Tip: Pharmacy Carrier Overlap
- Trang Riley (Unlicensed)
- Kenley Money
- Kathleen Hart (Unlicensed)
Number | 0027 |
|---|---|
Submitting Entities | All having PBM relationships or programs submitting duplicate claims |
Add Date | Jul 11, 2019 |
Update Date | Aug 17, 2022 Nov 13, 2024 |
Update |
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Description | Pharmacy claims can be received from both the submitting entity and its PBM. This gives the researcher the opportunity to examine the same prescription claims from both sources, providing some insight into the differences between the PBM and pharmacy information. Also, some carriers, e.g. Arkansas Medicaid, receive enrollment and claims data from related programs (HCIP, PASSE) that also submit data to the Arkansas APCD. NOTE: Arkansas Medicaid also uses a PBM. |
Action / Resolution | A suggested approach to identify claims duplicated by these relationships. Because it is not always known when a PBM has been engaged or if a carrier has related programs, this process will help target duplicate claims. Begin with the pharmacy claims for the selected study period. Using a member ID match (PC001+PC107 = ME001+ME107), append the Study_ID (ME998+ME013+ME014) from the enrollment data where the pharmacy claim fill date (PC032) falls between the enrollment dates (ME162A and ME163A). Create a subset containing the pharmacy claim submitting entity code (PC001), pharmacy claim member ID (PC107), pharmacy claim fill date (PC032), pharmacy claim NDC code (PC026), enrollment data Study_ID (ME998+ME013+ME014) and enrollment data Payer Type Category (ME001_CAT). Group on Study_ID and NDC code and evaluate records grouped where the pharmacy claim fill date (PC032) are the same and the pharmacy claim submitting entity code (PC001) and enrollment data Payer Type Category (ME001_CAT) are different. See the example below. PAYER Type groupings that should be examined for possible PBM or related program relationships: ME001_CAT = ‘PBM’,'EBD_PBM','MCRAdvPhrm','DNT','PASSE' Additional notes: Other data elements may be needed to strengthen the grouping. Failing to de-dup can negatively affect cost roll-ups.
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Category 1 | Merged SE & Overlap |
Category 2 | PBM |
Tip / Issue | Tip |
PC001 - Submitting Entity | Study_ID | PC107 - Member ID | PC026 - NDC Code | PC032 - Fill Date | ME001_CAT - Payer Type |
|---|---|---|---|---|---|
83470 | x18$gNMp=M1962-01-01 | 1234 | 00002015204 | 2023-06-01 | COM |
99CAR1 | x18$gNMp=M1962-01-01 | 837CAR | 00002015204 | 2023-06-01 | PBM |
99MCD1 | 028@h#x=F1961-01-01 | 69723 | 50090582400 | 2022-12-06 | MCD |
16244 | 028@h#x=F1961-01-01 | 98bz3tt | 50090582400 | 2022-12-06 | PASSE |