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