With the implementation of risk-adjusted payment methodologies for Medicare plans, complete and accurate submission and tracking of claims, encounter and prescription drug event (PDE) data are critical for the following reasons:

• Claims and encounter data are the basis of the risk scores that the Centers for Medicare and Medicaid Services calculates for each member (for both Part C and Part D payments) and are the critical drivers of your revenue stream
• PDE data drives the retroactive reconciliation of Part D payments as well as ongoing benefit/adjudication levels for members

However, submitting the data poses significant challenges, as CMS has stringent requirements on format, contents and interrelationships of data elements. If these aren't met, data can be rejected. Our experience indicates that a high percentage of data is rejected even when submitted in the correct format. This typically occurs because of discrepancies between CMS data and plan data and can have a significant impact on the revenue stream a plan receives from CMS; for example, for Part C, one missing or rejected claim for a member who has diabetes can result in a revenue drop of more than $2,000.

TriZetto Plan Data Management offers comprehensive solutions that address the challenges associated with data validation and submission for Part C and Part D. Solutions include:

• Data Manager: Submit claims, track results and provide the tools to correct and resubmit claims and encounter data for Part C and D risk-adjustment (RAPs).
• PDE Data Manager: Submit, track and provide the tools to correct and resubit pharmacy event data, and aggregates PDE data at the member, plan and PBP level to support Part D retroactive reconciliation.

• Ensures that data is submitted in CMS-required formats
• Helps the plan correct discrepancies that can result in reduced CMS payment
• Meets needs for Part C and Part D risk-adjustment as well as Part D retroactive reconciliation

Information

For more detailed information, please call 1-800-569-1222 or click on the link below. Request more information     Contact a sales rep