13.5 Drug Rebate Analysis and Management System (DRAMS) Flowcharts

Transcription

1 13.5 Drug Rebate Analysis and Management System (DRAMS) Flowcharts The DRAMS flowcharts are displayed on the following pages. The flowcharts include the following processes: DRAMS REBATE PROCESSING DRAMS REBATE ACCOUNTING DRAMS DRUG REBATE DISPUTE PROCESS ROCKY MOUNTAIN HEALTH PROCESS CITRIX CONNECTION PROCESS Drug Rebate Analysis and Management System (DRAMS) for Colorado page

2 ACS PBM Rebate ACS PBM Rebate Accounting CMS Labeler Drug Rebate Analysis and Management System (DRAMS) for Colorado December DRAMS Rebate Processing The following chart explains the overall flow of the drug rebate process. Drug Rebate Process v3.2 Within 38 days of state invoice postmark Interest starts 38 day after state receives dispute notification ACS PBM Rebate Services Team Jan. 05 Quarter End Day 30 Day 45 Day 60 Day 90 Send pricing info to CMS Submit rebates together wtih ROSI and PQAS for adjustments and disputes Submit payment due + possible interest Compile Rebate Data tape (URA & Contact info) and send it to states Report to CMS Local Office Deposits payments & send copies of check + doc to ACS Atlanta Report to Generate rebate invoices with CMS data + utilization data & send to the labelers ACS Allocates payments Close Send Invoice Collection Letter Send Collection Letter No response Credit the labeler for disputed amount Close Go through Resolution Process Not resolved Notes: 1. The labelers are existing ones and have already signed the Drug Rebate Agreement with CMS. 2. The utilization data is gathered from claims in PDCS on a weekly basis. 3. The utilization data and invoice information are sent to the CMS at the same time it is sent to the labelers. 4. Collection letters for unpaid invoices are sent to the labelers 2-3 times, first on the 38 th day after the state invoice postmark, then every 28 days after if no payment is promised. 5. Once the dispute is resolved, the labeler is supposed to pay the agreed amount. If no payment is received a collection letter is sent to the labeler. A second or third letter will go out every 28 days if needed DRAMS Rebate Accounting Process Note: The accounting team of the rebate department handles the quarterly claim, invoice and payment tasks. The following chart maps out the general flow of the accounting processes. Drug Rebate Analysis and Management System (DRAMS) for Colorado page

3 A6. Collection A5. Allocate Payment A4. Generate Invoice A3. Invoice Audit A2. Calculate Invoice A1. Claim Audit Drug Rebate Analysis and Management System (DRAMS) for Colorado December 2006 Drug Rebate Accounting Process v3.2 ACS PBM Rebate Services Team Jan. 05 This is done on a weekly basis to check out the accuracy of the claims and to reduce disputes proactively A1.1 Set up audit criteria in the A1.2 Run claim audit A1.3.1 Verify outliers with reference sheet A1.3.2 Verify outliers with dispute team A1.4 Display claim details and change units in the A1.5 Report unit changes to the claim process team A ACS state rep receives CMS tape A2.1.2 System loads claim data from PDCS A3.1 Set up audit criteria in the A4.1 Set up mailing threshold in the A3.2 Run invoice audit A4.2 Review and assign handling codes for underthreshold invoices ACS lockbox receives rebate checks & doc from the labeler. They deposit the checks for the state and send copies to ACS Atlanta A Retrieve data from CMS tape A3.3.1 Verify outliers with previous quarters A3.3.2 Verify outliers with dispute team A4.3 Freeze invoices ready for mail so no changes can be made to them A5.1 ACS state rep receives copies of checks together with ROSI & PQAS & original envelops A System loads CMS data the same night A4.4 Print invoice registry from the Manufacturer accounts have to be setup in RebateWeb and DRAMS A5.2 Log batch total of the checks in the A3.4.1 Clear audits if the outlier is accepted for business reason A3.4.2 Display claim details and change units in the A5.3 Log individual check in the A2.2 Calculate invoice in the A4.5 Print out invoices A4.8 Create electronic invoices A5.4 Check batch complete in the Each state has to be calculated separately in the A2.3 Check procedure results in the to verify the successful run A3.5 Select one labeler who has changes due to invoice audit and recalculate invoice for that labeler A5.5 Run interest due if it is past 38 days This is a iterative process until all audits are cleared A3.6 Run invoice audit again for the labeler affected by changes Each invoice contains a cover letter, current quarter invoice, utilization changes for prior quarters A4.6 Mail out invoice to the labeler A4.9 Upload invoices to RebateWeb A5.6 Allocate payment based on ROSI A4.7 Log mailing date in the A4.10 The logs the upload date A5.7 Allocate payment based on PQAS A5.8 Run weekly collection report 38 days after the invoice postmark A6.1 Check weekly collection report A6.4 Generate and send out collection letter to the labeler Next letter sent 28 days after Not paid Paid A6.5 Go through Allocate Payment process Drug Rebate Analysis and Management System (DRAMS) for Colorado page

4 DRAMS Drug Rebate Process Note: The tasks are handled by the Rebate Services Resolution Team In conjunction with and under guidance of the state of Colorado. Resolution Flowchart sends Rebate Invoice to Manufacturer Phase I Step 1 Manufacturer provides notice of dispute within 38 days Not Step 2 Within 90 days, provides initial response by contacting Manufacturer and determine basis for dispute Not Step 3 Exchange of Data and Negotiations - Within 150 days, the has to provide the Manufacturer with claims detail, a sampling of pharmacy claims or historical trends data Not Step 4 Post-Negotiation Decisions - To be completed within 240 days - the dispute resolution negotiations have to be completed resulting in one of the following options: Not decides to cease the dispute resolution process based on a costeffectiveness determination and the Manufacturer agree to a settlement and the Manufacturer can not agree on a settlement and proceed to Phase II Drug Rebate Analysis and Management System (DRAMS) for Colorado page

5 A dispute can proceed directly to Phase II, without proceeding through all the steps of Phase I, if: 1. One party does not comply with the requirements under any step of Phase I and 2. The compliant party requests the dispute proceed to Phase II. must schedule a hearing within 30 days of the completion of Phase I or within 30 days of the request by the compliant party to proceed to Phase II. Hearing must be conducted no later than 1 year from the 240th day after the receives notice of the dispute. Phase II Arbitration Mediation Not Not Administrative Hearing Not Judicial Hearing Drug Rebate Analysis and Management System (DRAMS) for Colorado page

6 D2. Historical D3. Collection (pre D1.Current (since ACS) ACS) Drug Rebate Analysis and Management System (DRAMS) for Colorado December 2006 Drug Rebate Process v3.2 ACS PBM Rebate ServicesTeam Jan days after the end of invoice period Claims detail could be provided via FTP site Responsive Rebate Business Analyst run quarterly dispute report Gather claim level details (CLD) Identify invalid, terminated and rebate ineligible NDC Send out initiation with CLD Research for invalid, terminated and rebate ineligible NDC Nonresponsive Negotiate agreement, log every advancement Follow up with 5 more contact efforts within 180 days, log every effort D1 Unit adjustment needed Adjust units in the based on the dispute result No unit adjustment Report the changes to the claim processing for adjustments Notify labeler for dispute result and request payment commitment Follow Collection Process D1 Not Report to CMS local office Report to the Labelers or s provide dispute report Data not available Data available D2.1 Run dispute code report Follow steps for Current Two quarters after the dispute was initiated Response payment Go through Allocate Payment process Once the payment is received and allocated, the disputed item will disappear from the dispute report Check the quarterly dispute report for unresolved NDC Generate and send out dispute collection letter to the labeler Next letter sent 28 days after No Response Report to CMS local office Report to the Drug Rebate Analysis and Management System (DRAMS) for Colorado page

7 Rocky Mountain Health Plan Process Drug Rebate Analysis and Management System (DRAMS) for Colorado page

8 Citrix Connection Process ACS provides the with read-only electronic access via Citrix metaframe over the internet to the DRAMS within a secure DMZ server environment. No processing occurs on state machines, and no data is transmitted over the internet merely screen print files. Access is performed by use of an ACS-provided client ICA file which establishes the connection over the internet to the ACS DMZ servers through double-firewalls, as illustrated below: Up to 5 accounts will be provided this access to the DRAMS via Citrix Server. The state should contact ACS Rebate Operations for assistance if additional account setups are required. Drug Rebate Analysis and Management System (DRAMS) for Colorado page

9 Document History Document History Date Rev. No. Change Section Author 01/28/ Initial version for implementation of the DRAMS for Colorado All csj 12/05/ Edits based on standards All Kevin Martin 12/14/ Edits based on state requirements All Chris Jacobs Drug Rebate Analysis and Management System (DRAMS) for Colorado page