Part D phase and accumulators and PDE <> BlueButton mapping

[Michael Rochlin]

Hi, I'm trying to make sure I'm showing people with medicare accurate information about their progress towards their deductibles.

PDEs are supposed to show a number of pieces of information that don't appear to be in EOBs for BlueButton and wondering if theres a way to access them:

- Tier

- Beginning/Ending Phase

- Formulary code

Theres also a reference to a BENEFIT_PHASE variable in the bluebutton docs but I can't find it anywhere in dummy or real data. 

Given a tier + contract number + plan benefit id, I think I can figure out whether the claim counts towards the deductible. At the least, with BENEFIT_PHASE or the Beginning/Ending Phase from the PDE I would be able to show the user what phase they are in.

Any advice would be very helpful.

Thanks 

[Brady Fausett]

Hello Michael,

Brady from the Blue Button API Team here.  I apologize for the delayed response.  These data fields are not currently available in our API, but I will make sure to take this to the Blue Button team about potentially adding these fields, if possible, in the future.  However, there are some fields that may be helpful for you to understand how much was paid for the medication as well as how much was paid by the beneficiary.  I will outline these fields below for you.

• Total Prescription Cost  -  This variable is the total cost of the prescription drug event and is taken directly from the original PDE.
  • you can find it within the FHIR response here: eob.item[N].adjudication[N].amount.value WHERE eob.item[N].adjudication[N].category.coding[N].system = "https://bluebutton.cms.gov/resources/codesystem/adjudication"
    AND eob.item[N].adjudication[N].category.coding[N].code =  "https://bluebutton.cms.gov/resources/variables/tot_rx_cst_amt"
• Patient Pay Amount  - This variable is the dollar amount that the beneficiary paid for the PDE without being reimbursed by a third party.
  • you can find it within the FHIR response here: eob.item[N].adjudication[N].amount.value WHERE eob.item[N].adjudication[N].category.coding[N].system = ""https://bluebutton.cms.gov/resources/codesystem/adjudication"
    AND eob.item[N].adjudication[N].category.coding[N].code =  "https://bluebutton.cms.gov/resources/variables/ptnt_pay_amt"

I hope this helps.  Let me know if you have any other questions.

Thanks!

Brady

[Dylan Klein]

Hi Brady,

I know it's been some time since this thread was active however I've found something relevant to this question. I found the following values in a PDE pharmacy EOB and it is not clear to me what is the member liability and the submitted amounts in this scenario? I'm trying to understand how to interpret the various codes.

Thanks!

Dylan

[Developer Group for CMS Blue Button API]

Hello - 

Regarding the various codes, here is some additional information from Research Data Assistance Center (ResDAC):

1. FHIR variable: paidbypatient
   Blue Button Varname: ptnt_pay_amt
   Definition: This variable is the dollar amount that the beneficiary paid for the PDE without being reimbursed by a third party.The amount includes all copayments, coinsurance, deductible, or other patient payment amounts, and comes directly from the source PDE. This amount contributes to a beneficiary's true out-of-pocket (TrOOP) costs, but only if it is for a Part D-covered drug (i.e., spending on non-covered drugs does not count toward the TrOOP amount). 
   
   

There are also codes that are sometimes considered part of member liability that was paid by a third-party payer. Note that these two variables are often $0 as discussed in this video (See the discussion about the member liability question at the 20:15 mark) 

2. FHIR variable: priorpayerpaid Blue Button Varname: other_troop_amt Definition: This is the amount of any payment made by other third-party payers that reduces the beneficiary’s liability for the PDE and counts towards Part D’s true out-of-pocket (TrOOP) requirement. Two examples are payments by qualified state pharmacy assistance programs or charities. This variable does not include amounts covered by the Part D low-income subsidy.

3. FHIR variable: priorpayerpaid Blue Button Varname: plro_amt Definition: This is the amount of any payment by other third-party payers that reduces the beneficiary’s liability for the PDE but does not count towards Part D’s true out-of-pocket (TrOOP) requirement.  Examples include payments by group health plans, worker's compensation, and governmental programs like the Veterans Administration and TRICARE.

Best,
-The Blue Button Team