Validations Medicaid Home provides you with a high-level view of potential issues per quarter, and compare the types and materiality of issues quarter over quarter in order to identify trends

Validation Test Definitions:

  • PHS-MEF: Pharmacy ID matches MEF
  • PHS-CE, Not MEF: Pharmacy ID matches CE NPI, however NPI not in MEF
  • PHS-CP-Unconf-H: Potential Contract Pharmacy PHS not yet confirmed with CE, high likelihood of duplicate discount
  • Part D: verified Part D dual eligible claim
  • Invalid RxID: Kalderos contacted provider who confirmed prescription number is invalid
  • FFS $0: FFS claim, no evidence of state payment
  • Duplicate: duplicate claim
  • MCO Incorrect Qtr: MCO claim invoiced using incorrect URA
  • Terminated: drug dispensed after product’s last lot expiration date
  • Qty Min/Max: Medicaid qty outside of min/max expected range

Dispute Codes (per Appendix C for CMS-304_304a_2017):

  • J: No state reimbursement reflected on claims level detail
  • M: Duplicate Claim
  • N: Discontinued/terminated NDC for which the shelf life expired
    more than one year from the dispense date (Documentation should
    support dispensed date)
  • Q: Utilization/quantity is inconsistent with the number of
    prescriptions
  • U: Product not rebate-eligible (e.g., product was not reported to CMS
    because product is not a covered outpatient drug, product is for a
    non-Medicaid State-only program, an HMO non-fee-for-service
    program, etc…)
  • X: PHS entity not extracted from State data (Documentation should
    include PHS provider number)
  • Y: State-invoiced managed care organization (MCO) claims based
    on date of payment (DoP) rather than date of service (DoS). (This
    adjustment code to be used only for MCO utilization beginning
    3Q2017 or later. The labeler should pay using the URA that applies to
    the suspected date of service, such as the preceding quarter, and
    should request claims-level data (CLD) from the state in order to
    apply claims to the correct invoice period and close outstanding
    balances.)

Validations - Claims Medicaid allows you to view all claims data available in Kalderos' data warehouse, any validation flags applied to data, and if the transaction has been marked for dispute.

PHS - MEF

  • Green: Covered Entity (CE) is on the Medicaid Exclusion File (MEF) for the quarter

PHS - CE not MEF

  • Green: CE is not on the MEF for the quarter, but based on other factors, Kalderos believes there's a high probability that a duplicate discount occurred

PHS - Confirmed

  • Red: CE said no duplicate discount occurred
  • Green: CE confirmed a duplicate discount occurred

Disputed?

  • Green: Kalderos has ran dispute logic (doesn't mean a dispute report has been generated and sent to state)

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