Publishing and Exporting Non-Coverage Gap Submission

About Submission Publish/Export

When the Submission is validated, the results are reviewed, and the validation analysis is marked as completed in the Run Validations card, the Submission is ready to be published. The Validation Analyst can manually run the Submission publish action. Using the Publish functionality:

Using the Publish option, the Validation Analyst can create a Submission in the downstream processing Payer application for the validated lines. A Submission is auto-created in the Payer application.
Using the Export option, the Analyst can export the validated submission lines. The exported .txt file containing the exported lines will be displayed on the Exports tab in the Publish window. The Analyst can later download the .txt file and use it for processing in the Payer application.

Notes:

For the Non-Coverage Gap Submission Submissions of type Commercial, the Analyst can export the validated submission line for processing in another system using the Export option or directly create a Submission in the Payer application using the Publish option.
The Analyst can export the validated submission line for processing in another system using the Export option for the Non-Coverage Gap Submissions of type Medicaid.
- Note: The Publish option is unavailable for Submission of type Medicaid.

How to Publish/Export Non-Coverage Gap Submission

This section describes how to publish/export a Non-Coverage Gap Submission.

In the Validata application, navigate to the Submission menu.
On the Submissions page, from the list table, click the Submission Name link to open the Submission.
The Submission details page is displayed.
Click the Publish Submission card.
Note: When a Submission is not validated and marked as Analysis Complete, the Publish card is not activated.

On the Publish card, there are two options:
- Publish: Select this option to publish the validated Submission lines and create a Submission in the Payer application.
  
  Note: The Publish option is unavailable for Submission of type Medicaid.
- Export: Select this option to export the validated Submission lines and use them for processing in another system.
The Publish window is displayed when you click the Publish or Export button. You can also select the Publish Options/Export option by clicking the ellipses on the Submission header section.

On the Publish/Export window, the Submission name is displayed in the header section. Specify the following details:

General details

Publish submission name:

By default, the name of the Submission is displayed. You can update the name of the Submission. The Publish submission name should have a unique value.

When you select the Publish option, a Submission will be created in the Payer application with this Publish submission name.
When you select the Export option, an export file will be created with the Publish submission name.

Transaction period:

By default, the Submission Rebate period start and end date value is populated. The Submission lines whose Date of Service value falls under the specified Transaction period range only those lines will be considered for the Publish/Export action. For example, if you specify a start date of 2023-07-31 and an end date of 2023-08-30, utilization lines with the Date of Service on or between those dates are included in the Publish/Export action. You can manually specify the Transaction period start and end date value in the YYYY-MM-DD format or choose using the calendar picker.

Line Status:

Publish/Export Lines with a particular Line status. The default selected option for this user input is Included. You can also choose one of the following options:

Included: All the lines in the Submission with Line Status value as Included will be considered for the Publish/Export action.
New: All the lines in the Submission with the Line Status value New will be considered for the Publish/Export action.
Excluded: All the lines in the Submission with the Line Status value Excluded will be considered for the Publish/Export action.

For example, for a Non-Coverage Gap Submission of type Commercial, when the Publish options is selected as CPP: Contract/Plan/Product, the lines with the same Contract, Plan, and Product are summarized on one line.
For a Non-Coverage Gap Submission of type Medicaid, when the Publish options is selected as CPQPM: Contract/Plan/Quarter/Product/Medicaid Record ID, the lines with the same Contract, Plan, Quarter, Product, and Medicaid ID are summarized on one line.

Note: When the manufacturer has procured the Formulary Compliance Evaluation submodule license when publishing the Submission line to the Payer application, additional summarization logic is followed. For detailed documentation, see Related Publish/Export Details with Formulary Compliance Evaluation Subscription.

Publish status: Publish/Export Lines with a particular Publish status. The default selected option for this user input is All. You can also choose one of the following options:

All: All the lines, irrespective of the publish status, i.e., either previously published or not published, will be considered for the Publish/Export action.
Published: The Submission lines that were earlier published will be considered for the Publish/Export action.
Not Published: The Submission lines that were not yet published will be considered for the Publish/Export action.

Backbill details

The Submission often includes lines with the Date of Service value before the Transaction Start Date. Using the Backbill details, you can set whether you want to include the lines containing a Date of Service before the specified Transaction Start Date.

Include backbills: This user input allows you to opt in or opt out of the Submission's backbill configuration. By default, the Include backbills toggle is set to Yes.
- You can set the Include backbills toggle to No if you do not want to consider the backbill Date of Service lines from the Submission for Publish/Export. Backbill-related user inputs will be hidden on the user interface.
- When the Include backbills toggle is set to Yes, the Analyst can specify the backbill period details, and those lines whose Date of Service falls within the defined backbill period will be considered for the Publish/Export.
Number of backbill periods: Specify the number of backbill periods in the text box. Lines with the Date of Service within the number of periods you specify before the Transaction Start Date are considered from the Submission for publish/export.
Backbill export period: When the Number of backbill periods is entered, you can specify the export period to use in relation to backbills. You can select one of the following options:
- Quarterly: This is the default selection for the Backbill export period. When Quarterly is selected, the Validata application will consider the value specified for the Number of backbill periods as the number of quarters.
- Monthly: When Monthly is selected, the Validata application will consider the value specified for the Number of backbill periods as the number of months.
  For example, the contract can be monthly or quarterly when creating a submission. When exporting/publishing submission lines, if backbills are included, the lines exported/published depend on the user input for the Number of backbill periods and Backbill export period.
  
  When the Backbill export period is Quarterly, Validata counts back three months for each quarter you specified starting from the Transaction Start Date. For example, if the Transaction period start date is April 1, 2023, and the Number of backbill periods is set to 1. Lines with Dates of service between January 1, 2023, and March 31, 2023 are considered for backbills. Lines with Dates of service prior to January 1, 2023 are not considered.
  
  When the Backbill export period is Monthly, Validata counts back the appropriate number of months you specified starting from the Transaction Start Date. For example, if the Transaction period start date is April 1, 2023, and the Number of backbill periods is set to 2. Lines with Dates of service between February 1, 2023, and March 31, 2023, are considered for backbills. Lines with Dates of service before February 1, 2023, are not considered.
Include backbills in summary: The Include backbills in summary toggle is set to No by default.
- When Include backbills in summary is set to Yes, the lines with Dates of service within the specified Backbill export period before the Transaction period start date are summarized in the same line.
- When Include backbills in summary is set to No, the lines with Dates of service within the specified Backbill export period before the Transaction period start date are summarized in a separate line.

Filters

Select the following filter options:

Contracts: Select the Contract ID to include in the export/publish file. Only those lines that contain the selected Contract IDs will be included in the export/publish process. When you do not select any Contract, all the lines in the Submission will be included in the export/publish process.

Note:
- The list of available contracts depends on the type of Submission, either Commercial or Medicaid. Commercial transactions also depend on whether it’s a Tricare transaction.
- The Contract ID List includes only those that are global or are associated with the current division.
Plans: Select the Plan to include in the export/publish file. Only those lines that contain the selected Plans will be included in the export/publish process. When you do not select any Plan, all the lines in the Submission will be included in the export/publish process.

Note:
- Plans include all trading partners regardless of the transaction type.
Products: Select the Products to include in the export/publish file. Only those lines that contain the selected Products will be included in the export/publish process. When you do not select any Product, all the lines in the Submission will be included in the export/publish process.

If you select a Product or Plan, the Submission must have been validated using the appropriate Identify rule set. For example, first, you would validate the Submission using the Identify Plan rule set and then choose the Plans to filter the exported data.

After providing the details on the publish Submission window, choose one of the following options:

Click the Export button to export the validated Submission result to a .txt file and use that later for processing in the Payer application. A confirmation message is displayed on the Submission Overview page, notifying the users that the Submission export has been initiated.

The downloaded export file can be viewed on the Exports tab when the export is completed. For detailed documentation about viewing the exported file, see the Viewing Exported Files.
Click the Publish button to auto-create a Submission in the downstream Payer application. After the successful publishing, a confirmation message is displayed on the user interface.

For detailed documentation about Publish progress and status details, see the Viewing Publish Progress and Status.

Publish Progress Status Details

The Analyst can verify the publish progress or status within the Submission in the Publish Submission card.

: This icon specifies that the Submission is not ready for Publish/Export.
: This icon specifies the Submission is ready to for Publish/Export. A user action is required.
: This icon specifies that the Submission publishing has been completed. After completing the publishing, the Re-Publish button is displayed on the Publish Submission card. Using the Re-Publish button, the Analyst again initiate the publish action for a Submission. For details, see Re-Publishing Submission.

The date and time when the publish action was completed is displayed.

Viewing the Exported File

The Validation Analyst can view and download the exported Submission on the Exports tab.

To view the Exports tab, do one of the following:

On the Publish Submissions card, click the Exports button.
or
On the Submission header section, click the ellipsis (there dots) and select Publish Options/Export.

On the Exports tab, the Analyst can view the following details:

File Name: Specifies the name of the exported file. The name provided in the Publish submission name field is assigned to the exported file.
Download: Using the download option, the Analyst can download the exported .txt file.
Type: The file type is displayed: One of the following options is displayed:
- Submission:
- Reversals:
Options: The Options column displays a consolidated list of all the options selected in the Publish Options tab, like Transaction period, Publish options, Export Mapping set name, and the Line Status value.
User: Specifies the name of the user who performed the export task.
Time: Specifies the date and time information when the file was exported.

You can apply filters on the exports table list and sort the columns.

Re-publishing a Submission

When a publish action is completed, the Re-Publish button is displayed on the Publish card. The Re-publish button on the Publish Submission card allows the Validation Analyst to re-publish a Submission.

On clicking the Re-publish button, the Publish window is displayed. The Analyst can specify the publish details and proceed with action by clicking the Publish button.

Related Publish/Export Details

Recommended Validations for Export and Publish Jobs

Before using the Export or Publish options for the Submission, you should run specific validations to ensure that the data exports correctly. The recommended validations depend on the values included in the Mapping Set used for the Publish/ Export process.

Table Name	Column Name	Recommended Validation
Line Level Details	Contract ID	Contract - Plan Identification or Contract - Product Identification
Line Level Details	Date Of Service	Date and Numeric, Time Validation
Line Level Details	Formulary Code	Formulary Validation
Line Level Details	Patient Pay Amount	Date and Numeric
Line Level Details	Pharmacy Service Type	Identify Pharmacy
Line Level Details	Plan ID Code	Identify Plan
Line Level Details	Plan ID Qualifier	Identify Plan
Line Level Details	Plan Name	Identify Plan
Line Level Details	Prescription/Service Reference Number Qualifier	Date and Numeric
Line Level Details	Product Description	Identify Product
Line Level Details	Product/Service ID	Identify Product
Line Level Details	Product/Service ID Qualifier	Identify Product
Line Level Details	Rebate Per Unit Amount	Date and Numeric
Line Level Details	Reimbursement Amount	Date and Numeric
Line Level Details	Reimbursement Date	Date and Numeric
Line Level Details	Service Provider ID	Identify Pharmacy
Line Level Details	Service Provider ID Qualifier	Identify Pharmacy
Line Level Details	Total Number of Prescriptions	Date and Numeric
Line Level Details	Total Quantity	Date and Numeric
Transaction Item	Unit of Measure	Date and Numeric

Exporting Backbills

When the Include backbills toggle is set to yes, the Submission lines are exported or published depending on the values set for the Number of backbill periods, Backbill export period, and Include backbills in summary fields in the Backbill details section of the Publish window.

Note that the Start Date and End Date could be quarterly, monthly, or something other than quarterly or monthly, for example, 1/1/2023 to 6/30/2023, or 1/1/2023 to 12/31/2023.

Note: The Include backbills in summary option is only available for Non-Coverage Gap Submissions. It is not available for Coverage Gap Submissions.

Backbills Period	Include X Periods	Include in Summarization	Results
Quarterly	1	No	Exports for the original transaction period, with the start and end dates defined for the export. Exports backbills for just one quarter, puts one row in the file with start and end dates reflecting the backbills quarter.
Quarterly	2 or more	No	Exports for the original transaction period, with the start and end dates defined for the export. Exports backbills for multiple quarters, however many back specified, puts one row in the file for each quarter, with start and end dates reflecting the backbills quarters.
Quarterly	1	Yes	Exports summarized data for the original transaction period, with the start and end dates defined for the export. Exports backbills for just one quarter, summarized with the original data based on selected option, with start and end dates reflecting the export start and end dates.
Quarterly	2 or more	Yes	Exports summarized data for the original transaction period, with the start and end dates defined for the export. Exports backbills for multiple quarters, summarized with the original data based on selected option, with start and end dates reflecting the export start and end dates.
Monthly	1	No	Exports for the original transaction period, with the start and end dates defined for the export. Exports backbills for just one month, puts one row in the file with start and end dates reflecting the backbills month.
Monthly	2 or more	No	Exports for the original transaction period, with the start and end dates defined for the export. Exports backbills for multiple months, however many back specified, puts one row in the file for each month, with start and end dates reflecting the backbills months.
Monthly	1	Yes	Exports summarized data for the original transaction period, with the start and end dates defined for the export. Exports backbills for just one month, summarized with the original data based on selected option, with start and end dates reflecting the export start and end dates.
Monthly	2 or more	Yes	Exports summarized data for the original transaction period, with the start and end dates defined for the export. Exports backbills for multiple months, summarized with the original data based on selected option, with start and end dates reflecting the export start and end dates.

Summarization Example

Note: This example is only relevant for Non-Coverage Gap Submission. It is not relevant for Coverage Gap data Submission.

Consider the following Submission:

Product	Contract	Plan	Dare of Service	Quantity
prod1	contr1	plan1	01/01/2022	100 units
prod1	contr1	plan1	01/03/2022	100 units
prod1	contr1	plan1	12/15/2021	100 units
prod1	contr1	plan1	06/16/2022	100 units

The following export and summarization properties are selected:

Start Date: 01/01/2022
End Date: 03/31/2022
Include backbill within 1 quarter

If Include Backbills in Summarization is not selected, backbill items are summarized separately and two lines are created, as follows:

Product	Contract	Plan	Start Date	End Date	Quantity	Items
prod1	contr1	plan1	01/01/2022	03/31/2022	200	1,2
prod1	contr1	plan1	10/01/2021	12/31/2021	100	3

If Include Backbills in Summarization is selected, backbill items are not summarized separately and one line is created, as follows:

Product	Contract	Plan	Start Date	End Date	Quantity	Items
prod1	contr1	plan1	01/01/2022	03/31/2022	300	1,2,3

Note: Because line 4 in the Submission does not fall within either the specified Transaction Start Date and Transaction End Date or the one backbill quarter to be included, it is not included in any of the summarized lines.

Related Publish/Export Details with Formulary Compliance Evaluation Subscription

[Applicable for Spring 2024 and later releases]

When a Submission is exported or published, the lines in the exported file and Submission created in the Payer application are summarized by the PBM Formulary ID and Date of Service, along with the selected Publish Option. For example, when the Publish Option is selected as CPP, along with Contract/Plan/Product, the Validata application also considers the utilization line's PBM Formulary ID and Date of Service value. For all the utilization lines exported/published from Validata to the Payer application, from the inbound utilization line, the month’s start date and end date to which the line’s Date of Service pertains is regarded as the Start Date and End Date for the utilization line.

For example, a Submission contains utilization lines as below:

When published/exported, the lines will be summarized based on the PBM formulary ID and Date of service month value. The lines with a common PBM Formulary ID and Date of Service that fall between a common Month Start Date and End Date are grouped together as one line.

Notes:

The Payer contract may undergo various setup or configuration revisions, which may pertain to effective-dated mid-month event changes to contractual formulary requirements, product or plan eligibility changes, and benefit rate and tier changes, in addition to Wholesaler Acquisition Cost (WAC) price changes. Now, when performing the monthly summarization for the utilization data lines, the Validata application slices the data by taking into consideration to these mid-month event changes. It summarizes data lines based on the selected Publish Option along with the PBM Formulary ID before and after the change dates.

For example, the Product with Product ID 19500100102 had a WAC price revision in the same month, and the WAC prices are defined for two different effective periods as below:

The inbound Rx utilization data contains this product with different Date of Service values, as shown in the below illustration:

When this Submission is published, the Rx lines are published to the Payer application, and the lines are summarized monthly based on the price effective dates. From the above example, the lines summarization happens as below:

There are two different Rx utilization lines with a Date Of Service value that falls in March 2023, but the lines are not summarized in a single utilization line in the Payer application as the WAC price changed. Hence, two different utilization lines are created with the Util Start Date and Util End Date values as per the WAC price effective period.

Master Data may undergo revisions, such as updates in the Manufacture Market Basket/Product Set and Product Hierarchy or dates used on the formulary requirements and Product Family changes, such as additions, deletions, and modification of the dates. When performing monthly summarization for the data lines, the Validata application slices the data by taking into consideration to these mid-month event changes. It summarizes data lines based on the selected Publish Option along with the PBM Formulary ID before and after the change dates.