Creating a New Non-Coverage Gap Submission Using a Submission Template

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Overview

When adding a new Submission to the Validata application, the Validation Analyst can choose the shortened workflow for Submission creation. In this shortened workflow, a predefined Submission Template is used to create a Submission. A Submission Template is an automated script that contains details like Submission header details, file settings (Mapping Set that will be used when importing files), validation setting (Validation details that will be used when validating a Submission), and publish settings (when publishing a Submission to the downstream Payer application). For detailed documentation about Submission Templates, see Submission Templates. When a Submission is created using a Submission Template, on the Submission Templates page, the Status value is displayed as Active’ to indicate that the template has been used.

Creating a New Submission Using Submission Template

To create a new submission, click New Submission on the Submissions page. The Use templates toggle is set to Yes by default. Proceed with this default selection. When creating a Submission using the shortened workflow, the analyst has to provide limited input on the New Submission page, as explained in this help documentation.

When the Use Templates toggle is set to No, the Analyst has to provide all the details on the New Submission page in different tabs. For detailed documentation about creating a Submission using the manual workflow, see Adding a new Submission.

Submission details

In the Submission details section, specify which type of Submission you want to create. This user input determines the kind of template that will be used in the Submission automation creation process. The default selection for the Submission type drop-down list is Non-Coverage Gap. Proceed with this selection to create a new Non-Coverage Submission using a Non-Coverage Gap Submission Template.

The fields presented on this page change based on the type selection. When you update the Submission type selection after specifying the details on this page, the previously added inputs will be cleared (only the Rebate period and Receipt date are retained), and you will have to refill the information on the New Submission page.

Template lookup

The Template lookup section allows the Analyst to search for templates by providing the details in the user inputs. The templates matching the user-defined input will be listed for user selection.

Rebate period: Provide the start and end dates for the rebate period. Templates that match this rebate period will be available for user selection, and the Submission will be created using this Rebate period value.
Receipt date: Specify when the validation analyst received the file from the PBMs. Enter a date in valid format (MM/DD/YYYY) or select a date using the date picker. The date value should be the current day or a past date; it can not be a future date.
Search contract to add contract details: Using this user can search for a Contract. You can search for a contract by adding the initial letters of the Contract Name/ID/ Description/Contract Segment/Customer Name or Customer ID in the search text box or using the scroll bar to view the available contract list. Choose a contract. Based on the Contract selection, the following contract details are populated:
- Contract ID
- Contract segment
- Contract name
- Contract type
- Customer name
- Customer ID
Template match: The matched templates are populated in the Template match drop-down list only when the user inputs are filled in the Rebate period, Receipt date, and Contract. The template match is retrieved in combination with the Rebate period specified and the Contract selected. When fetching the templates:
- The Contract assignment to the Submission Template and the configured effective periods are considered.
- Templates with Status values as Deleted, Draft (template was never published), Retired Draft or Retired statuses are ignored.
- Templates with Status values as Draft (when the Template was at least published once previously), Active, Active Draft, and Ready (published template) are considered by matching.
- When a template is in ‘Active Draft’ status, the settings and configurations presented for the Template on its latest Active status will be utilized during the automation creation process.

All effective periods available for a matched Submission Template are fetched in the drop-down list along with the Contract’s effective period assigned to the Submission Template. Choose the Template using which the Submission can be created.

See the Template Matching section in this help documentation for detailed documentation about how the Template match is done and how templates are displayed in the Template match drop-down list for user selection.

Template preview: In the Template preview, the chosen template’s details are displayed in the following format:
- Name of the Submission Template
- The ID of the Submission Template
- Contract assignment to the Submission Template effective period start and end date
- Effective period configuration start date and end date

Template preview is displayed as a link. Click this link to navigate to the respective Submission Template. Click on the tooltip icon to view the details about the selected Template:

File selection

The File Selection section allows the Analyst to select the files that will be included in the Submission.

Notes:

The supported file formats for uploading are .ncpdp, .txt, and .csv. All other file formats are unsupported.
A maximum of 10 GB file size is supported for uploading through file selection.
Note:
When the file size exceeds 10GB, an error message is displayed when uploading the file. The file's 'Size on disk' is considered for the file size. When the file's 'Size on disk' is greater than 10,737,418,240 (bytes) it is considered as a large file.
When the user selects a file that already exists in the Validata application to upload, the following alert message is displayed:
<File Name> was uploaded previously. Please use a different file.

Browse Local Files

Browse and add files from your local machine using the Browse Local Files option. Click Browse Local Files, then select the files from your system location.

Browse File Share

You can add files from the file share using the Browse File Share option. Click Browse File Share. The File Share window is displayed. All the files previously uploaded are listed on this window. Select the required files to include in the Submission.

Included files

When the file selection has been completed, the Included files table shows the list of selected files. In the Included files list, the following details are displayed:

File Name: The File Name shows the file's name uploaded to the Submission.
Medical Benefit: You can assign a Medical Benefit Rule Set to the files of ‘Commercial – Medical Benefit’ type to define the conversion that will be applied for the incoming medical benefit lines. The qualified utilization lines in the file will be converted and allocated using the configuration specified in Master Data. By default, the Medical Benefit toggle is set to Off. You can not assign a Medical Benefit Rule Set to the Submission. To assign a Medical Benefit Rule Set to the file, set the toggle to ‘On’ in the table row. When the toggle is set to On, the Mapping Set column value is automatically updated to reflect the Medical Benefit Mapping Set name (when a Medical Benefit Mapping Set is provided in the Template configuration page). Choose the Medical Benefit Rule Set name that will mapped to the utilization file.

Mapping Set: The Mapping Set name is pre-populated and retrieved from the matched Submission Template configuration. You can alter the selection in this column.
Send For 340B Eval: This toggle appears only when the Manufacturer has the 340B Vigilance Product License. By default, it is set to No. Set it to Yes to send the file for 340B Risk Assessment processing.
Include Date: The date and time when the file was added to the Submission. Pre-populated value and can not be altered.
Size: Size of the included file. Pre-populated value and can not be altered.

Create Submission

The Create button will be enabled for user selection when all the mandatory user inputs are filled in on the New Submission page. Click the Create button to create a new Submission with the provided details. The files will be imported to the Submission using the Mapping Sets specified in the template (unless an alternative file setting is selected when creating the Submission).

View Created New Submission

The newly created Submission is listed on the Submissions list table. To view the Submission, click on the Submission Name link.

When a new submission is created, the unique submission name is created by utilizing the Submission Template detail in the [year] [period] [contract_id] [contract_name] [type] [adjustment_incrementor] format, where:

[year] value is presented in YYYY format and retrieved from the Start and End of the Rebate period provided in the Template lookup section.
[period] value is presented as the time range of the rebate period in combination with the year value. It can be monthly or quarterly, depending on the program's rebate frequency.
- When the rebate start date and end date match any quarter’s start and end dates, Q is used in the [period], for example, 2024 Q1 - 2025 Q1.
- When the rebate start and end date do not match any quarter's start and end dates, M is used in the [period], for example, 2024 M12 - 2025 M01.
- When the rebate start and end date falls in the same quarter of a year, instead of a range, only a quarter number is used in the period, for example, 2024 Q1.
- When the rebate start and end date falls in the same month of a year, instead of a range, only a month number is used in the period, for example, 2024 M10.
[contract_id] is the Contract ID chosen in the Search contract to add contract details field.
[contract_name] is the Contract name chosen in the Search contract to add contract details field.
[type] value is presented as the type of Contract, such as commercial, Medicaid, Tricare, etc.
adjustment_incrementor] number value is appended to the Submission name to ensure that the name value is unique when users create a Submission using the same rebate period, contract, and effective period configuration. The incremator functionality increments the number at the end. For example: 2020 Q1 00011399 CVS Caremark 2 Commercial 1, 2020 Q1 00011399 CVS Caremark 2 Commercial 2, 2020 Q1 00011399 CVS Caremark 2 Commercial 3…..

Submission Details

The Submission header section and Manage Details, Validation Options, and Publish Options details specified in the Submission Template will be populated within the newly created Submission.

Note: The 'Include all dates of service’ toggle in the Validation Options is not included in the Submission Template configuration area. The toggle is set to Yes by default, and users can alter the selection as needed. For detailed documentation about Validation options, see the Validation Options documentation.

Submission Validation

When Validation automation is set to ‘Yes’ in the chosen submission template, Submission validation is initiated immediately after the automated Submission is created (when no error occurs during file import to the Submission). If Validation automation is not automated in the Submission Template, the user must manually initiate validation. All the validation settings provided in the Submission Template configuration are pre-populated in the Validation Options drawer. For detailed documentation about initiating Submission validation, see Run Validation Manually.

Submission Publish

In the selected Submission Template, when Automatically publish when submission is "Marked as complete" is set to Yes, the Submission publish will initiated immediately when the Submisison is marked as Complete (validation result review and analysis have been completed by the Validation Analyst). The defined Publish Settings will be used to publish the Submission and a Submission will be created in the downstream Payer application.

Note: The Publish automation only accounts for the first publish action within a Submission. Any following publish actions or publish reversal actions should be initiated by the user.

In the selected Submission Template, when the Automatically publish when submission is "Marked as complete" is set to No, the user has to publish the Submission manually. For detailed documentation about Submission Publish, see Publishing and Exporting Non-Coverage Gap Submission.

Template Matching

On the New Submission page, when the user specifies the Rebate Period and chooses a Contract, the Template lookup compares the provided data with the default and non-default templates available in the application and retrieves the matched list in the Template match list.

First, the matched template details are displayed in the following format:

<Name of the Template> (<ID of the Template>), Contract: <Contract’s assignment to Template effective period>, Configuration: <Configured Effective Period>

The Validata application matches the templates for the specified rebate period and the chosen contract. When the application finds templates in the application whose configuration period matches the submission rebate period and the Contract chosen in the new submission page is linked with that Submission Template, those submission templates are populated in the template match drop-down list.

For example, when creating a Submission, the Rebate period and Contract selection have been done as shown in the below illustration:

The application finds a match for where the Contract-Submission Template assignment is available, and its effective period comes within the Rebate period date range, as shown in the below illustration from the Submission Template user interface:

The name of the Template, ID of the Template, Contract Effective Period, and Template Effective Period are achieved based on the above match found. For example:

Demo Non-CG Template (10008), Contract: 01/01/2020 - 01/01/2021, Configuration: 01/01/2020 - 01/01/2021

Second, when the application finds more than one match of Submission Templates, the values are listed in descending order based on the percentage match order based on the percentage match.

Where the Contract percentage match is derived based on the following calculation:

Number of days overlapping between the Rebate period and the Contract effective period/Rebate period*100

For example, as per the below illustration:

The Rebate period range is 01/01/2020 to 02/28/2022, equal to 790 days, and The Contract effective period is 01/01/2020 to 01/01/2021. The overlapping period in this component's date range is 01/01/2020 to 01/01/2021, equal to 367 days.

Contract percentage is 367/790* 100 = 46.46%

Third, the Submission Template may have more than one effective period configured. When deriving the Config overlap % of the template match, the application derives the value using the below calculation:

Number of days overlapping between the Rebate period and the configured effective period in the Submission Template/Rebate period*100

For example, as per the below illustration, there are multiple effective periods exist for the Submission Template:

The Rebate period range is 04/01/2020 to 05/31/2023, equal to 1156 days, and the configuration effective period is 04/01/2021 to 05/31/2022. The overlapping period in this component's date range is 04/01/2021 to 05/31/2022, equal to 426 days.

Contract percentage is 426/1156* 100 = 36.85%

Important: After reviewing the Contract % and Config overlap %, the user can assign the template to create the Submission.