Final Automated TBT Guidance_dis

Final Automated TBT Guidance_dis.pdf

Coordination of Benefits between Part D Plans and Other Prescription Coverage Providers

Final Automated TBT Guidance_dis

OMB: 0938-0978

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 0938-0978 can be found here:

Document [pdf]

Download: pdf | pdf

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it
displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0978. The time
required to complete this information collection is estimated to average
1 hour per response, including the time to review instructions, search existing data resources, gather the data needed, and complete
and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.

Part D Sponsor Implementation Guidance—
Automated TrOOP Balance Transfer

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0978. The time
required to complete this information collection is estimated to average
1 hour per response, including the time to review instructions, search existing data resources, gather the data needed, and complete
and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for
improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05,
Baltimore, Maryland 21244-1850.

Part D Plan Sponsor Guidance on the Financial Information Reporting (FIR)
Transactions for Transferring True Out-of-Pocket Balances

Table of Contents
Background on TrOOP Balance Transfers ......................................................................... 3
Implementation Timing and Issues..................................................................................... 3
Pre-Implementation Testing and Certification ............................................................... 3
Plan Enrollment Types........................................................................................................ 4
Procedures for TrOOP Balance Transfer using FIR Transactions...................................... 6
Role of the TrOOP Facilitator ........................................................................................ 6
Inclusion of non-plans of record ................................................................................. 6
Evaluation of transaction responses............................................................................ 7
Part D Sponsors’ Requirements...................................................................................... 7
Multiple enrollments within a contract ....................................................................... 9
Multiple Enrollment Types ....................................................................................... 12
Receipt of Inquiry when a prior plan is known......................................................... 13
Sponsor requested FIR transactions.......................................................................... 15
Correction of unacceptable responses....................................................................... 15
FIR transaction rejects .............................................................................................. 15
Timing of the FIR Inquiry and Update Transactions.................................................... 16
FIR Transaction Response Time................................................................................... 16
Exceptions from Automated Processing....................................................................... 16
Scenarios ........................................................................................................................... 18

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

Background on TrOOP Balance Transfers
Part D rules require sponsors to track the beneficiary’s true out-of-pocket (TrOOP) costs
and gross covered drug spending and correctly apply these costs to the TrOOP and
benefit limits in order to correctly place the beneficiary in the benefit and provide the
catastrophic level of coverage at the appropriate time. The TrOOP threshold and gross
covered drug spending are calculated on an annual basis and must be transferred between
Part D plans if a beneficiary disenrolls and re-enrolls at any time before the end of the
coverage year.
The TrOOP-related data must also be transferred between Part D plans in those
circumstances in which a Part D plan other than the plan of record paid for covered Part
D drug costs as a primary payer and subsequently becomes aware; for example, through a
CMS enrollment reconciliation process, that the beneficiary is enrolled in another Part D
plan.
Currently, CMS requires the use of a manual process to transfer the TrOOP-related data
between plans; however, the National Council for Prescription Drug Programs (NCPDP)
has approved a Financial Information Reporting (FIR) transaction standard that will
support the automated plan-to-plan transfer of these data. The “TrOOP facilitation
process,” established by CMS to capture TrOOP-relevant data from Part D sponsors online and send these data to the appropriate Part D Plan for TrOOP calculation, will use
the FIR to electronically transfer the TrOOP-related data between plans.

Implementation Timing and Issues
Part D plan sponsors must be prepared to initiate systems testing in the new transactions
by September 1, 2008, complete systems certification by November 1, 2008 and be fully
prepared to respond to transactions for 2009 enrollees on January 1, 2009. Previously,
CMS had announced a July 1, 2008 implementation. However, this new implementation
timeline will obviate the need for a mid-year conversion from the current manual TrOOP
data transfer process to the automated FIR process and the development of associated
coding unique to the implementation year. With the January 1, 2009 implementation of
the new FIR transactions to electronically transfer TrOOP and gross covered drug costs,
further routine need for the manual data transfer process will be eliminated.

Pre-Implementation Testing and Certification

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

The TrOOP Facilitator in collaboration with CMS, NCPDP and industry representatives
will be developing a set of testing scenarios and a FIR testing certification process.
Guidance describing this process will be released when available. Part D sponsors must
ensure that their pharmacy benefit managers (PBM) or other processors are certified by
November 1, 2008. Therefore, we need Part D sponsors to require their PBM/processor
to cooperate fully with and respond timely to all contacts from the TrOOP Facilitator, to
participate in the testing process and achieve certification.
We remind sponsors that under the regulations at 42 CFR 423.464, Part D sponsors are
required to coordinate benefits with other Part D plans to transfer TrOOP and gross
covered drug costs when a beneficiary changes enrollment during the coverage year to
enable the new plan of record to properly position the beneficiary in the benefit.
According to this regulation, sponsors must also comply with CMS established processes
to ensure coordination between plans. If the procedures and timelines outlined in the FIR
testing and certification guidance are not adhered to by Part D sponsors and any
applicable plan contractors, we have the authority to consider the sponsor out of
compliance with the Part D requirements and to take appropriate action.
We believe the extended timeframe for implementation of the automated TrOOP balance
transfer process will allow adequate time for all sponsors to program and test. However,
if any sponsors are not prepared to respond to the FIR transactions at the time of
implementation, the other Part D sponsors will be required to operate dual systems for
TrOOP balance transfer data, responding to electronic transactions and transferring data
received manually from non-compliant sponsors to systems for electronic retrieval.

Plan Enrollment Types
For purposes of the automated TrOOP balance transfer process,
1. A “plan of record” - is a Part D sponsor with a valid, effective enrollment in the
CMS system for a Medicare beneficiary for whom the sponsor receives final
monthly payment. A sponsor may be the beneficiary’s initial plan of record for
the coverage year, a subsequent plan of record with a closed period of enrollment,
and/or the current plan of record.
2. A “non-plan of record” is a Part D sponsor that paid covered Part D drug claims
for a Medicare beneficiary for whom the sponsor did not have a valid and
effective enrollment in the CMS system and for whom the sponsor did not receive
final monthly payment. This may occur in situations in which the sponsor
submitted an enrollment transaction that was processed, but then audited off due
to CMS’ receipt of a subsequent valid enrollment transaction for the same
effective date, or if the sponsor’s enrollment transaction was not accepted by
v1

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

CMS and, therefore, is not in the CMS system. There might be multiple nonplans of record for a beneficiary during a coverage year, even for the same month.

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

Procedures for TrOOP Balance Transfer using FIR
Transactions
Role of the TrOOP Facilitator
Using the information the CMS TrOOP Faciliation Contractor receives nightly from the
CMS Medicare Beneficiary Database (MBD), the Facilitator will identify when a change
in enrollment at the contract-level has occurred and will generate a FIR transaction to
each prior sponsor with which the beneficiary was enrolled or which paid covered part D
drug claims for the beneficiary during the coverage year. Transactions will begin with a
FIR Inquiry to the earliest sponsor on record in the coverage year; that sponsor's Inquiry
response will be returned to the Facilitator. Each sponsor will respond with their monthly
gross covered drug costs and TrOOP amounts. If there are multiple plans prior to the
current plan of record, the accumulator values from the response just received are placed
in a FIR Exchange transaction and forwarded to the next sponsor. The Facilitator will
receive that next sponsor’s transaction response and will continue the process of
receiving and forwarding the prior accumulators until each subsequent sponsor in
consecutive order has received and responded to a FIR Exchange transaction. The final
Exchange transaction response will contain the year-to-date monthly TrOOP-related data
for all plans prior to the current plan of record; these accumulated monthly amounts will
then be forwarded by the Facilitator via a FIR Update transaction to the current plan of
record. The FIR transaction process flows, involving a single prior plan and multiple
prior plans, are detailed in section 4 of the NCPDP Financial Information Reporting
Standard Implementation Guide v1.0.

Inclusion of non-plans of record
As noted previously, TrOOP-related data must also be transferred between Part D plans
when a Part D plan other than the plan of record (i.e., a non-plan of record) paid for
covered Part D drug costs as a primary payer and subsequently becomes aware that the
beneficiary is enrolled in another Part D plan. This may occur if this other plan’s
enrollment was processed and then audited off due to CMS’ receipt of a subsequent valid
enrollment transaction for the same effective date, or if the enrollment in this other plan
was not accepted by CMS and, therefore, is not in the CMS system. Most audited
enrollments will be identifiable by the Facilitator, unless more than one record was
audited off on the same day; in this case, only the latest audited record will be reflected
on the TrOOP file.

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

In situations in which the Facilitator is unable to identify the existence of a non-plan of
record, in order for the TrOOP data to be transferred, the non-plan of record sponsor must
contact the Facilitator and request inclusion in the FIR reporting. To include these nonplan-of-record sponsors in the FIR process, the Facilitator must create a “proxy”
enrollment record identifying the sponsor, rather than CMS, as the source of the
information, the contact person providing the information and the date of contact. The
Facilitator will include the non-plan of record in the FIR transaction stream preceding the
actual plan of record for the month(s) the non-plan of record paid Part D claims.

Evaluation of transaction responses
CMS will work with the Facilitator to define a set of business rules for evaluating the
acceptability of sponsor FIR responses; these will be limited to edits to verify that there
are no missing/invalid data elements in the response that are required by the Facilitator to
generate the next FIR transaction in the stream. If any of these business rules are
violated, the Facilitator will suspend the transaction flow and contact the sponsor to
correct their transaction response. After the sponsor has completed correction, the
Facilitator will re-initiate the FIR transaction stream.

Part D Sponsors’ Requirements
Part D sponsors must track TrOOP-related data for their months of coverage for
beneficiaries who disenroll during the coverage year and report these data, even if the
accumulator values are zeros, to the Facilitator in response to FIR transaction requests.
Sponsors must also receive FIR transactions reporting TrOOP-related data reported by
prior plan sponsors through the Facilitator, update their systems to incorporate these data,
examine their claims history and any previously reported amounts from prior plan
sponsors to determine the impact of any changes in reported data on the beneficiary’s
position in the benefit and re-calculate, as necessary, any prior claims affected by
changes in the TrOOP accumulators.
A change at the contract level will trigger the FIR transaction process. If the beneficiary
changes plan benefit packages (PBPs) within a contract, the sponsor is responsible for
ensuring that the TrOOP balance and gross covered drug costs for all months of the first
PBP’s coverage are available to the subsequent PBP regardless of whether the PBPs
within the contract use the same or different processors.
Further, some sponsors use different contractors for eligibility/enrollment functions and
claims processing. It is the sponsor’s responsibility to ensure that the contractor
v1

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

responsible for TrOOP balance transfer has all eligibility and enrollment information to
properly administer the TrOOP balance transfer process consistent with this guidance and
the NCPDP Financial Information Reporting Standard Implementation Guide. This
would include having information to identify the beneficiary (e.g., the CMS date of birth)
and his or her eligibility and enrollment periods consistent with CMS requirements.

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

Multiple enrollments within a contract
When a beneficiary has multiple enrollments within a contract prior to a contract-level
enrollment change, the determination of which FIR transaction(s) is (are) sent and what
data are reported back on the transactions is dependent upon whether the BIN/PCN for
the multiple enrollments within the contract are the same or different. If there is a single
BIN/PCN for the multiple enrollments, the Facilitator will send a single transaction to the
processor and the processor will report all months of coverage for the multiple
enrollments. If there are different BIN/PCNs for the multiple enrollments within the
contract, the Facilitator will send separate transactions to each different BIN/PCN
combination and each processor will report for their months of coverage for that specific
BIN/PCN only.
The following scenarios describe the FIR reporting requirements in situations in which a
beneficiary has multiple plan enrollments within a contract during the coverage year,
involving the same and different BIN/PCN combinations.
Scenario 1
Beneficiary Enrollment History
Months of Contract/PBP
Plan
Coverage
Number
Jan. – Mar. S0001-001
A

BIN/PCN
611220/
1234567890

Apr.- May

S0001-002

611220/
1234567890

Effective
June

S0002-001

121212/
23232323bb

FIR
Processor
Transaction Response
FIR Inquiry Reports Jan.
– May data

FIR Update

When the Facilitator identifies the contract-level enrollment change to Plan C, a FIR
Inquiry transaction will be sent to the BIN/PCN for Contract S0001. Since the BIN/PCN
combination is the same for both contract S0001 PBPs, the processor will respond with
the January through May accumulators, reporting all months of enrollment in Plans A and
B. The monthly accumulators for January through May will be forwarded by the
facilitator to the Plan C sponsor in a FIR Update transaction.

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

Scenario 2
Beneficiary Enrollment History
Months of Contract/PBP
Plan
Coverage
Number
Jan. – Mar. S0001-001
A

BIN/PCN
611220/
1234567890

FIR
Processor
Transaction Response
FIR Inquiry Reports Jan.
– Mar. &
June – Aug.
data

Apr.- May

S0002-001

121212/
23232323bb

FIR
Exchange

June – Aug.

S0001-001

611220/
1234567890

FIR
Exchange

Effective
Sept.

S0003-001

999991/
1552bbbbbb

FIR Update

Reports
Apr. – May
data
Reports
Jan.- Mar
data & any
changes to
June - Aug.
data
resulting
from Apr.May data

When the Facilitator identifies the contract-level enrollment change to Plan D, a FIR
Inquiry transaction will be sent to the BIN/PCN for Contract S0001. Since the BIN/PCN
is the same for both Plans A and C, the processor will respond with the January through
March and June through August accumulators, reporting all months of enrollment in
Plans A and C. The Plan B sponsor will then receive a FIR Exchange transaction and
must respond by adding the April through May accumulators. Next, although Plan C has
already reported the June through August accumulators, the processor will receive a FIR
Exchange transaction from the Facilitator to provide Plan B data from April to May. Plan
C will then be required to make any necessary adjustments resulting from reprocessing
based on their receipt and review of the April through May data from Plan B. The
adjusted amounts may be reported in the current or next/later response to the Facilitator.
The accumulators for all months January through August will be forwarded by the
Facilitator to the Plan D sponsor in a FIR Update transaction.

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

Scenario 3
Beneficiary Enrollment History
Months of Contract/PBP
Plan
Coverage
Number
Jan. – Mar.
S0001-001
A

BIN/PCN
611220/
1234567890

FIR
Transaction
FIR Inquiry

Processor
Response
Reports Jan.
– Mar. data

Apr.- May

S0002-001

121212/
23232323bb

FIR
Exchange

Reports Apr.
– May data

June – Aug.

S0002-002

166666/
FIR
88Abbbbbbb Exchange

Reports June
– Aug. data

Effective
Sept.

S0003-001

999991/
1552bbbbbb

FIR Update

When the Facilitator identifies the contract-level enrollment change to Plan D, a FIR
Inquiry transaction will be sent to the BIN/PCN for Contract S0001. The processor will
respond with the January through March accumulators. Although Plan B and C are
within the same contract, the PBPs have different BIN/PCNs. Therefore, the Facilitator
will send a FIR Exchange transaction to the Plan B BIN/PCN and the processor will
respond by providing the April through May accumulators. A subsequent FIR Exchange
transaction will be sent to the Plan C BIN/PCN for that processor to report the data for
the months of Plan C enrollment; this is the June through August accumulator data. The
accumulators for all months January through August will be forwarded to the Plan D
sponsor in a FIR Update transaction.
While these scenarios do not depict every possible situation involving multiple plan
enrollments within a contract, they are illustrative of the application of the NCPDP FIR
transaction flow to these situations and the potential need for sponsors to respond to
sequential FIR transaction requests.
At any time a plan sponsor has paid Part D drug claims for a beneficiary who is later
determined to be enrolled in another plan and the sponsor has not received a FIR
transaction to report the beneficiary’s TrOOP-related data, the sponsor must contact the
TrOOP Facilitator to initiate the FIR process and include the additional sponsor in the
transaction stream.

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

Multiple Enrollment Types
Regardless of whether a sponsor is a plan of record or a non-plan of record, the sponsor
must receive FIR transactions with TrOOP-related data reported by prior plans (both
prior plans of record and non-plans of record), update their systems to incorporate these
data, examine their claims history and previously reported amounts from the prior plans
to determine the impact of these data on the beneficiary’s position in the benefit, and
recalculate, as necessary, any prior claims affected by the new TrOOP accumulator data.
The recalculation of prior claims by both non-plans of record and plans of record based
on the receipt new TrOOP-related data reported to them is necessary to ensure that
beneficiary adjustments resulting from the recalcuation are appropriately handled by the
sponsor that adjudicated the affected claim(s).
In addition, for any month in which a plan other than the actual plan of record for the
month (whether a prior plan of record or non-plan of record) has paid claims, the other
plan will precede the actual plan of record for the month in the FIR transaction stream.
The other plan’s accumulator data also will precede the actual plan of record’s claims
data for that month.
The following scenario describes FIR reporting in situations involving multiple
enrollment types.
Beneficiary Enrollment History
Months of Contract/PBP Plan
Coverage
Number
Jan. – Feb., S0001-001
A
but paid
(plan of
claims for
record)
Mar.
Mar. - June S0002-001
B
(plan of
record)

BIN/PCN
611220/
1234567890

FIR
Processor
Transaction Response
FIR Inquiry Reports Jan. –
Mar. data

121212/
23232323bb

FIR
Exchange

July – Aug.

S0003-001

C
(non-plan
of record)

999991/
1552bbbbbb

Effective
July

S0004-001

D
(plan of
record)

166666/
FIR Update
88Abbbbbbb

Reports
Mar.(including
Plan A data) –
June data
Reports July –
Aug. data

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

In August, the Facilitator identifies a contract-level enrollment change involving the
auditing off of the Plan C enrollment and the new enrollment in Plan D effective July. A
FIR Inquiry will be sent to the BIN/PCN for Contract S0001. The processor will respond
with the accumulator data for their months of enrollment, January and February. In
addition, because the Plan A paid claims in early March prior to receiving the TRR from
CMS reporting the beneficiary’s change in enrollment, the processor will include their
accumulator data for March as well.
The Facilitator will send a FIR Exchange transaction to the BIN/PNC for Contract S0002.
The processor will incorporate the Plan A data into their system, including applying the
March data from Plan A prior to the Plan B claims for March. After examining the
amounts previously reported and their own claims history and recalculating any prior
claims, as necessary, the sponsor will respond with their March through June
accumulators either as a response to that, or a future transaction, from the Facilitator.
A subsequent FIR Exchange will be sent to the BIN/PCN for the non-plan of record Plan
C. This sponsor will incorporate the Plan A and B data into their system. After
examining the amounts previously reported and their own claims history and
recalculating any prior claims, as necessary, the sponsor will respond with their July
through August accumulators either as a response to that, or a future transaction, from the
Facilitator.
The monthly accumulators for January through August will be forwarded to the Plan D
sponsor in a FIR Update transaction. With the retroactive enrollment of the beneficiary
in Plan D back to July, the Plan D sponsor must apply the July and August accumulators
reported by Plan C to each of those months prior to any claims Plan D adjudicated in July
and August.

Receipt of Inquiry when a prior plan is known
If a plan receives an Inquiry transaction from the Facilitator, but is aware there was a
prior plan, the plan should process the FIR Inquiry transaction. The identity of the prior
sponsor must be known and may be determined by the sponsor’s previous receipt of a
P2P Plan Payable Report (Report 43) from CMS requiring payment to another Part D
sponsor or the beneficiary’s presentation of a paper EOB from a prior Part D payer.
In the Inquiry response, the sponsor will report the financial accumulators for their
months of enrollment only and will retrospectively contact the Facilitator to identify the
v1

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

prior payer. The existence in the sponsor’s system of financial accumulators that were
not added as a result of a FIR transaction could be used in these instances to trigger an
alert that would identify the need for follow-up with the Facilitator.
If the Facilitator can verify the identified other sponsor had a terminated or
cancelled/audited enrollment for the beneficiary, that sponsor will be added, as
appropriate, to the FIR transaction process flow. Absent confirmation of a prior
enrollment transaction on the TrOOP file, the Facilitator will contact the other sponsor
and secure the information necessary to create a proxy enrollment record, add the sponsor
to the FIR process flow, and initiate a new round of transactions. Although this process
currently requires manual follow-up, CMS will work to develop an automated process to
handle these situations.

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

Sponsor requested FIR transactions
If a change in a beneficiary’s TrOOP-related data occurs outside the scheduled timing
cycle or is of such a magnitude that the sponsor believes it is important to transfer the
updated data without waiting for the next scheduled transaction, the sponsor should call
the TrOOP Facilitator’s help desk call center and request that a FIR transaction be
initiated. CMS will monitor the frequency of these requests and arrange for a secure
website to receive the requests if the volume warrants.

Correction of unacceptable responses
When the Facilitator suspends a FIR response transaction as unacceptable, for example, if
the accumulated TrOOP reported for a month is negative number, the sponsor must make
the necessary changes and, once made, the Facilitator will re-initiate the transaction
stream. Each sponsor must identify in the Health Plan Management System (HPMS) a
TrOOP Balance Transfer (TBT) Contact at the entity responsible for responding to the
sponsor’s FIR transactions. The Facilitator will contact this person to determine the
estimated timeframe for correction and resumption of the transaction flow.
In the interim, if the suspended transaction was part of the initial stream following a
contract-level change in enrollment, the Facilitator will continue the transaction flow with
the next payer. This will permit the new plan of record to receive all other accumulators
to position the beneficiary in the benefit. If the suspended transaction was part of a
subsequent flow, so accumulator data was reported previously to the new plan of record,
the Facilitator will not re-initiate the transaction flow until the problem is corrected and
the suspended transaction can be processed.
Sponsors should not routinely question balances reported on the FIR transactions,
including accumulated TrOOP reported in excess of the maximum. A sponsor may
initially report accumulated TrOOP amounts that exceed the maximum for the coverage
year, but must reduce reported TrOOP to the maximum in a subsequent transaction flow.
The resolution of an amount reported in excess of the TrOOP limit will require that the
sponsor examine claims-level data to determine which claims will require reprocessing.

FIR transaction rejects

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

Part D sponsors may reject FIR transactions for missing or invalid data; e.g., a
missing/invalid BIN number. However, under current CMS rules, X2 (Accumulated
Gross Covered Drug Cost exceeds maximum) will not be used.
The FIR transaction standard requires a patient date of birth, if known, in the patient
segment. If the date of birth is reported, the date reported in this field must match the
CMS date of birth to avoid rejects for a missing/invalid date of birth.

Timing of the FIR Inquiry and Update Transactions
For enrollment changes with prospective enrollment dates, the Inquiry transaction will be
sent 2 days prior to the new enrollment effective date. For enrollment changes with
retroactive effective dates, the Inquiry transaction will be sent the day following the day
the enrollment change is made in MBD and passed to the TrOOP Facilitator.
Subsequent Inquiry transactions will be sent weekly for a 4-week period, then monthly
for an additional 6 months or until March 31st of the following year, whichever is sooner.
This pattern of Inquiry transactions will be followed for each subsequent enrollment
change occurring during the coverage year. The series of transactions will always begin
with the beneficiary’s first plan for the coverage year; this plan may be the actual first
plan of record or another plan that paid claims believing the beneficiary was enrolled in
their plan.

FIR Transaction Response Time
The Facilitator will time out transactions without a response in 15 seconds. If a
transaction is timed-out, the Facilitator will retry the transaction every 15 minutes for 48
hours. If after the 48-hour period the plan never responds, the Facilitator will report the
occurrence to CMS for compliance action for sponsor failure to implement the FIR
transaction process as required. The Facilitator will also contact the sponsor’s TBT
Contact for an estimated timeframe for correction and, as indicated previously in the
discussion of the handling of unacceptable transaction responses, will continue the
transaction flow if it is the first one following an enrollment change or suspend the flow
pending correction if the transaction is part of a subsequent transaction stream.

Exceptions from Automated Processing

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

Part D sponsors should accept FIR data as reported unless a problem is identified.
Problems may be identified through conflicting information, such as paper EOBs
presented by, or on behalf of, the beneficiary, that suggests reported data are wrong.
Also, there will be rare situations in which a discrepancy exists between the CMS and
sponsor’s enrollment information for a beneficiary and the discrepancy affects the FIRreported data. These situations, or those in which the beneficiary complains that his/her
TrOOP accumulators are materially incorrect, must be removed from automated
processing. In these instances, the sponsor should contact the Facilitator’s help desk call
center to request the Facilitator suspend the FIR transactions until the discrepancy is
resolved or, if necessary, for the remainder of the coverage year. Once the error is
resolved, the Facilitator will remove the suspension and re-initiate the FIR process. A
manual process will be developed for the Facilitator and CMS to work with the sponsors
to resolve the discrepancy and to report any updates to the financial accumulators that
occur while the discrepancy is being resolved.

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

Scenarios
Scenario One: The beneficiary was enrolled in Plan A in January, 2008, in Plan B in
February, 2008 and in Plan C for the remainder of the year. Both Plan A and B had claim
activity as reflected below.
Month

January
February
March

Plan A
Accumulated
TrOOP
200.00

Accumulated
Gross Covered
Drug Cost
275.00

Plan B
Accumulated
TrOOP

50.00

Accumulated
Gross Covered
Drug Cost
200.00

New plan C
begins coverage

Plan C began adjudicating claims with the $475 drug spend and $250 TrOOP amounts
received from Plan B. In April, Plan A received a reversal on a $100 claim and in
response to the next FIR Inquiry reported the following updated information to Plan B.
Month

January

Plan A
Accumulated
TrOOP
150.00

Accumulated
Gross Covered
Drug Cost
175.00

Plan B compared the previous transaction from Plan A and determined that the drug
spend accumulator decreased by $100. Plan B administers the defined standard benefit.
The plan reviewed its claims history and determined that the $100 decrease moved Plan
B’s first $100 claim from the ICP back to the Deductible. Because Plan B needed to
recalculate this claim to change it from $75 plan pay, $25 patient pay to $100 patient pay,
the plan passed on the new Plan A accumulators and its existing February amounts to
Plan C. In order to “pay back the benefit” Plan B was responsible for recouping the $75
differential from the beneficiary. In response to the next FIR Exchange transaction
received, Plan B reported its updated amounts to Plan C as shown below.
Month

January
February

Plan A
Accumulated
TrOOP
150.00

Accumulated
Gross Covered
Drug Cost
175.00

Plan B
Accumulated
TrOOP

125.00

Accumulated
Gross Covered
Drug Cost
200.00

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

March

New plan C
begins coverage

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

Scenario Two: Same circumstances as described in Scenario One except Plan B
administers a Basic Alternative benefit with no deductible; for the first $2500 the plan
pays 75% and the beneficiary pays 25%. Plan B reviewed its claims history and
determined that the $100 decrease in Plan A gross covered drug cost had no claims
impact, because no claims were repositioned in different benefit phases. Plan B
forwarded to Plan C the updated Plan A amounts for January and the existing Plan B
accumulators for February.
Scenario Three: The beneficiary was enrolled in Plan A in January, 2008, in Plan B in
February, 2008 and in Plan C for the remainder of the year. Both Plan A and B had claim
activity as reflected below.
Month

January
February
March

Plan A
Accumulated
TrOOP
175.00

Accumulated
Gross Covered
Drug Cost
175.00

Plan B
Accumulated
TrOOP

125.00

Accumulated
Gross Covered
Drug Cost
200.00

New plan C
begins coverage

Plan C began adjudicating claims with the $375 drug spend and $300 TrOOP amounts
received from Plan B. In April, Plan A received documentation from the beneficiary
showing a $100 out-of-network prescription drug purchase. Plan A adjudicated the paper
claim and in response to the next FIR Inquiry reported the following updated information
to Plan B.
Month

January

Plan A
Accumulated
TrOOP
275.00

Accumulated
Gross Covered
Drug Cost
275.00

Plan B compared the previous transaction from Plan A and determined that the drug
spend accumulator increased by $100. The plan reviewed its claims history and
determined that the $100 increase moved Plan B’s first $100 claim from the Deductible
into the ICP. Because Plan B needed to recalculate this claim to change it from $100
patient pay to $75 plan pay, $25 patient pay, the plan responded to the next FIR
Exchange transaction by passing on to Plan C the updated Plan A amounts for January
and Plan B’s existing February amounts. Plan B was responsible for reimbursing $75 to
the beneficiary.

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

In response to the next FIR Exchange transaction received, Plan B forwarded its updated
TrOOP accumulator to Plan C.

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

Month

January
February
March

Plan A
Accumulated
TrOOP
275.00

Accumulated
Gross Covered
Drug Cost
275.00

Plan B
Accumulated
TrOOP

50.00

Accumulated
Gross Covered
Drug Cost
200.00

New plan C
begins coverage

Scenario Four: The beneficiary was enrolled in Plan A in January, 2008, in Plan B in
February, 2008 and in Plan C for the remainder of the year. Both Plan A and B had claim
activity as reflected below.
Month

January
February
March

Plan A
Accumulated
TrOOP
275.00

Accumulated
Gross Covered
Drug Cost
275.00

Plan B
Accumulated
TrOOP

50.00

Accumulated
Gross Covered
Drug Cost
200.00

Plan C begins

Plan C began adjudicating claims with the $475 drug spend accumulator it received from
Plan B. In April, Plan A received documentation from the beneficiary showing a $100
out-of-network prescription drug purchase. Plan A adjudicated the paper claim and in
response to the next FIR Inquiry reported the following updated information to Plan B.
Month

January

Plan A
Accumulated
TrOOP
300.00

Accumulated
Gross Covered
Drug Cost
375.00

Plan B compared the previously reported amounts from Plan A and determined that the
gross covered drug cost had increased. Plan B administers the defined standard benefit.
Based on a review of its claims history, Plan B determined that the $100 increase had no
claims impact, because no claims were repositioned in different benefit phases.
Therefore, Plan B responded to the FIR Exchange transaction by reporting the following
amounts to Plan C.

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

Month

January
February
March

Plan A
Accumulated
TrOOP
300.00

Accumulated
Gross Covered
Drug Cost
375.00

Plan B
Accumulated
TrOOP

50.00

Accumulated
Gross Covered
Drug Cost
200.00

New plan C
begins coverage

Scenario Five: The beneficiary was enrolled in Plan A in January and February, 2008
and in Plan B for March, 2008 and forward. Plan B administers the defined standard
benefit. Because Plan A had no claim activity, it reported zero accumulators to Plan B on
the initial Inquiry transaction and Plan B adjudicated a $100 claim in the Deductible on
March 1.
Later on March 1, Plan B received a FIR Update transaction reporting the following
amounts from Plan A.
Month

January
February

Plan A
Accumulated
TrOOP
200.00
100.00

Accumulated
Gross Covered
Drug Cost
225.00
250.00

Upon receipt of this transaction, Plan B reviewed its claims history and determined that
the $475 increase moved Plan B’s first $100 claim from the Deductible into the ICP. Plan
B recalculated this claim to change it from $100 patient pay to $75 plan pay, $25 patient
pay. Plan B was also responsible for reimbursing $75 to the beneficiary.

Scenario Six: The beneficiary initially enrolled in Plan A during the AEP in December
2007. On December 31, 2007, the beneficiary sends an application to Plan B for
enrollment effective January 2008. Both plans administer the defined standard benefit,

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

and both issue a member ID card to the beneficiary. In February, the beneficiary changed
enrollment to Plan C.
During the month of January, the beneficiary used the ID cards from both Plan A and B.
Prior to receiving the TRR reflecting the enrollment change, Plan A paid claims in
January totaling $100 all patient pay in the Deductible. Plan B then paid a $50 claim in
January, also all patient pay in the Deductible. Because the Plan A enrollment was
processed for January, the TrOOP Facilitator was able to identify the change of
enrollment to Plan B and sent a FIR Inquiry to Plan A.
Upon the subsequent enrollment change to Plan C, the Plan A and B amounts are
reported as follows:
Month

January

February

Plan A
Accumulated
TrOOP
100.00

Accumulated
Gross Covered
Drug Cost
100.00

Plan B
Accumulated
TrOOP

Accumulated Gross
Covered Drug Cost

50.00 Plan B

100.00 (Plan A) +
50.00 (Plan B) =
150.00(to new plan)

New plan C
begins
coverage

In March, one of Plan A’s paid claims from January was reversed by the pharmacy
decreasing the beneficiary’s gross covered drug cost and TrOOP amounts to $50. Plan A
reported the new accumulators to Plan B on the next FIR Inquiry transaction and
submitted a deletion PDE for the reversed claim.
Plan B reviewed its claims history and determined that the $50 decrease had no claims
impact, because no claims were repositioned in different benefit phases. Plan B sent the
updated amounts to Plan C as follows:
Month

January

February

Plan A
Accumulated
TrOOP
50.00

Accumulated
Gross Covered
Drug Cost
50.00

Plan B
Accumulated
TrOOP

Accumulated Gross
Covered Drug Cost

50.00 Plan B

50.00 (Plan A) +
50.00 (Plan B) =
100.00(to new plan)

Plan C begins

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

Scenario Seven: The beneficiary was in Plan A January-March 2008, in Plan B in April
and May 2008, and in Plan C for the remainder of the year. Both Plan A and B had claim
activity as reflected below.
Month

January
February
March
April
May
June

Plan A
Accumulated
TrOOP
150.00
125.00
31.25

Accumulated
Gross Covered
Drug Cost
150.00
125.00
125.00

Plan B
Accumulated
TrOOP

187.50
62.50

Accumulated
Gross Covered
Drug Cost

750.00
250.00

New plan C
begins coverage

Plan C began adjudicating claims with the $1400 in gross covered drug cost it received
from Plan B.
Plan A responded to the next FIR Inquiry transaction by reporting its existing
accumulators of $400 in gross covered drug costs and $306.25 in TrOOP to Plan B, but
Plan B was unable to respond before the Exchange transaction was timed out. The
TrOOP Facilitator retried Plan B as specified in their FIR protocol. Once Plan B
responded, a FIR Inquiry was again sent to Plan A, and on their Exchange transaction,
Plan B responded with their current balances. The TrOOP Facilitator then sent a FIR
Update transaction to Plan C reporting Plan A and B balances.

Scenario Eight: The beneficiary was in Plan A January-March 2008. During these
months, Plan A had claims activity. On March 12, the beneficiary elected enrollment in
Plan B for April, but subsequently, on March 29, elected enrollment for April in Plan C.
Because the Plan B enrollment was processed prior to the April cut-off, Plan B received a
TRR reporting the enrollment and issued a member ID card to the beneficiary. During
April, the Plan C enrollment was processed and Plan B enrollment was audited. The
beneficiary remained in Plan C through May and enrolled in Plan D effective June 2008.
With the TrOOP Facilitator’s identification of the Plan B enrollment, Plan A received an
FIR Inquiry transaction on March 31st and reported accumulators to Plan B.
Month

Plan A
Accumulated

Accumulated

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

TrOOP
January
February
March

100.00
175.00
31.25

Gross Covered
Drug Cost
100.00
175.00
125.00

Plan B began adjudicating claims in April with the $400 drug spend accumulator. The
Plan C enrollment was processed in April with a retroactive enrollment data of April 1.
Both Plan B and Plan C received TRRs reporting the Plan C enrollment, however prior to
receipt of this TRR, Plan B paid $100 in claims.
With the TrOOP Facilitator’s notification of the Plan C enrollment, Plan A again received
a FIR Inquiry transaction and reported their accumulators to Plan B. Plan B compared
this with the previous FIR transaction from Plan A, determined there had been no change,
and forwarded the following accumulators to Plan C.

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

Month

January
February
March
April

Plan A
Accumulated
TrOOP
100.00
175.00
31.25

Accumulated
Gross Covered
Drug Cost
100.00
175.00
125.00

Plan B
Accumulated
TrOOP

25.00

Accumulated
Gross Covered
Drug Cost

100.00

Plan C began adjudicating claims with the $500 drug spend accumulator it received from
Plan B, and had claims activity. With the TrOOP Facilitator’s identification of the Plan
D enrollment, Plan A again received a FIR Inquiry transaction and reported their
accumulators to Plan B. Plan B again compared this with the previously reported
amounts from Plan A, determined there had been no change, and forwarded the balances
to Plan C. Plan C compared this with the previous FIR Exchange transaction from Plan
B, determined there had been no change, and forwarded the balances to Plan D.
Month

January
February
March
April

May
June

Plan A
Accumulated
TrOOP

100.00
175.00
31.25

Accumulated
Gross
Covered
Drug Cost
100.00
175.00
125.00

Plan B
Accumulated
TrOOP

25.00

Accumulated
Gross
Covered
Drug Cost

100.00

Plan C
Accumulated
TrOOP

Accumulated
Gross Covered
Drug Cost

37.50 Plan C

150.00 Plan C

25.00 (Plan
B) +
37.50 (Plan
C) =
62.50(to new
plan)
125.00

100.00 (Plan B)
+
150.00 (Plan C)
=
250.00(to new
plan)
500.00

New Plan D

Plan D began adjudicating claims with the $1150 drug spend accumulator it received
from Plan C.

Scenario Nine: The beneficiary was enrolled in Plan A effective January 1, 2008 and the
plan had claims activity. On January 30, the beneficiary elected enrollment in Plan B
v1

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

effective February 1. Because the Plan B enrollment was processed after the February
cut-off, Plan A continued processing claims until mid-February when the Plan B
enrollment was processed and Plan A received a TRR reporting the audited enrollment.
On March 10, the beneficiary’s enrollment request for Plan C was processed with an
effective date of April 1.
In February, when the TrOOP Facilitator identified the Plan B enrollment, Plan A
received a FIR Inquiry transaction and reported the beneficiary’s accumulators to Plan B.
Month

January
February

Plan A
Accumulated
TrOOP
175.00
112.50

Accumulated
Gross Covered
Drug Cost
175.00
150.00

Plan B began adjudicating claims with the $325 drug spend accumulator. In March, the
pharmacy reversed a $75 February claim to Plan A changing the plan’s accumulators for
February. When the Plan C enrollment was processed in March, the TrOOP Facilitator
identified the enrollment change and sent a FIR Inquiry transaction to Plan A which
reported the following updated accumulators to Plan B.
Month

January
February

Plan A
Accumulated
TrOOP
175.00
75.00

Accumulated
Gross Covered
Drug Cost
175.00
75.00

Plan B reviewed its claims history and determined that the $75 decrease moved Plan B’s
first February claim from wholly in the ICP to straddling the Deductible and ICP.
Because Plan B needed to recalculate this claim, the plan reported to Plan C the updated
Plan A January accumulators, the combined Plan A and B February drug costs, and the
total of the updated Plan A February TrOOP amount with the previous Plan B February
TrOOP balance.
Month

January
February

Plan A
Accumulated
TrOOP
175.00
75.00

Accumulated
Gross Covered
Drug Cost
175.00
75.00

Plan B
Accumulated
TrOOP

Accumulated Gross
Covered Drug Cost

25.00 Plan B

100.00 Plan B

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

75.00 (Plan A) +
25.00 (Plan B) =
100.00(to new plan)

75.00 (Plan A) +
100.00 (Plan B) =
175.00(to new plan)

With the next FIR Inquiry transaction, Plan A reported unchanged accumulators for
January and February to Plan B. Plan B reported the accumulators as previously sent to
Plan C, except the plan was also able to send an updated TrOOP balance for February
reflecting the re-adjudication of the straddle claim.

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

Accumulated
TrOOP
January
February

175.00
75.00

Accumulated
Gross Covered
Drug Cost
175.00
75.00

Accumulated
TrOOP

Accumulated Gross
Covered Drug Cost

43.75 Plan B

100.00 Plan B

75.00 (Plan A) +
43.75 (Plan B) =
118.75`(to new
plan)

75.00 (Plan A) +
100.00 (Plan B) =
175.00(to new plan)

After re-adjudicating the first February claim that had previously been processed in the
ICP as $75 plan pay and $25 patient pay, Plan B was responsible for recovering the
additional amount owed by the beneficiary.

Scenario Ten: The beneficiary was in Plan A January-February 2008, then Plan B
during March through June. Both plans had claims activity during the months of the
beneficiary’s enrollment in their plan. Effective July, the beneficiary chooses to re-enroll
in Plan A.
With the TrOOP Facilitator’s identification of the Plan B enrollment, Plan A received a
FIR Inquiry transaction and reported accumulators to Plan B as follows:
Month

January
February

Plan A
Accumulated
TrOOP
75.00
75.00

Accumulated
Gross Covered
Drug Cost
75.00
75.00

Subsequent FIR Inquiry transactions were sent to Plan A according to the established
schedule and the accumulators reported to Plan B. Then, with the TrOOP Facilitator’s
identification in late June of prospective Plan A re-enrollment effective July 1st, Plan A
received a FIR Inquiry transaction and reported the accumulators to Plan B. Plan B
received and responded to a FIR Exchange transaction with the combined accumulators.
The following data were sent to Plan A in a FIR Update transaction and Plan A began to
adjudicate claims in July using $450 in gross covered drug costs.

2/5/2009

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it

Month

January
February
March
April
May
June
July

Plan A
Accumulated TrOOP
75.00
75.00

Accumulated Gross
Covered Drug Cost
75.00
75.00

Plan B
Accumulated
TrOOP

Accumulated Gross
Covered Drug Cost

25.00
100.00
14.25
25.00

25.00
100.00
75.00
100.00

Re-enrollment Plan A

Subsequently in early July, Plan A and B received TRRs indicating that the Plan A reenrollment was audited due to the beneficiary’s election to remain enrolled in Plan B.
However, because the Plan A re-enrollment was processed, Plan A paid claims in July
prior to receipt of the TRR. With the TrOOP Facilitator’s identification of the audited
Plan A re-enrollment and the continuation of Plan B enrollment, Plan A received a FIR
Inquiry transaction and reported their January, February and July accumulators to Plan B.
Month

January
February
March
April
May
June
July

Plan A
Accumulated TrOOP
75.00
75.00

23.75

Accumulated Gross
Covered Drug Cost
75.00
75.00

Plan B
Accumulated
TrOOP

Accumulated Gross
Covered Drug Cost

25.00
100.00
14.25
25.00

25.00
100.00
75.00
100.00

95.00

Plan B compared these data with the January and February accumulators previously
reported by Plan A to determine if there had been a change that would affect Plan B’s
adjudication of the claims processed during the period March through June. Plan B then
began processing claims in July with $545 in gross covered drug costs.

2/5/2009

File Type	application/pdf
File Title	The beneficiary was enrolled in Plan A in January, 2007, in Plan B in February, 2007 and in Plan C for the remainder of the year
Author	CMS
File Modified	2009-02-05
File Created	2009-02-05