| Data Review | Utilization Manager

Utilization Manager Fields - Covered Entities

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

Field
 Description
Status
 Account under which the script qualified: 340B, GPO, or WAC.
Service Date
 Date when the patient received a diagnosis after a covered entity visit.
MRN
 Patient’s medical record number
Visit
 Visit Number
Rx Number
 Prescription Number
Patient Type
 Patient type at the time of charge
CDM
 Charge Description Master. A CDM is a unique charge code assigned by a covered entity to a particular drug for billing purposes.
CDM Description
 Description of the CDM. Each covered entity may have its own charge code descriptions.
Quantity
 Number of pills or tablets in the prescriptions.
Amount
 Dollar amount, including copay, dispense fee, and revenue.
Primary Payor
 The first entity that pays for the claim.
Secondary Payor
 The second entity that pays for the claim.
Tertiary Payor
 The third entity that pays for the claim.
NDC
 National Drug Code. An NDC is a unique 11-digit, 3-segment numeric identifier required for each drug by the Food and Drug Administration. The first segment, the labeler code, is used to identify the firm that manufactures the drug. The second segment, the product code identifies a specific strength, dosage form, and formulation for a particular firm. The third segment, the package code identifies package forms and sizes.
NDC Description
 Description of the drug as provided by the FDA
MHI BUPP
 Billing Unit Per Package in 340B Architect
MHI Pkgs.
  The number of packages for that drug as listed in 340B Architect. The number of pills dispensed over the BUPP. The number of packages you can buy.
MHI Date Match
 Y – Script is within Pharmacy effective date
N – Script fell outside Pharmacy effective date (not eligible for 340B testing)
MHI Inpatient
 If this drug qualifies as an Inpatient, you will see a Y for Yes. Otherwise, you will see an N for No. Otherwise, you will see an N for No.
MHI Medicaid
 340B test results confirming whether or not a claim was qualified or disqualified based on having a Medicaid payor.
If the CP is Carving-In, MH will not test or disqualify on Medicaid payor type. The Pharmacy Setting in 340B Architect in this scenario will be Test Medicaid (PID) and Test Medicaid (MHI) = No. The MHI Medicaid column in Utilization Manager will always contain an “N”.
If the CP is Carving-Out, MH will test and disqualify on Medicaid payor type.
In this scenario, the MHI Medicaid column in the Utilization Manager can contain a “Y” or “N”.
Y indicates the claim has a Medicaid payor, which will disqualify it from the 340B program.
N indicates NO, the claim did not have a Medicaid payor; therefore it does qualify for the 340B program (assuming it passes all other testing).
MHI Orphan
 340B test results Orphan drug eligibility
Orphan Drug Exclusion policy states that:
  •  If a 340B qualified drug is used to treat an Orphan designated disease, it cannot be replaced at the 340B price. Instead, it will be replaced at the non-340B account price.
  •  If a 340B qualified drug is used to treat a non-Orphan related disease, and meets all other qualification tests, it can be replaced at the 340B price and will accumulate on the 340B account.
Test results include:
N – Indicates No, the NDC is not an orphan drug; may qualify for 340B.
X – Indicates that the NDC is an orphan drug and the diagnosis received for the patient was not orphan related, therefore, this claim may qualify for 340B.
Y – Indicates Yes, the NDC is an orphan drug and MH has not received the diagnosis for the patient to confirm whether or not it was orphan related. Claims with a Y indicator are in the non-340B account status (GPO) until the diagnosis information is received.
Z – Indicates that the NDC is an orphan drug and the diagnosis received for the patient is orphan related. Drugs with a Z indicator are not eligible for 340B and will have non-340B status.
MHI 340B Drug
 340B test results confirming if a 340B price exists in the customer’s drug catalog.
Y indicates Yes, drug catalog price exists; may qualify for 340B.
N indicates No, a drug catalog price is not present; does not qualify for 340B.
MHI Drug Exclude
 340B test results indicating if an applied Qualification Filter qualified or disqualified a specific NDC.
Y indicates a qualification rule was applied; does not qualify for 340B based on this test
N indicates a qualification rule was not applied; does qualify for 340B based on this test
MHI IsPatient
 If the CE sends to Macro Helix a list of patients whose prescriptions are to be tested for 340B eligibility, then this flag is set to Y (yes). If N (No), no patient prescriptions are tested. The IsPatient means this patient IS an inpatient.
MHI Is Employee
 If the CE sends to Macro Helix a list of employees whose prescriptions are to be tested for 340B eligibility, then this flag is set to Y (yes). If N (No), no employees prescriptions are tested.
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.
Import Date
 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.
ID
  A unique Macro Helix code auto generated by the database. It incremented by one when new script is received. 

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