CMS Pub. 100-18, ch. 14, § 50.14.4

The plan-to-plan reconciliation process resolves those situations in which a Part D sponsor

other than the sponsor of record paid claims for a beneficiary during the initial transition

period. However, situations will continue to arise outside the plan-to-plan process in which

other payers that are not Part D sponsors either pay when they should not have paid at all, or

pay more than they should have, because they paid out of the correct payer order. In these

situations, Part D sponsors are required to work with these providers of other prescription

drug coverage to resolve these types of payment issues. Other payers, as well as

beneficiaries, are entitled to seek compensation from the Part D sponsor once the Part D

enrollment is confirmed.

Therefore, sponsors should implement processes to handle payment resolution directly with

other Non-Part D payers, beneficiaries, and others who are holding receivables on the

beneficiaries’ behalf without seeking recovery from pharmacies. Sponsors may not restrict

the payment resolution process by imposing timely filing requirements on these other parties

that are more restrictive than the timeframe required in Federal regulations at § 423.466(b).

This provision, revised in the February 2015 F inal Rule (80 FR 7912) requires Part D

sponsors to coordinate benefits with SPAPs and other entities providing prescription drug

coverage, beneficiaries and others paying on the beneficiaries’ behalf for a period 36 months

from the date on which the prescription for a covered Part D drug was filled.

In instances when Medicaid has paid for a covered Part D drug and then seeks

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reimbursement from Part D, the sponsor should handle the Medicaid subrogation as follows:

3. Refund Medicaid the lesser of the sponsor’s out-of-network pharmacy allowed

amount or the amount sought by Medicaid.

4. Apply no beneficiary cost-sharing or low-income subsidy to the claim.

The pharmacy-initiated reverse and rebill approach supports only a portion of the retroactive

claims adjustments a Part D sponsor must handle. Therefore, sponsors must work directly

with other payers to resolve reimbursements and recoveries for the majority of retroactive

claims adjustments. Resolution of these latter adjustment actions becomes more complex by

the absence of the other payers’ amount paid on the N transaction to the Part D plan. In

order to ensure the confidentiality of pharmacy pricing information, coordination of benefits

on initial claims is accomplished by reporting to the Part D sponsor only the amount of the

beneficiary’s payment after the supplemental payment.

As a result, a Part D sponsor attempting to determine refund or recovery amounts without

having the pharmacy reverse and rebill the original claim must calculate the amount of any

supplemental payment made by another payer by determining the difference between the

Part D cost-sharing and the beneficiary amount paid after the supplemental payment. While

CMS acknowledges that electronic transaction standards are not yet available to support

timely, reliable, and precise coordination on adjusted claims when multiple payers are

involved, it continues to hold sponsors accountable for making best efforts to coordinate

benefits generated by claim adjustments.