Tip: Managing overlap between Medicare fee for service claims and Medicare Advantage Plan claims

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99MCR1, Medicare Advantage SEs

Jul 14, 2022

Feb 22, 2023 Mar 13, 2024

Included in March 2024 Data Tips Email

For data requesters receiving Arkansas Medicare fee for service data.

Arkansas Medicare fee for service claims include claims managed through Arkansas Medicare Advantage commercial plans. 

Medicare Advantage plans found in the commercial data on the Arkansas APCD can be identified using this methodology: 

Medicare Advantage plans do not always have plan names that can easily be identified as Medicare Advantage.  These plans can be identified when Insurance Product Type Code (ME003, MC003, PC003) contains the values  ‘HN','HS','MA','MB','MD','MDV','MH','MHO','MI', or ‘MPO' or when ME001, MC001 or PC001 = ‘60054M’ or '10155’. Tip: Medicare Advantage Plans

The match criteria in the table below is recommended to find the Medicare fee for service claims associated  with commercially based Arkansas Medicare Advantage plans.  NOTE:  It is important to exclude either the Medicare fee for service claim or the Medicare Advantage commercial claim to avoid duplication. Each claim type contains different information therefore an assessment of each is recommended.

Active

Active

Medicare Advantage

Medicare Fee for Service

Tip

Merging Criteria

Description

Notes:

APCD.PHM.PC026_Drug_Code = MCR.PartD.PROD_SRVC_ID

Drug Code Match

and APCD.PHM.PC027_Drug_name = MCR.PartD.BN

Drug Name Match

and APCD.PHM.PC032_Fill_Date = MCR.PartD.SRVC_DT

Fill Date Match

and APCD.PHM.PC043_PRESCR_ID = MCR.PartD.RX_SRVC_RFRNC_NUM_VARCHAR

Script Number Match

value formatting required to eliminate leading zeros

and APCD.PHM.PC033_Qty_Disp = MCR.PartD.QTY_DSPNSD_NUM

Quantity Dispensed Match

and APCD.PHM.PC034_Days_Supply = MCR.PartD.DAYS_SUPLY_NUM

Days Supply Match

and PC043_PRESCR_ID = MCR.PartD.PRSCRBR_ID

Prescriber ID Match

and APCD.PHM.STUDY_ID = MCR.PartD.STUDY_ID

Study ID Match

Study IDs must be retrieved from Member/Beneficiary data

and APCD.PHM.PC036_PD_AMT = (MCR.PartD.LICS_AMT+CVRD_D_PLAN_PD_AMT)-MCR.PartD.NCVRD_PLAN_PD_AMT)

Paid Amount Match

Calculation required