CMS Pub. 100-18, ch. 14, § 50.14

Pharmacies generally rely in good faith on the information returned on an E1 or sponsor

approval of claims by receipt of a paid claim status. In some cases due to enrollment issue,

the wrong payer paid for a prescription. Given the volume of drug claims that pharmacies

would need to re-adjudicate as a result of incorrect Part D enrollment information available

at the point-of-sale, re-adjudication would have imposed a significant administrative and

financial burden on pharmacies. Therefore, payer-to-payer reconciliation procedures were

developed to mitigate the administrative and financial burden involved with re-adjudication

of claims.

CMS requires that sponsors use the payer-to-payer process. In addition, unforeseeable

future events may necessitate processes to reconcile payments when a payer other than the

correct Part D sponsor of record pays as primary for a covered Part D drug for an enrollee.

These other reconciliation processes may be developed by CMS to accomplish payment

reconciliation without involving pharmacy reversal and re -adjudication of claims or the

public release of a payer’s proprietary information, such as negotiated rates.