CMS Pub. 100-18, ch. 14, § 50.14.1

Beneficiaries have the opportunity to change their Part D plan enrollment during the

coverage year, which consequently creates situations in which, due to lags associated with

the enrollment process and information systems updates, the sponsor from which a

beneficiary has transferred makes payment for covered prescription drug costs incurred after

the effective date of the beneficiary's enrollment in the new sponsor of record. In 2006,

CMS developed a plan-to-plan ( P2P) reconciliation process with sponsor participation. This

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process, implemented in three phases, enables CMS to process prescription drug event

(PDE) data in these P2P transition situations and allow for financial reconciliation between

the affected Part D sponsors. The process's design reflects the consensus of sponsor

participants to prevent disclosure of proprietary pricing information by masking the NDC

coding. Furthermore, to protect sponsors from exposure to costs outside the initial formulary

transition period, CMS established a 30- day P2P transition period. Therefore, the P2P

transition period includes claims with dates of service less than or equal to the later of:

1. 30 days after the effective date of the new plan enrollment, or

2. 30 days after the date CMS processes the new contract of record enrollment.

To address the payment reconciliations needed to resolve these enrollment transition issues,

CMS requires the ongoing use of the P2P reconciliation and reimbursement process.

Therefore, throughout each coverage year, Part D sponsors will continue to receive monthly

P2P reports showing the payables and receivables for which financial settlement is required.

PDE guidance describing the process is available on the CMS Website; see Appendix B for

the specific Web address.

When an enrollment record is retroactively terminated (audited off) and the audited off plan

has paid claims for the beneficiary, the plan may include these costs to non-benefit expense

component of the bid. This guidance super sedes the CMS memo dated November 25th 2015

“Updates Regarding Automated TrOOP Balance Transfer and Plan to Plan

Reconciliation”.