Viewing Reversals Lines in the Non-Coverage Gap Submission

About Reversals

When a Non-Coverage Gap Submission is validated using a Validation Set that contains the Coordination of Benefit (COB) Validation Rule Set, the COB rule set checks for duplicates between data in the selected current Submission and across Submissions from the same or different source and market segment (A line of business that you define for which Submission data is submitted) so that the Manufacturer does not overpay reimbursements. The Validata application uses the Segment priority to determine how duplicates are handled when running the Coordination of Benefits (COB) validation. For more details about Segments, see Segments and Segment Sets.

For example:

• There is Submission 1 and Submission 2 that contain duplicate lines. Submission 1 has a Segment value, which has a lower priority than Submission 2 Segment value. Submission 1 has been validated and published, followed by Submission 2, which has been validated using a Validation Set that contains the Coordination of Benefit (COB) Validation Rule Set. When duplicate lines are identified in Submission 2 (the Segment of Submission 2 has a higher priority than Submission 1), on the Submission 2, Reversals tab, the Validation Analyst can view the Lines that caused reversals with the Reversals Status column value as Caused Reversals. On the Submission 1, Reversals tab, the Validation Analyst can view the published Lines that contain reversals. The Validation Analyst needs to take the required action on Submission 1, which includes reversals.

• There is Submission 1 and Submission 2 that contain duplicate lines. Submission 1 has a Segment value which has either a higher priority than Submission 2 or a similar priority Segment value. Submission 1 has been validated and published, followed by Submission 2, which has been validated using a Validation Set that contains the Coordination of Benefit (COB) Validation Rule Set. When duplicate lines are identified in Submission 2 (the Segment of Submission 2 has either the same or lower priority than Submission 1), the lines from Submission 2 are assigned with a COB duplicate error. In this case, the duplicate lines are handled like any other that receives a validation error. It is assigned an overall status depending on the severity levels of its accumulated errors.

For more details, see Understanding How Validata Handles Duplicates for the COB Validation.

Building upon the BRG automated integration capability included in Fall 2023 RP2, an additional feature has been added to enable ongoing reprocessing of the Duplicate Discount validation related to BRG. Validata 340B Vigilance add-on has been expanded by introducing an on-demand and configurable re-processing function that also utilizes the integration with BRG to identify potential 340B-related reversals in bulk after submissions have been published and paid. For Rxs that have already been paid, if a later finding identifies a match to the 340B Rx data, a reversal is created using Validata’s reversal framework to enable the user to reverse out the previous units and pull back rebates as an adjustment within a future processing period.

• For Rxs that have already been paid, if a later finding identifies a match to the 340B Rx data, a reversal is created using Validata’s existing reversal framework to enable the user to reverse out the previous units and pull back rebates as an adjustment within a future processing period.

• When an Rx line was omitted from rebate eligibility because of a match to the 340B Rx content and later that Rx was updated to no longer be 340B, the re-processing capability will identify it and, assuming the associated error was the only reason for its exclusion, can permit the ESI/Ascent Rx to now be paid, also as part of the existing reversal process.

On the Reversals list table, the Validation can track the source of the reversal from the value displayed in the Reversal Type column. When the reversal lines are migrated from a version prior to Fall 2023 RP2 to Fall 2023 RP2 or a later version, those lines also will contain the Reversal Type value as COB, which identifies that those lines resulted from the Coordination of Benefit (COB) Validation Rule Set execution.

For more details, see 340B Reprocessing Execution Result.

Viewing Reversals

For the Non-Coverage Gap Submissions, you can view the reversals for lines processed by the Coordination of Benefit Rule Set validation within the Submission. In the Submission details page, the Reversals tab displays the Reversal lines. On the Reversals table, the Reversals Status column displays Caused Reversals, which means that the respective line caused Reversals.

Click on the arrow icon under the Line ID column to view the Line details that contain the reversal caused by this current Submission Line.

You can navigate to the Line Details page of the Submission containing reversals by clicking the Line ID link. You can also navigate to the Submission, where the Line contains reversals, by doing one of the following:

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

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

For detailed documentation about the columns displayed on the Reversals table, see Reversals list table columns section.

For detailed documentation about skipping/accepting reversal lines, see How to Accept/Skip Reversals Lines.

How to Accept/Skip Reversal Lines

When the lines in a Submission with a Lower Segment value that has already been published contain reversals due to the availability of duplicate lines in a Submission with a higher segment value, the Validation Analyst should take action either by skipping or accepting the reversal line within the Submission details page. By accepting the lines containing reversals, the Analyst can include the lines to create a Reversal Publishing. For more details, see How to Publish Reversals. The Analyst can omit the lines from Reversal Publishing by skipping the lines containing reversals.

To Accept/Skip Reversal Lines:

1. Navigate to the Submission.

2. Go to the Reversals tab.

3. On the Reversals tab, a number is displayed next to Reversals, which notifies the Validation Analyst line count that requires an action from the Validation Analyst. This count value gets auto-updated based on the Validation Analyst’s action by accepting or skipping the reversal lines.

4. The lines on the Reversal list table are sorted based on the Reversal Status column value. The Lines for which an action is required from the Validation Analyst are listed at the top. The line within the Reversals list table contains one of the following Reversal Status values:

   • New: New reversal requiring an action from the Validation Analyst either to select accept or skip.

   • In Progress: The Validation Analyst has accepted the reversal but has not yet published it.

   • Processing: Accepted by the Validation Analyst and is included in the current reversal publishing process by the system.

   • Skipped: The reversal is to be omitted from the publishing process. In the following scenario, the lines contain a Skipped status:

     • The lines that have not been published previously from the Submission.

     • The Lines that contain reversals, but the Validation Analyst changes their Reversal Action to Skip.

   • Published: The reversal has been published.

5. The Original lines used to flag reversals are included in the table and do not have a Reversal Status.
   

6. When the lines that contain reversal and an action is required from the Validation Analyst to handle the reversals, on the Reversal list table, the Reversal Action column is in editable mode. When the line does not require an action from the Analyst, the Reversal Action column remains read-only. When a utilization line is identified as a reversal and has a ‘Published Status’ value as ‘Not Published’, the Reversal Status column is displayed as New, and the Reversal Action column is in read-only mode. When the Validation Analyst Publishes the Submission and the reversals line’s ‘Publish Status’ value is updated to ‘Published’, then the respective line is a valid reversal line and the Analyst can proceed with updating the Reversal Action as Accept or Skip.

7. For accepting or skipping one or more reversal lines:

   • Select the lines on the Reversals list table.

   • Accept and Skip option is displayed.
     
     

   • Select one of the following options:

     • When the Accept option is selected, the Analyst can create the Reversal Publishing for the accepted lines. Once the Reversal Action is set to Yes, the Reversal Status of the Line changes to In progress, which notifies the Validation Analyst that it has accepted the reversal but has not yet published it.
       Note: You can change the user input to Skip when required.
       or

     • When the Skip option is selected, reversal is omitted from the publishing process.
       Note: Once you select the Skip option and the Reversal is skipped, the Analyst can not accept it in the future. The Reversal Action user input turns disabled.

Publish/Export Reversals

Model N Validata allows the Validation Analyst to export the reversals to a flat file for further processing in another Payer module or create a Submission directly in the Payer application. After taking the required action to accept or skip the reversal lines, the validation analyst can publish/export the reversals.

When the reversal lines are exported/published, Model N Validata changes the quantity and total prescription amounts from positive to negative values or vice versa. For example, if the quantity for the historical line is 100 and it is marked as a pending reversal against an item in the “winning” validating Submission, the quantity in the export Submission is set to -100. Similarly, if the total prescriptions were 2, the total prescriptions in the export file is set to -2. For more details, see Understanding How Validata Handles Duplicates for the COB Validation.

The files are placed in a shared directory on a server designated by the system administrator for the standard reversal export. Contact your system administrator for information about gaining access to this location. Model N Validata also provides an option to summarize the data prior to exporting it.

Notes:

• To ensure correct results when exporting reversals, you must first run the appropriate validations on the Submission from which you intend to export/publish data. The validations that you must run depend on the values specified in the export mapping set. Recommended Validations for Export Reversals and Create Submission Reversals Jobs provide a list of the validations required for correct processing for various mapping set values.

Reversals List Table Columns

This section lists all the group headers and the column details displayed on the Reversals 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.

• 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.

• 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.

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.  

• Publish Status: Displays the Publish status for the Reversals line. When the reversal line is not published the value is displayed as Not Published. When the reversal line is published the status is displayed as Published.

Reversal

• Reversal Type: Displays the type for the reversals. This column helps the Analyst to understand whether the reversal has resulted from the Coordination of Benefit validation set or from 340B re-processing. One of the following values is displayed:

  • 340B: Identifies that the reversal is yielded after 340B re-processing. For more information about 340B re-processing, see 340B Reprocessing Configuration.

  • COB: Identifies that the reversal is yielded from the Coordination of Benefit validation set result.

• Reversals Category: 
  [Applicable for Fall 2023 RP2 HF7 and later releases]
  Displays the category of reversals. One of the following values is displayed:

  • Clawback: This Reversal Category value is used to represent more traditional use cases where the relevant lines were published and paid and need to be clawed back. In this case, the sign of the affected transactions is flipped to the opposite sign to address the clawback action. This category applies to COB Reversals as well as 340B scenarios where the line was published and paid, then later identified as a 340B error as part of the 340B reprocessing execution.
    Note: For the Reversal lines with Reversal Type as COB, the Reversal Category column value should only be Clawback.

  • Push: This Reversal Category is used as a way to identify lines that were previously not published due to an error but the error has been removed and was the only error, thus opening the door for publication and inclusion in the rebate calculation. This value exists for 340B Reversals and simplifies the identification of these new actionable lines and permits the Reversal Action to be set to Accept or Skip, similar to other reversals. In this case, the relevant lines are published with the received sign represented within the line and are not flipped to the opposite value.
    Note: For the Reversal lines with Reversal Type as 340B, the Reversal Category column value is displayed as Clawback or Push depending on the Line Status and 340B Reprocessing validation result (810 error added or removed).

• 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.

  • New: New reversal requiring an action from the Validation Analyst either to select accept or skip.

  • In Progress: The Validation Analyst has accepted the reversal but has not yet published it.

  • Processing: Accepted by the Validation Analyst and is included in the current reversal publishing process by the system.

  • Skipped: The reversal is to be omitted from the publishing process. In the following scenario, the lines contain a Skipped status:

    • The lines that have not been published previously from the Submission.

    • The Lines that contain reversals, but the Validation Analyst changes their Reversal Action to Skip.

  • Published: The reversal has been published.

• Reversal Action: When the lines that contain reversal and an action is required from the Validation Analyst to handle the reversals, on the Reversal list table, the Reversal Action column is in editable mode. When the line does not require an action from the Analyst, the Reversal Action column remains read-only. When a utilization line is identified as a reversal and has a ‘Published Status’ value as ‘Not Published’, the Reversal Status column is displayed as New, and the Reversal Action column is in read-only mode. When the Validation Analyst Publishes the Submission and the reversals line’s ‘Publish Status’ value is updated to ‘Published’, then the respective line is a valid reversal line and the Analyst can proceed with updating the Reversal Action as Accept or Skip.

Submission

• Submission ID: 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

• Override Reason: The reason for overriding.

• Override Comment: Any comments provided for overriding.

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: Specifies the Record Type for the line.

• 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: Specifies the Medicaid ID.

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

• Primary Provider Type Code: Specifies 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:

  • 810 – The risk assessment finding value of 810, indicates that the evaluated Rx Transaction Item within the Submission matches to an available transaction within the BRG repository of definitive 340B Rx utilization data as provided by Covered Entities (CEs) on behalf of manufacturers. This 810 value represents both the assigned 340B Duplicate Discount Indicator and the internal validation error code assigned to the Rx transaction when this finding is identified.

  • 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 the 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.