Details
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Change Request
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Resolution: Unresolved
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Medium
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US CARIN Real-time Pharmacy Benefit Check (RTPBC) (FHIR)
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1.0.0
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Pharmacy
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IG Home Page
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Clarification
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1.0.0
Description
NCPDP added a dedicated section to pricing guidance in the RTPB Standard Version 11 (published in January 2021) Implementation Guide.
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Business Need/Purpose:
Pricing guidance was added to RTPB Standard Implementation Guide based on the following two recommendations:
- Add pricing guidance about pricing fields being an estimate.
- Look at patient pay component fields that leverage accumulator fields as part of the calculation.
- Each RTPB transaction submitted will use the current plan benefit accumulator fields, to calculate the patient pay components with the sum of the components returned in the Estimated Patient Financial Responsibility field. This will be at transaction level and not a plan benefit level.
- If the prescriber is submitting 5 RTPB requests, where at a claim level the 3^rd^ RX would buy down the deductible, this would not be reflected in the patient pay field in the RTPB response.
- Information about patient pay components and estimated patient financial responsibility, including an example with a patient pay component for an accumulator was added to pricing guidance.
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Pricing guidance from RTPB Standard Implementation Guide:
Each RTPB transaction (request and response) reflects a moment in time and is designed to provide an estimate of the patient’s out of pocket costs. A patient’s actual out of pocket cost may vary depending on the timing between the RTPB request(s) and the corresponding NCPDP claim billing request/response transactions, as well as the order of the claim billing transactions when multiple prescriptions occur.
The total estimated patient’s out of pocket cost is reflected in the ESTIMATED PATIENT FINANCIAL RESPONSIBILITY (F17-YE) field. This field is a summation of the different patient responsibility components that may apply based on the benefit structure (e.g.: copay, co-insurance, deductible, brand drug, non-formulary brand drug, health savings account, etc.). The following patient responsibility pricing field guidance associated to NCPDP Telecommunication claim billing responses should also apply to RTPB responses.
- ESTIMATED PATIENT FINANCIAL RESPONSIBILITY (F17-YE) is Required
- Zero is a valid value
- Value cannot be negative
- Patient Pay Component Count (C94-KP), Patient Pay Component Qualifier (C95-KQ) are Required
- Patient Pay Component Amount (C93-KN) is Required
- Zero is a valid value
- Negative values may be associated to Specific Patient Pay Component Qualifiers (C95-KQ) (e.g., Health Plan Savings Amount).
- The sum of the Patient Pay Component Amounts (C95-KQ) must equal the Estimated Patient Financial Responsibility (F17-YE)
- All Patient Pay Component amounts, applicable to the patient’s benefit for this claim, that impact the Estimated Patient Financial Responsibility (F17-YE) must be returned, even when the impacted Patient Pay Component Amount or Patient Pay Amount is $0.
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Example 1: Plan Benefit Patient Liability = $0 Copay, No HSA, No Deductible
F17-YE ESTIMATED PATIENT FINANCIAL RESPONSIBILITY: $0.00
C94-KP PATIENT PAY COMPONENT AMOUNT COUNT: 1
C95-KQ PATIENT PAY COMPONENT QUALIFIER (AMOUNT OF COPAY): 05
C93-KN PATIENT PAY COMPONENT AMOUNT: $0.00
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Example 2: Plan Benefit Patient Liability = 0% Co-Insurance for Generics
F17-YE ESTIMATED PATIENT FINANCIAL RESPONSIBILITY: $0.00
C94-KP PATIENT PAY COMPONENT AMOUNT COUNT: 1
C95-KQ PATIENT PAY COMPONENT QUALIFIER (AMOUNT OF CO-INSURANCE): 07
C93-KN PATIENT PAY COMPONENT AMOUNT: $0.00
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Example 3: Plan Benefit Patient Liability = 100% co-insurance until $1,000 plan deductible is met, HSA funds apply
F17-YE ESTIMATED PATIENT FINANCIAL RESPONSIBILITY: $0.00
C94-KP PATIENT PAY COMPONENT AMOUNT COUNT: 2
C95-KQ PATIENT PAY COMPONENT QUALIFIER (AMOUNT APPLIED TO PERIODIC DEDUCTIBLE) 01
C93-KN PATIENT PAY COMPONENT AMOUNT $110.00
C95-KQ PATIENT PAY COMPONENT QUALIFIER (HEALTH PLAN-FUNDED ASSISTANCE AMOUNT) 09
C93-KN PATIENT PAY COMPONENT AMOUNT -$110.00