Pharmacy Claims and Patient Alert Data

  • Presentation is also available in Portable Document Format (PDF)

December 2017

Pharmacy Claims Extract File – Need

PPS have requested a timelier, more actionable pharmacy data set to better manage their attributed population.

Use Cases from PPS
  • Medication Adherence Measures
    • Utilize the claims data to determine claims that have been restocked (i.e. medications not picked up). PPS can reach out to the patient ASAP and provide care.
    • Medication reconciliation is facilitated by knowing if a medication was picked up by the patient.
  • Discharge Medications in Care Transitions:
    • Nurses following–up with patients on a number of items, including confirming patients picked up their discharge medications.
    • Timely medication information facilitates the care transition.
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Pharmacy Claims Extract File – Overview

  • Currently, PPS receive monthly claims data for all claim types that have a 6–month lag over a rolling 1 year service period.
  • The Pharmacy Claims Extract will encompass only pharmacy claims data and utilize a 0–1 month claims lag over a rolling 1 year service period (date of service).
  • (Example) Jan 8, 2018 Data Release:
    • Reflects members attributed to PPS in December using 6–month lag;
    • Reflects claims as of claims data run (mid Dec 2016 – mid Dec 2017);
    • There will always be a lag within 1 month due to processing time and;
    • Goal to continue to reduce lag in future monthly runs.
  • The 1st Pharmacy Claims Extract will be integrated with the standard monthly PPS Data file processing:
    • 1st release scheduled for Jan 8, 2018.
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Pharmacy Claims Extract File – Data Components

  • Example of Claims Extract fields that will be in the Pharmacy claims extract:
    Pharmacy Field Description
    Drug Label Name The name of the Drug being prescribed.
    Generic Product Code Identifies whether the drug is a branded drug or generic drug.
    Member ID Member Identifier (aka CIN).
    NDC National Drug Code of the prescription being filled.
    Days´ Supply The estimated number of days´ supply dispensed for a prescription.
    Prescriber Name The Name of the Prescribing Provider.
    Quantity Dispensed The Quantity of the prescription being dispensed.
    Service Date The Date the Prescription was filled.
  • There will be 3 new pharmacy specific fields:
    Pharmacy Field Description
    Number of Refills Authorized The number of refills authorized for a prescription.
    Pharmacy Name The name of the pharmacy filling the prescription.
    Refill Code The refill number for the prescription.
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Patient Alert File – Project Overview

  • Patient Alerts is a composite of multiple 3M measures that is based on the most recent claims data available.
  • Patient Alerts will be processed and provided to PPS with up to a 1 month lag.
  • The Patient Alert data set will provide PPS targeted patient registries that are actionable in care management workflow.
  • Key elements include:
    • 3M CRG (Clinical Risk Groups)
    • 3M Flags
    • 3M Metrics: PPVs and PPRs
  • The Patient Alert data extract is a monthly file that will be shared through the PPS monthly data file process.
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Patient Alert Flags – Overview

  • There are several flags available which can help you:
    • Prioritize patients for care management intervention;
    • Highlight potential gaps in care and opportunities to improve patient outcomes and;
    • Useful for describing population shifts in illness burden over time.
  • Some examples include...
    Flag Definition How to use the flag
    Newly Chronic Member recently assigned a chronic status. Can be an indication for a PCP to reach out to this patient to discuss a care plan.
    Chronic Fall-Out Member who previously was identified with a chronic condition but in the most recent data, the member has lost evidence of this status. May be an indication that the member is not following their care plan.
    Persistent High Needs Individuals (PHNI): Indicates a member whose utilization patterns demonstrate consistent high use of resources as compared to other members with similar health status. Can indicate a need for intervention.
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Patient Alert – Metrics

  • There are also several metrics that provide insight into the patient´s recent activity. When used in combination with the flags, they can provide utilization details that give insight into a patient´s consumption of resources:
    • Potential Preventable Visits (PPVs) and;
    • Potential Preventable Readmissions (PPRs).
  • These metrics will allow for quicker adjustments to the interventions.
    • A patient who is flagged as newly chronic may have been discovered during a potentially preventable emergency department visit
    • A patient who is flagged as a jumper may have had their severity level increase due to a recent potentially avoidable hospital admission
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Patient Alert File – Project Schedule Update

  • PPS will receive their first Patient Alert Extract for claims paid through December 31, 2017 along with the other monthly MCD files on February 7, 2018.
  • Supplemental webinars and training documentation to further explain how to interpret/use the data will be provide to the PPS as the release dates of both files near.
  • Patient Alert data logic for SUD
    • Members with SUD indicative CRG will be removed.
    • Members with SUD indicative EDCs will not be removed. Rather, the SUD indicative EDC will be removed from the member record.
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