Attachment 99 – MPC Pharmacy Provider Authorization Form Package, Records to be provided via Fax Anticipated

OMB#: 0935-0118

Medical Expenditure Panel Survey – Medical Provider Component

Reference #: «PROVIDER_ID»

Attachment 99

Medical Expenditure Panel Survey

Medical Provider Component

Pharmacy Provider

Authorization Form Package,

Forms by Fax Anticipated

«DATE»

«CONTACT_NAME»

«FAX_NUMBER»

Total Pages (including cover sheet): «TOTAL_PAGES»

Total Number of Patients: [FILL]

«Instructions»

Thank you for taking the time to speak with me earlier. This package contains the study information and signed customer authorization forms that I said I would send to you. These forms were signed by your customers who are actively participating in this research study. These signed forms allow us to contact you for a few pieces of information about the prescriptions that you provided to these customers in 2017. We need to collect the following:

NDC, Quantity Dispensed, Drug Name, Days Supplied (if available), Customer Payment per Rx, 3^rd Party Payment/Reimbursement per Rx, and 3^rd Party Type (e.g., Medicare, Private, Manufacturer, Discount, Charity.)

«SPECIAL_COMMENT»

Enclosures:

• Letter from the CDC and AHRQ

• Confidential Customer Check List

• Fax Coversheet and Mail Return Form

• Frequently Asked Questions (FAQ)

• «TOTAL_AFS» – Signed Authorization Forms

	DEPARTMENT OF HEALTH & HUMAN SERVICES Agency for Healthcare Research and Quality

«DATE»

Dear «POC_NAME»:

We understand that one of our data collection specialists has talked to you about the Medical Provider Component of the Medical Expenditure Panel Survey. We are appreciative of the contributions you and your health care agency are providing to this important study that is being conducted for the Agency for Healthcare Research and Quality (AHRQ) and the Centers for Disease Control and Prevention (CDC), both part of the U.S. Department of Health and Human Services. We wanted to take this opportunity to tell you more about the study.

The objective of the study is to provide accurate information to government policymakers and private researchers about the rapidly changing health care situation in this country. To accomplish this goal, we have collected data from a cross-section of American households on how they used and paid for health care during 2017. With the written permission of members of these households, we are now contacting their pharmacy providers to determine the actual fill dates, NDC, charges, sources of payment/reimbursement and the amount that was paid. One or more of your pharmacy customers have given us written authorization to request this information from your records.

The study materials enclosed with this letter include a list of your pharmacy customers who have agreed to participate in the survey and an authorization form for each customer.

This survey is authorized by section 902(a) of the Public Health Service Act [42 U.S.C. 299a]. Participation is voluntary, but we are depending on you to help us toward a more complete understanding of the nation’s health care. The client information we obtain will be used for research purposes only and will be released publicly only in summary form in which establishments or individuals cannot be identified. The confidentiality of client information is protected by Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 242m(d)]. Information that could identify a client or establishment will not be disclosed unless that client or establishment has consented to such a disclosure.

A Data Collection Specialist from our contractors, RTI International (RTI) and Social and Scientific Systems, Inc. (SSS), will call shortly after you have received these materials to see if you have any questions and to arrange for the collection of these data. If you have questions about the forms or procedures, or would prefer to upload the records using the project’s electronic portal, call RTI-SSS, toll-free at «TOLL_PHONE_NUMBER».

Sincerely,

Gopal Khanna, M.B.A. Director Agency for Healthcare Research and Quality	Charles J. Rothwell, M.B.A, M.S.  Director National Center for Health Statistics Centers for Disease Control and Prevention

Confidential Customer Checklist – PLEASE RETURN

Thank you for taking the time to provide this billing information.

Step 1: Please check the appropriate box next to the customer name on the list below to indicate which of the following applies to each customer: you were able to locate the customer’s records for 2017, you were able to locate the customer but there were no 2017 records, or the individual is not a customer.

Step 2: Please Provide the Complete 2017 Records for Each Customer for whom you were able to locate 2017 records. For each customer listed below, we are requesting information for all 2017 prescriptions each customer received between January 1, 2017 and December 31, 2017.

FOR EACH CUSTOMER PRESCRIPTION WE NEED THE FOLLOWING EIGHT ITEMS:

Date Filled

NDC

Quantity Dispensed

Drug name

Days Supplied (if available)

Customer Payment per Rx

3^rd Party Payment/Reimbursement per Rx

3^rd Party Type (e.g., Medicare, Private, Manufacturer, Discount, Charity)

Please include label headers on your reports in the closest way possible to the variables that we are looking for in the study, or provide a key. We have noticed that it is easy to miss 3^rd Party Payments/Reimbursements and Types when returning records. If this information is not available please make a note on the paperwork that you return to us to reduce the number of follow-up calls.

Should you prefer to return copies of the records by fax or mail: Please use the Fax Cover Sheet or Mail Return Form included on page 4 of this fax. Please include this completed Confidential Customer Check List, along with any records for those customers that received prescriptions in 2017.

Should you prefer to return copies of the records by electronic portal: Please call RTI-SSS, toll-free at «TOLL_PHONE_NUMBER».

The customer(s) listed below have given us written authorization to contact you and request information from your records. Copies of the signed authorization forms are included in this fax.

						Check 1 For Each Customer
Provider Name		Customer Name	Customer Address	Date of Birth	Sex M/F	2017 Rx Found	Cust Found No 2017 RX	Not a Cust

Fax Cover Sheet and Mail Return Form

When returning the Confidential Customer Checklist and copies of the records, please use this page as either a Fax Cover Sheet or Mail Return Form. This form is not necessary if you are responding via the electronic portal.

To	Data Collection Specialist
Fax	«TOLL_FAX_NUMBER»
Phone	«TOLL_PHONE_NUMBER»
From
Reference Number	«GID»
Date
Total Pages (including cover sheet)

Please send mail to:

M



EPS-Medical Provider Component

«MEPS_MAIL_ADDRESS»

REFERENCE#: «GID»

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 «TOLL_PHONE_NUMBER» and destroy the contents of this fax immediately. Thank you.

Frequently Asked Questions

What is the Medical Expenditure Panel Survey (MEPS)?

MEPS is a nationwide research study conducted to learn more about the health care services people use, the charges for those services and the sources that pay for them. MEPS is conducted annually by the U.S. Department of Health and Human Services through the Agency for Healthcare Research and Quality and the Centers for Disease Control and Prevention. Major components of MEPS include surveys of:

• A nationally representative sample of households;

• Hospitals, physicians, home care providers, and pharmacies reported by the household participants; and

• Providers of health insurance.

MEPS is the most complete source of data available on health care use and expenses in the United States and is used by government policymakers and private researchers.

How are pharmacies chosen for the MEPS Pharmacy Component?

Pharmacies were named by respondents in the household data collection as sources of prescribed drugs during 2017. These household respondents signed HIPAA-compliant forms authorizing and requesting each of their pharmacies to release the information sought by the study.

How do I know the information will be kept confidential?

The confidentiality of data collected for MEPS is protected by Federal law under Sections 944(c) and 308(d) of the Public Health Service Act [42 U.S.C. 299c-3(c) and 242m(d)]. No information that could identify an individual or establishment will be disclosed unless that individual or establishment has consented to such a disclosure.

Personal identifying information such as names or addresses are removed before information from the study is made available to researchers. Findings are published in statistical summaries and tables and micro-data is released on “public use” data files.

Why should this pharmacy participate?

Prescription medicines are a major component of health care costs. The information that you supply will supplement that given by your customer and help us build a more complete picture of health care expenditures for respondents in our study. Your customers have asked specifically for your help by signing the authorization form.

Who is collecting this data?

The U.S. Department of Health and Human Services has chosen RTI International (RTI) and Social and Scientific Systems, Inc. (SSS) to administer the study. A professionally trained data collection specialist from RTI-SSS will contact each pharmacy.

What information is needed?
For each of the customers on the enclosed list, we need this information about their prescriptions. For each prescription in 2017, we will need:

• Date Filled

• NDC

• Quantity Dispensed

• Drug Name

• Days supplied (if available)

• Customer Payment per Rx

• 3^rd Party Payment/Reimbursement per Rx

• 3^rd Party Type (e.g., Medicare, Private, Manufacturer Discount etc.)

What questions will the data collected answer?

MEPS data provide answers to many important questions. For example:

• How much of prescription costs are covered by insurance?

• What do people pay out of pocket for medications?

• What medicines are people receiving?

• What types of medications are not covered by insurance plans?

What is the electronic portal?

Pharmacies can upload MEPS records through a secure electronic portal. If you prefer to upload the records using the project’s electronic portal, call RTI-SSS, toll-free at «TOLL_PHONE_NUMBER».

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 «TOLL_PHONE_NUMBER» and destroy the contents of this fax immediately. Thank you.

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, 5600 Fishers Lane, Rockville, MD 20857, Attention: PRA Paperwork Reduction Project (0935-0118). (Please do not send patient data to this address as it will delay data processing.)