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 should be reported in the Eligibility and deductibles next file. See below. applied. 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. If claims are processed by a In instances more than CHIA’s objective is to third-party administrator, one entity administers a create a comprehensive who is responsible for health plan, the health care database that must include submitting the data and how carrier and third-party data from all health care should the data be administrators are carriers and all their submitted? responsible for submitting vendors (TPAs, PBMs, data according to the DBAs, CSOs, etc.) to specifications and format complete the view of the defined in the Submission health service delivery Guides. CHIA expects each system. party to report the Organization ID of the other party in the Delegated Benefit Organization ID (PC072) field to assist in linkage between the health care carrier and the third party administrator. Types of Data collected in the Pharmacy Claim File Submitter-assigned Identifiers CHIA requires various Submitter-assigned identifiers for matching-logic to the other files, Product and Member Eligibility. Some examples of these elements include PC003, PC006, PC107 and PC108. These elements will be used by CHIA to aid with the
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 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. If claims are processed by a third-party administrator, who is responsible for submitting the data and how should the data be submitted? In instances more than one entity administers a health plan, the health care carrier and third-party administrators are responsible for submitting data according to the specifications and format defined in the Submission Guides. CHIA expects each party to report the Organization ID of the other party in the Delegated Benefit Organization ID (PC072) field to assist in linkage between the health care carrier and the third party administrator. CHIA’s objective is to create a comprehensive database that must include data from all health care carriers and all their vendors (TPAs, PBMs, DBAs, CSOs, etc.) to complete the view of the health service delivery system. Types of Data collected in the Pharmacy Claim File Submitter-assigned Identifiers CHIA requires various Submitter-assigned identifiers for matching-logic to the other files, Product and Member Eligibility. Some examples of these elements include PC003, PC006, PC107 and PC108. These elements will be used by CHIA to aid with the
v5-apcd-pharmacy-claim-file-submission-guide-FINAL.docx