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May 2014 Manufacturer Webinar

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Presentation on theme: "May 2014 Manufacturer Webinar"— Presentation transcript:

1 May 2014 Manufacturer Webinar
Angela Stanley, CMS, Division of Payment Reconciliation

2 Agenda CGDP Data Overview CGDP Appeals Website and Portal Improvements
An EFT Reminder Live Q&A

3 CGDP Data Overview Amanda Johnson,
Director, Division of Payment Reconciliation

4 Discount Eligible Beneficiary Distribution

5 Discount Eligible Beneficiaries in Defined Standard Plans

6 Discount Eligible Beneficiaries in Enhanced Alternative Plans

7 Discount Eligible Beneficiaries in Employer Group Waiver Plans

8 Quarter Beneficiaries Enter the Gap

9 Discount Eligible Beneficiaries by Benefit Phase, Program-wide

10 2013 Ending Benefit Phase for EGWP Discount Eligible Beneficiaries

11 2013 Ending Benefit Phase for EA Discount Eligible Beneficiaries

12 2013 Ending Benefit Phase for All Other Plan Types Discount Eligible Beneficiaries

13 Average Gap Discount Amount per Beneficiary
2011 $ 2012 $ 2013 $

14 Coverage Gap Discount Program (CGDP) Appeals Independent Review Entity (IRE) for the Centers for Medicare and Medicaid Services (CMS)

15 Independent Review Entity for CGDP
Review appeals of denied disputes

16 CGDP Appeals Affirm the appeal Deny the appeal (disagree with denial)

17 File TPA Dispute Correctly

18 Know the Guidance Not calculated correctly
Not calculated with accurate data Explain why determination is incorrect

19 Reason Codes Duplicate Invoice Item Closed Pharmacy
Not a Covered Part D Drug

20 Reason Codes Aberrant Quantity High Price of the Drug
Last Lot Expiration

21 Reason Codes Marketing Category Excessive Gap Discount Not NDA Not BLA
Single Cumulative

22 Excessive Gap Discount Single Claim
2013 – TrOOP is $4,750 and the plan covers 2.5% of negotiated drug costs [($4,750÷0.975) X 0.50] 2014 – TrOOP is $4,550 2013 – Maximum discount $2,435.90 2014 – Maximum discount $2,307

23 Excessive Gap Discount Cumulative Claims
Depends on secondary payers and their TrOOP status maximum discount for multiple claims is $4,871 decreases to $4,667

24 Appeals Received

25 Appeals by Reason Codes

26 Appeal Outcomes

27 DRN Outcomes

28 Affirmed Examples Part D Sponsor stated the PDEs would be adjusted
Incorrect calculation Incorrect NDC Incorrect quantity Incorrect data submitted Exceeded maximum discount Not Part D Covered Drug

29 Denied Examples Supporting evidence absent Prior Authorization present
Non covered drugs Excessive gap discount Inappropriate doses Excessive cost Prior Authorization present

30 Conclusion File your dispute correctly File your appeal timely
Respond to communications received from the IRE

31 CGDPAppeals@ provider-resources.com

32 Website and Portal Improvements
Art Spaziano, Manager Palmetto GBA Medicare Part D, CGDP TPA

33 Website and Portal Improvements
TPAdministrator.com FAQ ListServ Announcement History Manufacturer’s Portal Payment Confirmation Support for negative amounts Detail reports Confirmation responses Sponsor Mailboxes Web based payment confirmation

34 TPAdministrator.com FAQ

35 TPAdministrator.com FAQ

36 TPAdministrator.com ListServ Announcement History

37 Manufacturer’s Portal Bi-directional Pymt Confirmation

38 Manufacturer’s Portal Detail Reports

39 Manufacturer’s Portal Confirmation Responses

40 EFT Reminder Art Spaziano, Manager Palmetto GBA
Medicare Part D, CGDP TPA

41 EFT Information for Manufacturers and Sponsors
It’s the only way you can receive what you’re owed No Dependency on APPS system Opportunity to update each quarter No update needed if there are no changes Reminders will be sent prior to each update deadline Full set of EFT records redistributed each quarter Important for Manufacturers & Sponsors to download their respective files each quarter Granular description of changes issued with each update EFT info for some DMs still missing!

42 Contact Information Art Spaziano, Manager Palmetto GBA Medicare Part D, CGDP TPA

43 Contacting the TPA TPA website - http://tpadministrator.com Phone
Help Line: – Option 1 Hours: Monday thru Friday 8am to 7pm ET General inquiries regarding the invoicing and payment process should be sent to Webinar slides will be posted to the TPA website Suggestions for future webinar topics should be sent to Questions related to dispute files, EFT information, invoice corrections – Website - Dispute support documentation

44 Resources Medicare Drug Benefit Group
Questions related to the Manufacturers Agreement, changes of ownership, terminations, compliance / administrative-related issues, policy address is Discount Program Manufacturer’s Page HPMS Website Updating CMS contact and labeler code changes - Website - Password Resets - Non-password access assistance Independent Review Entity (IRE) for Discount Program appeals. - Website

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