years, the record type that serves as the basis for the Sponsor Payment Confirmation Report must change from the PTOT record to the TPAMT record.
Mapping from the Sponsor Summary Report TPAMT record to the Contract Payment Confirmation Report TPAMT record, the Date of Payment and Payment Amount are added into the positions previously designated as reserved filler space.
Similarly, mapping from the Sponsor Summary Report TPACT record to the Contract Payment Confirmation Report TPACT record, the Date of Payment and Payment Amount are added into the positions previously designated as reserved filler space.
Changes to the Contract Payment Confirmation Report Response File:
Only two changes were made to the Contract Payment Confirmation Report Response File in order to maintain consistency with changes to other file layouts and to reflect the change in record type now used for payment confirmation. The first change occurs on the fifth line, field #2 which now reports the Current Reporting Period from the TPACH record. The second change occurs on the seventh line, field #5 which now reports TPAMT record instead of the PTOT record type.