Auditing
             Vender Management
             Reporting
             Clinical Services
  Medicare Specific Services

          Medicare Part D Reporting
          Data Validation
          Prescription Drug Event (PDE) Auditing
          & Reconciliation

          Retiree Drug Subsidy (RDS) Reporting
          Medicare Formulary Management
          Part D Application Support
          Patient Safety Reporting
          Coverage Gap Discount Reporting
          & Reconciliation

          Part C & Part D Data Validation
          Compliance Plan Review
          Part D Option Analysis
          Payment Reconciliation
          Acumen Reporting
Medicare Specific Services

Medicare Part D Reporting

IPC/EvergreenRx will review for reasonableness, accuracy, and submit to CMS (if contracted) by the applicable timeline as defined for each specific reporting element.

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Data Validation

CMS requires plans to use a third party auditor to confirm the data reported by all plans are reliable, valid, complete and comparable among sponsoring organizations. The audits focus on how data is collected, stored and reported.

The goals of the audit are to determine whether:

o “Adequate processes” are in place to assure accurate and valid data results
o The contractor has reported “accurate results” (i.e., determine data issues that may inhibit accurate reporting)

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Prescription Drug Event (PDE) Auditing & Reconciliation

IPC/EvergreenRx policy is to provide timely, legislatively compliant and accurate submissions of Prescription Drug Event (PDE) data to Centers for Medicare and Medicaid Services (CMS) for our Medicare Prescription Drug Plan (PDP) clients. PDE are submitted to CMS with the intent of providing a timely and accurate adjudication of claims for the PDP sponsor. This includes the receipt of properly formatted files created by the PBM, based on standards set by CMS, submission of claims via Gentran for CMS review and approval and dissemination and maintenance of responses and reports from CMS. If the PBM cannot create the submission file and not warranted in the PBM’s contract, IPC/EvergreenRx can create the aforementioned formatted file and submit to CMS, depending on the contractual agreement between IPC/EvergreenRx and the PDP sponsor.

IPC/EvergreenRx’s detailed PDE Reconciliation and Accuracy review includes:

o Verifying PDE data files are submitted as processed in the adjudication systems
o Validating CPP, NPP, GDCA, GDCB, LICS and Reported Gap Discount Amount
o Reviewing the PBM process for correcting and reprocessing failed PDE transmissions and rejected PDE records
o Verifying True Out-of-Pocket (TrOOP) and Total Drug Spend Accumulation calculations are in accordance with CMS guidelines.

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Retiree Drug Subsidy (RDS) Reporting  

IPC/EvergreenRx policy is to identify all paid Medicare Part D covered drug cost for members enrolled in the Medicare benefit and accurately calculate Retiree Drug Subsidy for submission to CMS. This policy will result in subsidy payment to the client.

IPC/EvergreenRx’s detailed RDE Reporting review includes:

o Comparison of claims to Medicare eligible members
o Identification of Part D covered NDCs
o Calculation of Gross Retiree Cost (GRC), Threshold Reduction (THR), Limit Reduction (LR), Gross Eligible (GE), Estimated Cost Adjustment (ECA), Available Retiree Cost (ARC), and Subsidy Paid (SP)

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Medicare Formulary Management

Provide various utilities to support the submission, review and approval of the formulary oversight for organizations including those offering Medicare Part D benefits. This process includes:

o Comparison of proposed formulary changes to the current formulary
o Changes in clinical protocols, Prior Authorizations, Step Therapies, etc.
o Drug Pipeline management and new drug coverage recommendations
o Advice on maximizing low cost (mostly generic) drug options within each covered therapeutic class

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Part D Application Support

Assist client with submission of CMS application to become a Part D plan sponsor and offer a Medicare Part D plan in accordance with the Medicare Prescription Drug Benefit Plan.

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Patient Safety Reporting

Compare available health and prescription drug plans to make informed Medication Therapy Management (MTM) enrollment decisions.

Download the clients CMS six patient safety measures quarterly to identify outliers and ensure proper actionable items are addressed at a caregiver’s level (Client, PBM, Physician or Member).

High Risk Medication (HRM)

Diabetes Treatment (DT)

Drug to Drug Interaction (DDI)

Diabetes Medication Dosage (DMD)

Adherence (ADH)

Antiretroviral HIV/AIDS Medications

IPC/EvergreenRx also identifies pharmacy claims with a day supply of less than 3 and a quantity greater than 29 for both Medicare and Non-Medicare members.

All outliers’ claims are identified and sent to the PBM for review/resolution.

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Coverage Gap Discount Reporting & Reconciliation

IPC /Evergreen Rx receives the Coverage Gap Discount data with the claims data files then compiles that information with the PDE and Coverage Gap Report at the end of each quarter. IPC /Evergreen Rx also creates a spreadsheet with each reconciliation for each client to use in recording the amounts they have received from each manufacturer during the reconciliation process. Once all payments for the quarter have been received, IPC/Evergreen Rx creates the submission file for each client to submit to CMS as proof the payments were received.

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Part C & Part D Data Validation  (DEF)

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Compliance Plan Review (DEF)

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Part D Option Analysis (Def)

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Payment Reconciliation (Def)

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Acumen Reporting (Def)

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