Duplicate Lines in Non-Coverage Gap Submission

Duplicates Overview

Duplicates exist in utilization data for a variety of reasons. Since most pharmaceutical manufacturers define duplicates differently, you must understand what is meant by a "duplicate." Every pharmacy serializes prescription reference numbers. You have a duplicate when the utilization line has the same prescription reference number, filled at the same pharmacy, for the same product, on the same day. Some other factors are also considered when identifying the duplicates, like Fill Numbers, Date of Service, Quantity of Scripts, Product ID, and Debit/Credit Pairs.

Validata provides the following validations that check for duplicates:

• Duplicate Check: Checks for duplicates between data in the selected Submission and across all Submissions. You can either specify that duplicates be identified within data received from the same source (internal duplicate check) or within data received from different sources (external duplicate check). You can define the columns of data that are compared for duplicates, as well as the date of service and transaction data selections. For detailed documentation, see Validate Submission Files for Duplicates and Configuring the Duplicate Check Rule Set.

• Debit/Credit Pair: Validates debit/credit pairs in a Submission. You can either specify that debit/credit pairs be identified within data received from the same source (internal debit/credit pair check) or within data received from different sources (external debit/credit pair check). You define the columns of data that are compared for debit/credit pairs, as well as the date of service and transaction data selections.  For detailed documentation, see Validate Submission Files for Duplicates and Configuring the Debit/Credit Pair Check Rule Set.

• Coordination of Benefits: Checks for duplicates between data in the selected Submission and across all Submissions from the same or different source and market segment. You can specify against which source and segment data the Submission utilization line is compared. You determine how duplicates are handled by ranking the comparable market segments. You can also reverse transactions on duplicates that have been previously exported/published. For more information, see Configuring the Coordination of Benefit Rule Set.

When the Submission is validated using one of the above three validations, and the validation mechanism finds duplicate lines in the Submission, those duplicate lines are displayed under the Duplicate tab on the Submission Details page. The Validation Analyst can view the lines that contain duplicates within this Submission and across Submissions listed on the Duplicates page table. This allows the Validation Analyst to take the required action by removing the duplicate lines from one of the Submissions.

Viewing the Duplicate Lines

To view the duplicate lines:

1. Open a Submission.

2. Click the Duplicates Tab.
   All the Lines included in the Submission that are duplicated within this Submission and duplicates across Submissions are displayed in the table. For a detailed description of the columns displayed in the Duplicates table, see List of Columns on the Duplicates Table.

3. The duplicate lines from the current Submission are listed on the Duplicates table by default. On clicking the arrow icon on the Line ID, the Analyst can view all the other linked Submissions to which the respective Utilization Line is associated.
   
   

4. Click the Line ID link to navigate to the respective Submission > Line Level Details page. You can also navigate to the Submission, where the Line is duplicated, by following one of the below:

   • Mouse over the Submission ID, and a popup window is displayed showing the Submission details. Click Go to Submission link.

   • Mouse over the Submission Name, and a popup window is displayed showing Submission details. Click Go to Submission link.

On the Submission page, the Analyst can take required action like removing the file from the Submission. When the file containing lines that have been processed for duplicates is deleted from one Submission, the Error Code value and the Line Status in the other Submission will be auto-updated. For more information, see Removing Files From a Submission that Contains Duplicates.

List of Columns on the Duplicates Table

This section lists all the group headers and the column details displayed on the Duplicates list table, as per the 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 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 one error, and the error codes flow beyond the width of the Error Code column, the number indicator specifies the number of errors associated with the utilization line. Click on the Error Code to view the full description of the errors.

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.  

Submission

• Submission: Specifies the ID of the Submission with which the Line is associated.

• Submission Name: Specifies the Name of the Submission with which the Line is associated.

• Rebate Period: Specifies the Rebate Period start and end date for the Submission.

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: Displays the override reason specified when overriding the error severity of the utilization line.

• Override Comment: Displays the override comment specified when overriding the error severity of the utilization line.

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.

Transaction Descriptive

• Record Type: [TBD]

• Data Level: [TBD]

• Line Number: [TBD]

• 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.

Removing Files From a Submission that Contains Duplicates

The Validation Analyst can delete the file from a Submission that contains a duplicate line within the Submission. For details about deleting files from a Submission, see Delete Included File.

• When deleting a file that includes a CDP error, where one of the lines in the debit/credit match is in another file(s) in the same or in the other submission(s), the CDP error will be removed from the other line in the other file. The status of the other line in the other file might be due to this update. On the Submission Details page, Process and results overview section, the matrix values like Line and Units count and Amount value will be auto-updated with the changes done.

• When deleting a file that includes a DUP error, where one of the lines in the duplicate match is in another file(s) in the same or in the other submission(s), the DUP linkage will be removed from the other line in the other file. The status of the other line in the other file might be due to this update.

• When deleting a file that includes a COB error, where one of the lines in the duplicate match is in another file(s) in the same or in the other submission(s), the COB Error Code will be removed from the other line in the other file. The status of the other line in the other file might be due to this update. On the Submission Details page, Process and results overview section, the matrix values like Line and Units count and Amount value will be auto-updated with the changes done.