Are denied claims to be No. Wholly denied Denied line items of an reported? prescription claims should adjudicated claim aid with not be reported at this time. utilization analysis. If for some reason a prescription has multiple claim lines and the claim pays but a line in that claim denies, all claim lines should be sent, similar to the denied claim line philosophy used in medical claims. Should previously paid but Yes. Claims that were paid The reporting of Zero Paid now Voided claims be and reported in one period Pharmacy Claims aids with reported? and voided by either the the analysis of services Provider or the Carrier utilized, Member Eligibility should be reported in the and deductibles applied. next file. See PC110 below. What types of claims are to The Pharmacy Claims file is CHIA has adopted the most be included? used to report any pharmacy widely used specification at claim sent to and paid by this time to allow for the Carrier/PBM. comprehensive analysis. The word is used Yes. Member and Patient Member is used in the claim ‘Member’ in the specification. Are are to be used in the same specification to strengthen and manner in this specification the reporting bond between ‘Member’ ‘Patient’ used synonymously? Member Eligibility and the pharmacy claims attached to a Member.
Are denied claims to be reported? No. Wholly denied prescription claims should not be reported at this time. If for some reason a prescription has multiple claim lines and the claim pays but a line in that claim denies, all claim lines should be sent, similar to the denied claim line philosophy used in medical claims. Denied line items of an adjudicated claim aid with utilization analysis. Should previously paid but now Voided claims be reported? Yes. Claims that were paid and reported in one period and voided by either the Provider or the Carrier should be reported in the next file. See PC110 below. The reporting of Zero Paid Pharmacy Claims aids with the analysis of services utilized, Member Eligibility and deductibles applied. What types of claims are to be included? The Pharmacy Claims file is used to report any pharmacy claim sent to and paid by the Carrier/PBM. CHIA has adopted the most widely used specification at this time to allow for comprehensive analysis. The word ‘Member’ is used in the specification. Are ‘Member’ and ‘Patient’ used synonymously? Yes. Member and Patient are to be used in the same manner in this specification Member is used in the claim specification to strengthen the reporting bond between Member Eligibility and the pharmacy claims attached to a Member.
v6-apcd-pharmacy-claim-file-submission-guide-FINAL.docx