Issue: AETNA Pharmacy Versioning

0116

60054A, 60054M, 81973, 90328

Jul 14, 2022

May 24, 2023

Included in June 2023 data tip email.

AETNA identified a potential issue within the pharmacy claims for entities 60054A, 60054M, 81973, and 90328. Some pharmacy claims for these entities contain the same information but different claim numbers. Per AETNA, these are called intra-day reversals.  The claim comes in and is backed out the same day for various reasons.  Since pharmacy is point of sale, this may occur on the same day. 

To identify these claims, data users can group the data by PC001 (SE ID), PC006 (Policy Number), PC107 (Member ID), PC005 (Claim Line), PC017 (Paid Date), PC027 (Drug Name), PC032 (Fill Date), and PC058 (Script Number) and find groupings where there are multiple distinct counts of PC004. Sum the paid amount (PC036) on all records in the group. If the total = $0, do not use any of the records in the group. If the total > $0, select the record with the payment amount that aligns with the total paid. These scenarios should be reviewed prior to final selection.

Active

Resolved for entities 60054A, 60054M, 81973

Versioning

Data quality

Issue