| Data Review | Utilization Manager

Utilization Manager Fields - Contract Pharmacy

The table below describes each of the fields on the Utilization Manager screen for a Contract Pharmacy. Scroll to the right to see all of the fields. 

Field
 Description
Status
 Account under which the script qualified: 340B, RTL, or WAC
TransCode Transaction Code = is the NCPDP standard for Identifying fills VS. reversals
B1 - Fill transaction
B2 - Reversal transaction
Q1- Cash fill transaction for QS1 
Q2 - Cash reversal transaction for QS1
RxNumber
 Pharmacy assigned prescription number
FillNumber Number that corresponds with the fill/refill of a prescription. First fill is 0, next fill is 1, and so on
Dispensed
 Transaction date and time the claim was adjudicated and passed through the switch (pharmacy system)
Written Date
 Date the prescriber wrote the prescription
ServiceDate
 Date the prescription was dispensed/filled
Patient Last
 Last name of the patient for the prescription
Patient First
 First name of the patient for the prescription
Zip Code
 Postal zip code of the patient’s address
Birth Date
 Patient’s date of birth
MRN
 (Medical Record Number) Unique patient identifier provided by the covered entity
Doctor DEA
 Prescriber's Drug Enforcement Administration identifier for the purpose of authenticating and tracking prescriptions for controlled substances
Doctor NPI
 National Provider Identifier is a unique 10 digit identification number for covered healthcare providers (prescriber's)
NDC 
 11 digit National Drug Code
NDC Description Description of the NDC dispensed
Days Supply
 Number of days prescription should last based on dispensing instructions
Amount
 Gross charge amount for dispense (including copay, dispense fee, and revenue)
Copay
 Patient's portion to pay for a prescription
DispenseFee
 Negotiated and agreed fee the covered entity pays the contract pharmacy for 340B qualified dispenses
Revenue
 For 340B qualified contract pharmacy dispenses, the revenue amount minus the dispensing fee, which is paid to the covered entity
MHI Drug Cost
 		The catalog price of the drug at the time of dispense
Quantity
 The prescription quantity dispensed
BUPP
 		Billing Units Per Package. 
MHI Pkgs
 		The number of packages accumulated per NDC.
BIN
 		Bank Identification Number
PCN
 		Processor Control Number
GRP
 Insurance group number 
Primary Payor
 		BIN of first payor for a claim of Coordination of Benefits transaction
Sec Payor BIN BIN of second payor for a claim of Coordination of Benefits transaction
Sec Payor PCN PCN of second payor for a claim of Coordination of Benefits transaction 
Sec Payor GRP GRP of second payor for a claim of Coordination of Benefits transaction 
MHI Date Eligible
 		340B Architect tests that the prescription occurred on or after the 340B eligible date.
Y = YES, the prescription was occurred on or after the 340B eligible date.
N = NO, the prescription did not occur on or after the 340B eligible date. 
MHI 340B Drug 
 		340B Architect checks if a 340B price exists in the customer’s drug catalog for the dispensed drug.

Y = Yes, a 340B price exists in the drug catalog; may qualify for 340B.
N = No, a 340B price does not exist in the drug catalog and will not qualify for 340B.
MHI Medicaid
 		340B Architect will test and disqualify any dispenses with a Medicaid payor. Most CP's Carve-Out Medicaid.

Y = Yes, the dispense has a Medicaid payor, and will disqualify for 340B.
N = NO, the dispense did not have a Medicaid payor; and potentially can qualify for 340B.
MHI Orphan
 		340B Architect tests if NDCs are on the MH Orphan List.

Y = Yes, the dispensed NDC is on the MH Orphan list and will be disqualified.
N = No, the dispensed NDC is not on the MH Orphan list and can potentially qualify for 340B status. 
Exp Orphan 340B Architect tests if NDCs are Orphan Exceptions for entities that classify as Critical Access, Rural Referral, Sole Community, or Free Standing Cancer.
Orphan Exception: The manufacturer has extended 340B-like pricing for specific NDCs. These exceptions are granted on a drug by drug and pharmacy by pharmacy basis. Your pharmacy must contact MH Support to have any Orphan Exceptions activated.

Y = Yes, the dispensed NDC is an Orphan Exception and can potentially qualify for 340B status .
N = No, the dispensed NDC is not an Orphan Exception.  
MHI Drug Exclude
 		340B Architect tests if the NDC dispensed is on an exclusion list.

Y = Yes, the NDC is listed on a drug exclusion list, and will disqualify.
N = No, the NDC is not on a drug exclusion list.
MHI DEA Match
 		340B Architect tests prescriptions against prescribers listed in Qualification Filters/Doctors Qualified By DEA/NPI as Standard or Extended. The list is provided and managed by the covered entity. 

Y = Prescriber is listed as Standard
N = Prescriber is not listed or deactivated
Z = Prescriber is listed as Extended DEA list. 
MHI Code Match
 		340B Architect tests prescriptions against the CE provided patient encounter data, checking if it relates to the encounter by diagnosis code.  Also referred to as Code Match.

Y = Diagnosis code is related to the prescription; may qualify for 340B.
N = Diagnosis code is not related to the prescription; does not qualify for 340B.

Note: for Retail Pharmacies, to be eligible for 340B a claim there must a  Y in either the MHI DEA Match or MHI ICD9 Match column; both cannot be N.
MHI Other Match
 		340B eligibility test results indicating whether or not an existing qualification filter or rule is impacting eligibility

N = qualification rule or filter is impacting eligibility; does not qualify for 340B based on this test
Y = qualification rule or filter is NOT impacting 340B eligibility; may qualify for 340B.
Employee
 Employee = Case when we have a patient list loaded in their qualification filters then patient or employee will be changed to ‘Y’ (with the addition of one of the two rules regarding patients or employees the scripts identified with patients would either auto qualify or be able to qualify with a Dea OR ICD9 match) Please note we do not disqualify based on those list only add the ability to identify and possibly qualify.
Patient
 Patient = Case when we have a patient list loaded in their qualification filters then patient or employee will be changed to ‘Y’ (with the addition of one of the two rules regarding patients or employees the scripts identified with patients would either auto qualify or be able to qualify with a Dea OR ICD9 match) Please note we do not disqualify based on those list only add the ability to identify and possibly qualify.
Trans Resp Status
 Transaction Response:
R - Rejected
D - Duplicate
A - Approved
P - Paid
C - Captured (cash claims)
Please note we do not use/ignore “R”, “D”, & “C” Transaction responses. “P” is for a Paid Claim and  “A” is used for an Approved Reversal
MHI Rewind Date
 		Date the claim was rewound per Rewind requirements within Pharmacy Settings
MHI Locked
 		Indicates if a script is Frozen. 
Y = Script is frozen and will not be tested for 340B eligibility
N = not frozen and will be tested for 340B eligibility
Filename
 Name of the data file individual claim was included in
ImportDate
 Date that data was imported into 340B Architect. These were put in place initially for billing purposes.
Qualified Date
 The date a claim qualifies for 340B.
Disqual Date
 The date a claim changes status from 340B to GPO/WAC/RTL. These were put in place initially for billing purposes.
WrittenLocation Location within the hospital in which the Rx was written. 
WrittenLocationMatch Does claim have a corresponding written location (electronically prescribed Rx only). 

Y= Match to Written Location list 
N= Not a match to Written Location list
blank= Claim was not tested for Written Location
ID
 A unique Macro Helix code auto generated by the database. It incremented by one when new script is received. 
TPISClaimID

Unique transaction ID assigned by Macro Helix for TPIS integrations (only TPIS PIDs show fields related to TPIS). 
InboundFileImportDate Date and time a file from a TPIS processor imported into 340B Architect. 
InboundFileName Name of inbound file from TPIS processor. 
MHIClaimStatus Status of the TPIS transaction. 

O= 340B Qualified Rx has been sent to the TPIS processor
C= Rx has been captured by TPIS as 340B 
M= Rx has been disqualified by Macro Helix and TPIS processor notified 
D= Rx disqualified by TPIS processor
MHIClaimStatusDesciption Transaction status as provided by TPIS processor. 
TPISClaimStatus Transaction status as provided by TPIS processor. 
TPISClaimStatusReason Transaction status reason as provided by TPIS processor. 
Compound Y = Rx is a compound. 
N = Rx is not a compound. 
HID
 Macro Helix identification number for CE
Prescriber Last Name Last name of the prescriber. 
Pt Res Code Desc

This is the standard description for each of the Patient Residence Codes.  If we don’t receive a code this field will remain blank
Prescription Origin Code Code indicating the how the prescription was obtained. 

0= Not known
1= Written 
2= Telephone
3= Electronic - SCRIPT or HL7 standard transactions. 
4= Fax Machine
5= Pharmacy. This value is used in any situation where a new Rx number needs to be created from an existing valid prescription such as traditional transfers, intrachain transfers, file buys, software upgrades/migrations, etc. 
PAP True up Price
This value is populated when a PAP enabled PID has a prescription that did not qualify for PAP. Reconciliation takes place on these prescriptions and the value is populated in that field. This is an optional feature and is not turned on for all PAP clients.
TPIS 340B Price 340B Price as provided by the TPIS processor. 
CE Receivable Indicated the amount a CE will be invoiced for this Rx as reported by the TPIS provider. 
Reimbursement Model Indicates how a dispense fee is calculated. 
Outbound File Name Filename in which Rx was reported to TPIS provider for processing. 
Date Sent Date the Rx was reported to TPIS provider for processing. 
Pt Res Code This code is sent via a switch file for each prescription. It describes where the patient lives, such as at home, hospice, nursing home, long-term care, prison, etc. CE’s can choose to exclude certain codes from 340B eligibility in Qualification Filters.  
Pt Res Code Exc

Y = Patient Residence Code has been excluded from 340B eligibility 

N = Patient Residence Code has not been excluded and will be tested for 340B eligibility


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