Viewing the Line Level Details For Non-Coverage Gap Submission

About Line Level Details Tab

When the Validation Analyst creates a new Submission, the imported lines to the Validata application from those utilization files are listed on the Line Level Details tab. All lines included in the particular Submission with their relevant details and column headings are listed on the Line Level Details table. 

Note: The Validation Analyst can only view the Line Level Details tab for the Standard Submissions. For Coverage Gap Submission, the Data Lines tab is available.

On the Line Level Details list table, the Analyst can:

• Review the line details before and after validating the Submission on the Line Level Details list table.

• Override Errors and Line Status for selected lines after a Submission is validated. For more information, see Overriding Submission Line's Validation Result.

• Change the associated Contract ID for the selected lines. For more information, see Change the Contract for the Line.

• View the history of a selected Line

• Add comment to a selected Line

• Sort and filter the lines on the Line Level Details table

• Copy the Line details 

• Download the Line Level Details table records

Line Level Details list table

This section lists all the group headers and the column details displayed on the Line Level Details list table, as per presentation order on the table. The columns are grouped under a group header on the list table. 

• Line ID: The unique system-generated ID assigned to the utilization line.

• Comment: By clicking the comment icon, the Analyst can view if there are any existing comments added to the utilization line and also can add new comments for a utilization line.

• Error Code: Displays the error codes that are tagged to the utilization line when a Submission is validated. 

Notes:

• An empty value is displayed Until the Submission is validated using a Validation Set.

• An empty value is displayed when a Submission is validated, but the lines do not have any errors. 

Each error code is displayed in the column as an abbreviation of the complete error code with a color shading to indicate the severity level.

• Warning (Yellow)

• Major (Orange)

• Critical (Red)

When a utilization line is associated with more than two errors, and the error codes flow beyond the width of the Error Code column, the number indicator specifies the additional number of errors associated with the utilization line. For example, if there are 7 errors stamped to a line, it will display 2 errors and show (+5).

Hover on any of the Error Codes or the additional number indicator value to view the full list of the Error Codes along with a description of the error.

Notes:

• You can override the severity of the error from a severity level Major to Warning. For detailed documentation, see Overriding Submission Line's Validation Result.  

• You can not override the severity of the error when the severity level is critical.

• Line Status: Displays the current status of the utilization line. One of the following values is displayed:

  • New: The Line Status column displays New when a Submission is created and not validated.

  • Included: When Submission is validated using a Validation Set, and the submitted utilization line is not stamped with an Error Code of severity level Critical or Major, the line is assigned an Included status.

  • Excluded: When Submission is validated using a Validation Set, and the submitted utilization line is stamped with an Error Code of severity level Critical or Major, the line is assigned an Excluded status.

The Validation Analyst can override the Line Status for the utilization Lines.

• The Line Status of a utilization line can be manually updated from Included to Excluded.

• The Line Status of a utilization line can be manually updated from Excluded to Included only when the Error Code severity level is of type Major. The  Line Status of a utilization line with an Error Code severity level Critical can not be overridden. 

When a utilization Line Status is overridden manually from Excluded to Included or vice versa, the Line Status column displays one of the following values:

• Override -Excluded

• Override - Included

For detailed documentation about the Override Line Status, see Overriding Submission Line's Validation Result.  

Error Results

• Reversal Status: The reversal status that resulted from the Coordination of Benefit validation, if any. This column contains an empty value when no result is yielded from the Coordination of Benefit validation.

• Publish Status: Displays the Publish status of the utilization line. One of the following options are displayed:

  • Published

  • Not Published

• Override Reason: The Override reason.

Submission Descriptive

• File Name: Displays the name of the utilization file in which the utilization line data is included.

• Type: Displays the type of the Submission. 

• Duplicate Processed: specifies whether duplicate checking has been performed on this utilization line. One of the following values is displayed in this column:

  • Yes: Duplicate checking has been performed on this utilization line.

  • No: duplicate checking has not been performed on this utilization line.

Transaction Descriptive

• Record Type: Specifies the record type.

• Data Level: Specifies the data level for the line.

• Line Number: Specifies the line number.

• Claim Number: A unique identifier for a prescription and claim processor.

• Record Purpose Indicator: Displays the purpose of the record being submitted.

• Medicaid Record ID: Displays the Medicaid record ID of the utilization line. A value is displayed in this column for the Submission of type Medicaid.

Contract

• Contract ID: Displays the Contract ID associated with the utilization line.

Dates/Time

• Date Of Service: Displays the date the prescription was filled or the professional service was rendered.

• Adjudication Date: Displays the date the claim or adjustment is processed.

• Adjudication Time: Displays the time the claim or adjustment is processed.

• Quarter: Displays the corresponding quarter of monthly Submissions, for example: 2023Q1, 2023Q2, 2023Q3, 2023Q4. A value is displayed in this column for the Submission of type Medicaid.

Product

• Product/Service ID Qualifier: Displays the Code qualifying the value in the Product ID field.

• Product/Service ID: Displays the ID of the product/service submitted in the utilization line.

• Product Description: Displays the description of the product/service submitted in the utilization line.

• Unit of measure: Displays the unit of measure for the Product submitted in the utilization line.

• UPPS: Displays the value of the UPPS used in conversion.

• UOM Conversion Factor: Displays the Value of UOM Conversion Factor used in the conversion.

Rx Descriptive

• Prescription/Service Reference Number Qualifier: Displays the code that qualifies the Prescription/Service Reference Number.

• Benefit Stage Qualifier: Displays the code that qualifies the Benefit Stage Amount.

• Other Coverage Code: Displays the code that indicates whether the patient has other insurance coverage.

• Prescription Origin Code: Displays a code to identify how the pharmacy received the prescription.

• Dispense As Written (DAW)/Product Selection Code: Displays a code that indicates whether the prescriber's instructions regarding generic substitution were followed.

• Compound Code: A code that indicates whether the prescription is a compound.

• Diagnosis Code Qualifier: The qualifier code identifies the patient's diagnosis.

• Diagnosis Code: A code that identifies the diagnosis of the patient.

• Dispensing Status: A code indicating that the quantity dispensed is a partial fill or the completion of a partial fill. This value is only used when inventory shortages do not allow the full quantity to be dispensed at once.

Rx Metrics

• Fill Number: A code indicating whether the prescription is original or refilled.

• Total Quantity: The total quantity submitted in the utilization line.

• Rebate Days Supply: The days of product supply submitted in the utilization line.

• Total Consumed Unit: The calculated total Consumed Units of the product submitted in the utilization line.

•  Prescription Type: The type of the prescription, either a new/refill, an adjusted prescription, or a reversal.

• Total Number of Prescriptions: The total number of prescriptions included in the utilization line.

• Requested Rebate Amount: The total rebate requested for the submitted product in the utilization line.

• Rebate Per Unit Amount: The amount per unit for the submitted product in the utilization line.

Plan

• Plan ID Qualifier: A code indicating the type of data submitted in the Plan ID Code field.

• Plan ID Code: The ID assigned to identify the Plan.

• Plan Name: The name of the plan.

Service Provider

• Service Provider ID Qualifier: The code that qualifies the Service Provider ID.

• NCPDP ID: The assigned NCPDP ID to the pharmacy.

• Medicaid ID: 

• Pharmacy Service Type (UTIL): The type of service the pharmacy provides.

• Primary Provider Type Code:

• Service Provider Name: The pharmacy's name that submitted the utilization line.

• Service Provider Address/ Address 2/ City/ State/ Zip/ Postal Code/Country Code: The address, city, state, and postal code of the Pharmacy that submitted the utilization line.

• Entity Country Code: The country of origin of the prescription. The value is an ISO standard two-letter country code. For a list of supported country codes, visit https://www.iso.org/obp/ui/#search/code/.

Formulary

• Formulary Code: The type of Formulary benefit design utilized by the Plan.

• PBM Formulary ID [Applicable for Spring 24 and later releases]: Displays the Formulary ID shared by the Pharmacy Benefit Manager (PBM) as part of the utilization submission. 

• Cross Reference File ID: The cross reference File ID for the patient.

• Health Plan Product Name: The health insurance coverage benefits that are offered to a patient using a particular product network type.

• Prior Authorization Indicator: A code indicating the health insurance or plan may require pre-authorization for certain services.

• Step Therapy Indicator: Indicates that the patient can try less expensive options before "stepping up" to more expensive drugs.

• Quantity Limit Indicator: Indicates the limit on the quantity of services that the patient will receive.

• 340B Discount Indicator: Indicates if the patient can avail 340B discount.

• LIS Level: Indicates if the patient has limited income and is eligible for a government program.

Segment

• Segment Qualifier 1-6: A definition of how the rebates are stratified in the batch number for the Segment fields.

• Segment 1-6: The business segmentation of rebates to permit one file to go to each manufacturer.

Patient Liability

• Patient Pay Amount: The amount to be paid by the patient to the pharmacy.

• Amount Applied to Periodic Deductible: The amount to be collected from a patient that is applied to a periodic deductible.

• Amount Exceeding Periodic Benefit Maximum: The amount to be collected from a patient included in the 'Patient Pay Amount' due to the patient exceeding a periodic benefit maximum.

• Amount of CoInsurance: The amount of a covered health care service a patient pays after paying the deductible.

• Amount of CoPay: The co-pay amount is usually a fixed amount for different services and drugs, varying depending on the nature of treatment or medication required.

• Amount Attributed To Processor Fee: The Amount to be collected from the patient included in the Patient Pay Amount due to the processing fee imposed by the processor.

• Amount Attributed To Sales Tax: The Amount to be collected from the patient included in the Patient Pay Amount due to the sales tax.

• Amount Attributed to Provider Network Selection: The amount to be collected from the patient included in the Patient Pay Amount due to the provider network selection.

• Amount Attributed to Product Selection/Brand Drug: The amount to be collected from the patient included in the Patient Pay Amount due to the patient's selection of a Brand product.

• Amount Attributed to Product Selection/Non-Preferred Formulary Selection: The amount to be collected from the patient included in the Patient Pay Amount due to the patient's selection of a Non-Preferred Formulary product.

• Amount Attributed to Coverage Gap: The amount to be collected from the patient that is due to the patient coverage gap.

• Health Plan-Funded Assistance Amount: The amount from the health plan-funded assistance account for the patient that was applied to reduce the Patient's Pay Amount. 

Market Basket

• Therapeutic Class Code Qualifier: The type of data being submitted in the Therapeutic Class Code field.

• Therapeutic Class Code: A code assigned to the product submitted in the utilization line.

• Therapeutic Class Description: A text description of the Therapeutic Class Code.

Reimbursement

• Reimbursement Qualifier: The content of the data submitted in the Reimbursement Amount field.

• Reimbursement Amount: The amount that the plan reimburses the pharmacy. 

• Reimbursement Date: The date that the provider was reimbursed for the Product submitted in the utilization line.

Patient

• Encrypted Patient ID Code: The encrypted patient ID.

• Patient Eligibility End Date: The date a patient becomes no longer eligible for the coverage.

• Patient Eligibility Start Date: The date a patient becomes eligible for the coverage.

Prescriber

• Prescriber ID Qualifier: A code qualifying the Prescriber ID.

• Prescriber ID: The ID assigned to the prescriber.

Invoice Details

• Invoice Type 1-5: A description of the transaction type.

• Invoice Rate 1-5: The rate used for the calculation.

• Invoice Price 1-5: The price used for the calculation.

340B Vigilance

Note: The functionality related to 340B Duplicate Discount Validation is available only if you have licensed the 340B Vigilance.

• Send For 340B Evaluation: Specifies whether the Submission in which the Utilization Line is included is opted in for 340B duplicate discount risk assessment. 

• 340B Duplicate Discount Indicator: When a Submission is processed as part of the 340B Duplicate Discount Validation, the process yields the identification of individual utilization line that have a finding. The output is one of the five values that are displayed in this field, the 340B Duplicate Discount Indicator. 

  Each of the five values are identified and defined below and are listed in descending order of priority. Each transaction that yields a finding as part of the risk assessment is only marked with one 340B Duplicate Discount Indicator value, which would be the highest value from the list below (for details, refer to Risk Assessment Validation Details).

  The following values are assigned to the 340B Duplicate Discount evaluated items, as applicable:

  • D0 – When a utilization line contains a 340B Duplicate Discount Indicator finding value of D0, this indicates that the evaluated utilization line matches to a deterministic, or definitive, 340B transaction as verified by the associated Covered Entity (CE) and maintained in either the Medicaid or Commercial Claims Clearinghouse.

  • P1a – When a utilization line contains a 340B Duplicate Discount Indicator finding value of P1a, this indicates that the evaluated utilization line contains a probabilistic finding resulting from the Medicaid Exclusion File (MEF) Risk Assessment for a pharmacy identifier listed in the MEF for a state that does use the MEF to prevent duplicate discounts.

  • P1b – When a utilization line contains a 340B Duplicate Discount Indicator finding value of P1b, this indicates that the evaluated utilization line contains a probabilistic finding resulting from the Medicaid Exclusion File (MEF) Risk Assessment for a pharmacy identifier listed in the MEF for a state that does not use the MEF to prevent duplicate discounts.

  • P2 – When a utilization line contains a 340B Duplicate Discount Indicator finding value of P2, this indicates that the evaluated utilization line contains a probabilistic finding resulting from the Duplicate Discount Risk Assessment by evaluating the prescriber and dispenser NPIs along with the Product NDC, CE scope of services, and Date of Service details.

  • P3 – When a utilization line contains a 340B Duplicate Discount Indicator finding value of P3, this indicates that the evaluated utilization line contains a probabilistic finding resulting from the Pharmacy Risk Assessment by evaluating various aspects of the dispenser and Date of Service details.

• 340B Transmission Date: Specifies the date on which 340B risk assessment batch processing has been initiated for the utilization line.

• 340B Transmission Status: Specifies the current 340B risk assessment batch processing status for the utilization line.

• 340B Clearing House Indicator: The 340B Clearinghouse Indicator is an additional identifier to indicate which deterministic clearinghouse, Medicaid or Commercial, the definitive Rx match was found.  

  One of the  following values are assigned to the 340B evaluated items:

  • DM - Medicaid Deterministic Claims Clearinghouse

  • DC - Commercial Deterministic Claims Clearinghouse

Flexible Fields

Flexible Fields configured as 'Active' will appear here with the given 'Label Name'.

Medical Benefit Descriptive

• Place of Service Code: The code identifies where a product or service is administered.

• Original Line Quantity: The Quantity on the incoming line is copied here. This value is populated only if the line has the JCode Conversion Status as 'Success'.

• Original Unit of Measure:  The UOM on the incoming line is copied here. This value is populated only if the line has the JCode Conversion Status as 'Success'.

• Billed Amount: Total reasonable and customary fee providers charge to provide the type of service received.

• Allowed Amount: Allowable charges for covered services based on the specially negotiated fee between the provider and MCO.

• Date Prescription Processed: The date when the Payer processed the product prescription transaction.

• Quarterly Member Indicator: Number indicating the number of times a member is billed in the billing period.

• Risk Plan Sponsor Code: Code applicable to the plan sponsor at risk for the Submission.

• Prior Authorization Required: An indicator, such as Y/N, characterizing whether a prior authorization was requested for the Submission.

• Co-Pay Percentage: The Co-Pay % applicable to the Medical Benefit transaction.

JCode Details

• JCode: Specifies whether the utilization line items are associated with a specific HCPCS Code or JCode .

  Note: JCode is only available for standard Submissions (i.e Non-Coverage gap Submission)of type 'Commercial - Medical Benefit'.

• JCode Modifier 1-4: A Code indicating drug and other items.

Medical Benefit Conversion

• JCode Conversion Status: Conversion Status of the line from JCode - NDC conversion process. The following are the statuses available for conversions.

  • Success

  •  Error 

  • Not Qualified

• JCode Conversion Error: An error message indicating if any errors occurred during the conversion process.

• Allocation Variable Value: Specifies the allocation variable value used in the conversion.

• HCPCS Conversion Factor: Specifies the conversion factor value used in the conversion.

• National Sales Ratio: Specifies the calculated National Sales Ratio used in the conversion.

Viewing Line Level History

The Validata application maintains the history of all actions taken on every Line within a Submission, including validate, change contract, include, exclude, override, export, assign reversal, export reversal, and clear reversal. You can view the details specific to each action taken, including when the action occurred and who initiated it. The Validation Analyst can view the Line Level history for a select row on the Line Level Details table.

To view Line Level history, do one of the following:

1. On the Line Level Details table, select a row. The History icon is displayed.

   
   Note: When more than one row is selected on the Line Level Details table, the History icon is disabled.

2. Click the History icon. A window is opened. In the header section of the window, the selected Line’s ID is displayed, and the history table is shown.

Or

1. On the Line Level Details table, right-click on the line.

2. Select the History option. A window is opened. In the header section of the window, the selected Line’s ID is displayed, and the history table is shown.

Sorting and Filtering the Lines on the Line Level Details table

All the lines included in the Submission are displayed on the Line Level Details list table. The Validata application allows the Analyst to sort and filter the lines on the Line Level Details list table by applying the available filter options. The filter/sort choices made by the user will be retained from user session to user session until the user changes the options, either by resetting, changing the sort/filter, or selecting from the saved searches. The Analyst can save the filter/sort applied to the Line Level Details list table using the Saving Searches option.

Adding Comment to a Line

The Validation Analyst can add any comments to a selected line to keep track if any future actions required for the line or to notify other users about the respective line.

Note: Comments added to the line-level details list are associated with an entire line. The line-level comment is different from the reason comment that is added for error severity overrides.

To add a Comment to a line:

1. On the Line Level Detail table, click the comment icon, next to the Line ID.
   or
   On the Line Level Detail table, select the Line and click the comment icon.
2. A pop-up window is opened, and the comments tab is displayed.
   In the Comment drawer, you can view if there are any comments added previously to a Line.
3. Specify the comment text in the Add new comment text box. Click the enter icon.

Copy Line Level Details

The copying Line Level feature allows the Validation Analyst to copy the Line Level Details table row information to the clipboard for insertion into another Submission. The Analyst can copy one or more than one selected Line’s information from the list table.

The copy Line action is different from the duplicate Lines.

The Analyst has the following three copying options:

• Copy:

This option copies just the line row information without the header and group header. Only the cell information from the table is copied.

• Copy with Headers

This option copies the selected line row information along with the relevant column headings for the cells.

• Copy with Group Headers

This option copies the selected line row information along with the relevant group headings.

Downloading the Line Level Details list Table Rows

The Validation Analyst can download the lines from the Line Level Details list table in Excel or CSV format. The Analyst set the preference when downloading the lines:

• Download all the rows or only the filtered rows displayed on the Line Level Details list table.

• Download all the columns or only the configured columns displayed on the Line Level Details list table.

Note: When a Line contains any comments, on the downloaded records the comment text will not displayed. Only a Yes or No value will be displayed for the comment component in the downloaded file, where:

• Yes: Specifies, the line contains a comment.

• No: Specifies, the line does not contain a comment.

To download the Line Level Details list table rows:

1. Click the overflow menu on the Line Level Details page (three stacked dots).

2. Select the Download option.

3. The Download Options window is displayed. Specify the following details:

   1. For the Rows field, All is the default selected option. This means all the rows on the Line Level Details list will be downloaded. When you have applied any filters and to download only the filtered rows, opt in for the Filter Only option. When there are no filters applied to the Line Level Details list table, and the user input for Rows is Filtered Only, all the rows from the Line Level Details list table will be downloaded.

   2. For the Columns field, All is the default selected option. Selecting 'All' will include all available columns. Selecting 'Visible Only' will include only columns currently chosen to display. The columns will be downloaded in the order currently shown on the Line Level Details list table. The downloaded data will retain the sort applied to the contents on the Line Level Details list table.

   3. From the File Format drop-down, select in which format you want to export the data. By default, CSV is chosen. You can also set the Excel option.

   4. A default file name is displayed in the File Name field. You can update the default name.

   5. Click Ok.

4. The downloaded file is saved on your local machine.