CMS Pub. 100-18, ch. 14, § 50.8.1

In 2009, Part D sponsors began using NCPDP Financial Information Reporting (FIR)

standard to transfer TrOOP balances and gross covered drug costs whenever a beneficiary

makes an enrollment change at the contract-level during the coverage year. The transfer

process begins with the CMS Part D Transaction Facilitator’s identification of a change in

enrollment at the contract level. Upon identification of the change, the facilitator generates a

FIR transaction to each prior sponsor with which the beneficiary was enrolled or that paid

covered part D drug claims for the beneficiary during the coverage year. Transactions begin

with a FIR Inquiry to the earliest sponsor on record in the coverage year; that sponsor's

Inquiry response is returned to the facilitator. Each sponsor responds with their monthly

gross covered drug costs and TrOOP amounts. If there are multiple plans prior to the

current plan of record, the accumulator values from the response just received are placed in

a FIR Exchange transaction and forwarded to the next sponsor. The facilitator receives that

next sponsor’s transaction response and continues the process of receiving and forwarding

the prior accumulators until each subsequent sponsor in consecutive order has received and

responded to a FIR Exchange transaction. The final Exchange transaction response contains

the year-to-date monthly TrOOP-related data for all plans prior to the current plan of record;

these accumulated monthly amounts are then forwarded by the facilitator via a FIR Update

transaction to the current plan of record.

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An updated version of the CMS automated TrOOP balance transfer implementation

guidance issued by CMS on October 20, 2008, is included in Appendix C. Detail on the FIR

transaction standard is provided in the latest version of NCPDP Financial Information

Reporting Standard Implementation Guide available to NCPDP members on their Website;

see Appendix B for the specific Web address.

Plan sponsors are notified of unsuccessful transactions via daily beneficiary-level exception

reports from the CMS Part D Transaction Facilitator to both the sponsor’s processor’s and

the sponsor’s automated Troop Balance Transfer (TBT) contacts (as entered in the Health

Plan Management System (HPMS)). CMS expects that when issues arise, they are resolved

expeditiously to achieve successful transfer of the beneficiary data in a timely manner 100

percent of the time. Sponsors should not delegate problem-solving to their claims processor

alone; certain issues leading to transaction failure are beyond the scope of the processor’s

responsibility. For example, a significant number of problems that have occurred to-date

appear to stem from inconsistencies between the 4Rx data reported to CMS and used by the

CMS Part D Transaction Facilitator for the TBT transactions, and the 4Rx data in the

sponsor’s processor system. It is the responsibility of the Part D sponsor to ensure that

consistent beneficiary-identifying data are reported to CMS and its Part D claims processor,

and that any inconsistencies are corrected. Part D sponsors must ensure not only that they or

their delegated enrollment-processing vendors submit accurat e 4Rx data on behalf of all

enrollees upon enrollment in accordance with section 50.1 of this chapter, but also that

previously submitted 4Rx data are updated within CMS whenever processing arrangements

cause this data to change for existing enrollees.

NOTE: If a sponsor changes its FIR processor, the sponsor must ensure that FIR

transactions are routed to the appropriate processor and that transactions related to the prior

year(s) can continue to be processed for the 36-month period required by CMS

(§ 423.466(b)). This may require making arrangements either with the former processor to

continue processing prior year FIRs or with the new processor to assume that responsibility

See section 50.14 of this chapter for more information on the 36-month time period and

Appendix C for more information on the FIR process.