Attachment 99 – MPC Pharmacy Provider Letters, Email Templates, and Other Documents

Attachment 98

Medical Expenditure Panel Survey

Medical Provider Component

Pharmacy Provider

Letters, Email Templates and Other Documents

OMB#: 0935-0118

Date	«DATE»
To	«CONTACT_NAME»
Provider	«PROVIDER_NAME»
Fax	«FAX»
Toll-Free Project Phone Number	1-877-267-2877
Items Sent	Additional Data Requested
Total Pages (including cover sheet)	«TOTAL_PAGES»

Special Comment

Recently, we spoke about prescription services your pharmacy provided to specific patients, and charges and payments for those services. It has been determined that pieces of critical data are still needed. We are including a list of the missing data. Once completed, please call 1-877-267-2877 and we will arrange for one of our Data Collection Specialists to collect that data from you, or you can return it by fax or mail: If faxing material, please fax to: If mailing material, please send to: MEPS-Medical Provider Component Director 1009 Slater Rd, Suite 120 Durham, NC 27703

Thank you for participating in this important study!

If you do not receive all pages or transmission is unclear, please call 1-877-267-2877

For additional information log on to http://www.MEPS.AHRQ.gov.

Notice - Public reporting burden for this collection of information is estimated to average 5 minutes per patient. Any comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden should be sent to: AHRQ/MEPS Reports Clearance Officer, John M. Eisenberg Building, Room 5036, 540 Gaither Road, Rockville, MD 20850, Attention: PRA Paperwork Reduction Project (0935-0118). (Please do not send patient data to this address as it will delay data processing.)

This fax includes confidential information, and may be used only by the person or entity to which it is addressed. If the receiver of this fax is not the intended recipient or his or her authorized agent, the receiver is hereby notified that dissemination, distribution or copying of this fax is prohibited. If you have received this fax in error, please notify the sender by calling 1-877-267-2877 and destroy the contents of this fax immediately. Thank you.

OMB#: 0935-0118

Provider Name :

Patient Name:

DOB:

Prescription Date:

Missing Data:

Patient Name:

DOB:

Prescription Date:

Missing Data:

Patient Name:

DOB:

Prescription Date:

Missing Data:

Patient Name:

DOB:

Prescription Date:

Missing Data:

Patient Name:

DOB:

Prescription Date:

Missing Data:

Patient Name:

DOB:

Prescription Date:

Missing Data:

Patient Name:

DOB:

Prescription Date:

Missing Data:

OMB#: 0935-0118

Fax Cover Sheet or Mail Return Form

TO	Data Collection Specialist
Fax	1-866-309-4557
Phone	1-877-267-2877
From
Date
Total Pages (including cover sheet)

If mailing material, please include this Fax Cover Sheet or Mail Return Form in your envelope.

Thank you.

Please send to:



MEPS-Medical Provider Component Director

1009 Slater Rd, Suite 120
Durham, NC 27703

T his fax includes confidential information, and may be used only by the person or entity to which it is addressed. If the receiver of this fax is not the intended recipient or his or her authorized agent, the receiver is hereby notified that dissemination, distribution or copying of this fax is prohibited. If you have received this fax in error, please notify the sender by calling 1-877-267-2877 and destroy the contents of this fax immediately. Thank you.

When sending out AFs, please add these comments to the FAX, located on the Disposition Screen. Look under Cover Sheet Comment. This form will allow us to enter a personal comment to the POC. Hopefully, this will keep the Data Retrieval process to the minimum. Use the copy and paste features to avoid typing too much.

Dear______________________________:

We have noticed that it is easy to miss the third party payments and types for this study (such as Medicaid, Medicare, Workers Comp, Tricare, etc.). This information is important for this study. If you are unable to provide these, it would be helpful to note this on the paperwork that you will be sending to us.

Also, it would be helpful to label the headers on your reports in the closest way possible to the information that we are looking for in the study (Date Filled, Patient Paid, Insurance Paid, etc.).

Thank you for your help,

___________________, Data Collection Specialist

DATE

CONTACT INFO

Dear xxxx,

You may have heard of our research study MEPS which is authorized yearly by your customers to obtain their prescription profiles. We are contacting you in an effort to honor your customers’ wishes to release their prescription profiles for our yearly research on how people use and pay for health care in the U.S.

Because so many of your customers are interested in having their prescription data as part of our research study, we have arranged a centralized way of requesting and receiving the profiles through me. If you could help by identifying a corporate point of contact with which I could work to send the HIPAA compliant authorization forms and in turn receive the customers’ prescription profiles, it would help our research while also addressing your customers’ wishes.

We work with many corporate pharmacies such as yours with whom we have efficiently centralized requests and release of profiles. Following are options that may accommodate your staff’s participation needs:

• We pay a fee per record released to cover your staff labor and overhead.

• We provide a consolidated spreadsheet (sample enclosed) with all customer names, identifiers and locations where customers obtained prescriptions.

• HIPAA compliant authorization forms (samples enclosed) and spreadsheets can be loaded on a disc for ease. Some facilities do a data import directly on a disc and return that to us instead of paper.

• If you use HealthPort or other such 3^rd party companies to release records on your behalf, we have arrangements to receive the records through them with your approval.

• If a data agreement or other business agreements need to be signed, we are familiar with that process.

Please consider these options and let me know what works best. I’ve included my card and contact information on the letter for ease in follow up.

Thanking you in advance for your consideration!

Lourdes M. Suárez, MPM

MEPS Senior Negotiator

919-287-4366

[email protected]

DATE

POC INFO

Dear NAME,

It has been some time since I have re-contacted you about honoring your patients’ wishes to release their [prescription, medical, billing] records to us for our yearly research study. You may recall that MEPS is a study about how healthcare is used and paid for in the U.S. and about ## of your PROVIDER NAME patients ask us every year to contact you about releasing their records.

TEXT FOR POLICY: When last we spoke, it was not your company policy to release your patients’ [prescription, medical, billing] records. I am hoping that by contacting you at a later date, this policy has changed and that your patients’ wishes can now be honored. Please review the enclosed authorization forms. This will be our only request for YEAR on behalf of your patients which we hope will satisfy their wishes while respecting your staff workload.

TEXT FOR LESS BURDEN: We make every effort to make this request on behalf of your patients in a manner that does not overburden your staff. Should sending the full ### of requested records be burdensome, please consider sending just the [30 OR WHATEVER LESSER #] enclosed. This will be our only request for YEAR on behalf of your patients which we hope will satisfy their wishes while respecting your staff workload.

Please reconsider releasing these valuable records to us to provide us with the statistical power our research study needs. Of course don’t hesitate to contact me with any questions or needs to support your team. Thank you in advance.

Best regards,

Dear ________________,

Thank you for taking the time to speak with me to discuss your participant in the MEPS-MPC. I understand that our authorization forms are not accepted by your pharmacy. Because of this, the RTI International IRB has written the enclosed letter to help address the concerns you have. I will follow up with you in a few days to confirm you received the letter. In the meantime, I have listed the information we are looking to collect for the patient(s) at your pharmacy. If you have any questions, please contact me at the phone number below.

Sincerely [DCS name]

FOR EACH PATIENT EVENT WE NEED THE FOLLOWING:

DATES OF SERVICE

NDC

QUANTITY FILLED

QUANTITY UNIT

DAYS SUPPLIED

THIRD PARTY PAYER AMOUNT

THIRD PARTY PAYER TYPE (Private, Public, Medicare, etc.)

PATIENT PAYMENT

TO FAX RECORDS: 866-309-4557

TO MAIL RECORDS: 1009 Slater Road. Suite. 120

Durham, NC 27703

TO PROVIDE DATA VIA PHONE: 877-267-2877

December 23, 2014

Dear Sir or Madam:

I am writing this letter to ask for your help with a research study that RTI International is conducting for the U.S. Department of Health and Human Services (DHHS). This study, the Medical Expenditure Panel Survey Medical Provider Component (MEPS MPC), provides important information to government policymakers and private researchers about the rapidly changing health care situation in this country. Over the past couple of years many important changes have taken place in how people choose their providers of medical care, the way in which health care is paid, and the kinds of health insurance plans and services covered by those plans. Because of these changes, it is important to have the most up-to-date information on the prescribed medications your patients receive and how charges for these medications are paid.

Patients who received prescribed medications at your pharmacy are included in the MEPS MPC. These patients have signed HIPAA Authorization Forms granting us permission to obtain information from you regarding their prescription medications for the year 2014. These authorization forms contain all the elements for authorization that are required by HIPAA and specify an expiration date of 30 months after the patient signs the form. None of the signed authorization forms for your patients have expired, so we respectfully ask that you release information to us for the study, as specified in the authorization form and agreed-to by your patients.

Thank you. Please do not hesitate to contact me at [email protected] if you have any questions.

Sincerely,

Martha K. Wewer, J.D.

Privacy Officer

RTI International

DATE

Dear,

Your customer above, enrolled in the MEPS study for two years, has given us written authorization to request data from their prescription records for the year 2014. To fulfill your customer’s request, we need your help. The information we need:

• Dates and NDC for all prescriptions filled in 2014

• Quantity filled, quantity unit, and days supplied for each prescription

• Customer payment, third party payment, and third party payer type for each prescription. For example: Medicare, Medicaid, Workers Compensation, Private or Commercial, etc.

MEPS

The Medical Expenditure Panel Survey studies how Americans use and pay for healthcare. The information we're requesting is not available anywhere else, so it is important we speak with you to obtain it. Last time we contacted you, it was not a convenient time for you and you felt unable to accommodate our request.

Time & Money

We can reimburse your cost to retrieve and provide the information to us. We do understand you are busy; the data collection call only takes a few minutes and we can contact you at your convenience. We can send a prepaid FedEx envelope if you wish to ship records, or we can give you a fax number to fax in records.

Confidentiality

Personal identifiers, including your practice, will not be associated with the data we collect and confidentiality will be fully protected. Findings are published in statistical summaries and tables; anonymized data is released in public use datasets.

Please!

I will call you in the coming days to see if there is a way that works for your practice to provide your patient's information that we need. Thank you very much in advance for your further consideration!

DCSNAME

Data Collection Specialist

OMB#: 0935-0118

[DATE] MEPS ID#: 1XXXXXX

[Provider Name]

[Provider Address]

[Provider City/State/zip]

Attn: To Whom It May Concern

Thank you for your participation in the Medical Expenditure Panel Survey - Medical Provider Component (MEPS-MPC). We appreciate your assistance in providing information for this very important study.

Enclosed you will find the payment you require for providing billing records for participation in the MEPS-MPC.

The following patient(s) information is requested:

Patient’s Name

Patient’s Name

Patient’s Name

The information we need to confirm for each patient:

• Date of Service

• Services Provided

• Diagnoses/Conditions

• Payments and who made them (private insurance, Medicare, Medicaid, out-of-pocket, etc.)

• Charges for each service provided and total charges

Your participation enables the MEPS-MPC to report thorough and accurate information about health and health care costs in the United States.

If you have any questions, please contact us at 1-866-800-9203.

Thank you in advance for your time and assistance.

DATE

Thank you for sending the prescription profiles for patients who authorized their release to us for the purposes of our research. Enclosed you will find the corresponding payment for your services.

Please let me know if you have any questions and we look forward to collaborating again in the future.

Best regards,

Lourdes M. Suárez, MPM

MEPS Negotiator

[email protected]

Tel. 9190287-4366

Fax 866-309-4557

DATE

POC

Dear POC,

Thank you very much for sending your customers’ YEAR prescription profiles. It was such a pleasure working with you and I cannot emphasize enough the significance of your support in honoring your customers’ wishes to have prescription records as part of the MEPS research study.

Again, thank you for replying so promptly. We will be in touch again next year!

Best,

Lourdes M. Suárez, MPM

MEPS Pharmacy Negotiator

Tel. 919-287-4366

Fax 866-309-4557

[email protected]