Stream: CARIN IG for Blue Button®
Topic: Pharmacy EOB Member Penalty
Kate Dech (Oct 13 2021 at 23:34):
There are some pharmacy benefit designs that charge the member a penalty for product, network, or channel selection. The most easily explained scenario is a member-pay-the-difference penalty for choosing a Brand Drug when there is a Generic Available. We are looking to see where we would map this in the Pharmacy EOB item.adjudication:adjudicationamounttype. The issue is which C4BB Adjudication Category Discriminator code to use. There is a required binding to the values and there isn't a code for penalty. The closest option we could see was "noncovered." However in the CPCDS mapping, it looks like noncovered has been earmarked for a specific NCPDP value
"Line noncovered amount - Non-Covered Amount represents the NCPDP financial response field Amount Exceeding Periodic Benefit Maximum." Can we use Noncovered for multiple things on one claim - like a penalty + exceeding benefit max? Or can there only be one 'noncovered' amount? Thanks!
@Mona O
Last updated: Apr 12 2022 at 19:14 UTC
