How to Submit Data for the Qualified Health Plan Pharmacy Benefit Manager
Drug Data, Pricing and Rebate Review
Pharmacy benefit managers (or PBMs) and Qualified Health Plan (or QHP) issuers
that do not contract with PBMs are required to report prescription drug benefit pricing
and rebate data to CMS as a requirement of the Qualified Health Plan
Pharmacy Benefit Manager Drug Data, Pricing and Rebate Review
(or QHP PBM DPR2).
For each reporting year,
submitters report data from the previous plan year that has ended.
Submitters are PBMs that are contracted with issuers,
or issuers that submit this data on their own behalf.
Once this QHP PBM DPR2 data is collected, CMS reviews the data
and notifies submitters whether any corrections are needed to the data.
If corrections are needed, CMS allows for re-submissions.
Let’s walk through preparing QHP PBM DPR2 data for submission.
Submitters submit a set of QHP PBM DPR2 data per issuer associated with their PBM,
per reporting year.
A “set” of data includes: Issuer-Level Aggregate Data, which is submitted
in the Health Insurance Oversight System (or HIOS)
Pharmacy Benefit Manager Module user interface;
A Detailed Data File attachment; and An Issuer-Level Attestation attachment.
The detailed data file supports the issuer-level aggregate data
with additional details about the prescriptions dispensed
and the rebate amounts at the plan ID and National Drug Code (or NDC) levels.
Each detailed data file must be a pipe-delimited CSV file,
and multiple CSV files may be required if the total number of
plan ID and NDC combinations exceeds a million records.
When submitting this data in HIOS, the submission must consist of a ZIP file
containing one or more CSV files for the same issuer.
Each detailed data file consists of the following fields:
The issuer’s 14-character HIOS plan ID;
The 11-digit NDC;
The total number of prescriptions dispensed for the associated NDC
within the associated HIOS plan ID;
The total number of prescriptions dispensed through retail pharmacies
for the associated NDC within the associated HIOS Plan ID;
The total number of prescriptions dispensed through mail order pharmacies
for the associated NDC within the associated HIOS plan ID; and
The total rebate amount received for the associated NDC
within the associated HIOS plan ID.
The issuer’s 14-character HIOS plan ID must match the issuer’s HIOS ID and state,
and the first 10 characters must be a valid HIOS product ID;
a warning will be issued for an invalid product ID.
The NDC must be provided as exactly 11 digits with no dashes. Additionally,
the combination of HIOS plan ID and NDC must be unique across the file.
The next three fields must be provided as a non-negative whole number.
The final field must be formatted without a currency symbol and without commas.
Up to 12 characters are allowed before the decimal,
and the precision after the decimal can be (but is not required to be)
up to three characters. It is recommended that submitters prepare
all data for a given data set prior to logging into HIOS to submit the data.
Now, let’s walk through managing the Pre-Submission Issuer List in the
HIOS Pharmacy Benefit Manager Module. Before submitting QHP PBM DPR2 data,
a user must be registered in HIOS with the Submitter role.
Submitters that have been granted access to the HIOS
Pharmacy Benefit Manager Module will be able to access
the Pre-Submission and Submission functions within the module.
Keep in mind that while these pages are always accessible,
the submitter functions to create and edit data are only enabled
within the window timeframes or when a correction is requested by CMS
outside of the Submission window.
The pre-submission and submission windows are both displayed
in the Pharmacy Benefit Manager Module.
The Pre-Submission page informs CMS of issuers submitting on their own behalf
or the issuers for which a PBM submits data,
prior to the data collection period. Each PBM has a single Pre-Submission Issuer List
that all authorized submitters in a PBM will have access to.
Issuers who submit their own data will be able to access this page
and connect their organizations as well.
To associate issuers to a PBM for the current reporting year,
select Pre-Submission in the Pharmacy Benefit Manager Module.
From the PBM Pre-Submission Issuer List page, select Add Issuer.
Issuers may be searched for by HIOS Issuer Name or HIOS Issuer ID.
Select the desired search criteria and select Next.
This step is the same for issuers that are not contracted with PBMs
that are submitting on their own behalf.
Depending on the selected search criteria,
enter the issuer name or 5-digit HIOS issuer ID and select Search.
From the search results, select the Add button next to each issuer
you intend to add to the Pre-Submission Issuer List.
Up to 10 issuers can be added per request,
and additional requests can be submitted if more than 10 issuers need to be added.
Selected issuers will appear in the Items Added to Request section.
If you need to remove a selected issuer from the request,
either select the X next to that record in the Items Added to Request section,
or select Remove next to the issuer record in the search results list.
Once you’ve selected the desired issuers that should be added
to the Pre-Submission Issuer List, select Next to confirm your request.
Review the list of issuers, and select Submit to submit your request.
A confirmation message indicating the selected issuers were added
to the Pre-Submission Issuer List will appear at the top of the screen.
On the PBM Pre-Submission Issuer List page,
all issuers associated with the PBM for the current reporting year will display.
Issuers added to the list can be removed by selecting Remove,
and confirming the removal.
Now, let’s walk through submitting QHP PBM DPR2 data.
Once a submitter has the prepared detailed data file and the signed attestation form,
a submission can be created for that submitter.
In the Pharmacy Benefit Manager Module, select Submission to begin submitting
data files for each issuer previously added to the Pre-Submission Issuer List.
To create a new submission for an issuer,
select Create from the Actions column for the applicable issuer.
On the Create Submission page, enter the issuer-level aggregate data,
which is organized into four main sections: Rebates; Manufacturer Price Concessions;
Pharmacy Amounts; and Allocation Methodology.
Select Next to move to the next section.
If needed, select Revisit this step to return to a prior section.
For data collection specifications related to issuer-level aggregate data,
reference the Pharmacy Benefit Manager User Guide
located in the HIOS Knowledge Center.
After entering the issuer-level aggregate data, attach the detailed data file
and issuer-level attestation form to the submission.
Select Browse to locate the desired files and select Add
to add the files to the submission. To remove any added files,
select Remove next to the added file name.
After adding the detailed data file and issuer-level attestation form,
select Next to review the full submission.
Select Submit or return to a previous step to make any revisions to your submission.
A confirmation that the submission is accepted for processing will appear
at the top of the screen, and you will be returned to the
PBM Submission Issuer List page.
The submission will have a status of Pending Data Verification
and cannot be edited until the data verification is complete.
Once complete, you will receive the data verification results for the detailed data file
via email. There are two possible results:
This first possible result is Successful Data Verification, meaning the submitted
detailed data file met the established file structure and data verification criteria.
The submitted data may or may not have data warnings
that should be further reviewed,
but warnings do not result in a failed submission.
The second possible result is Failed Data Verification,
meaning the submitted detailed data file failed to meet one or more
of the established file structure or data verification criteria.
If there are data verification warnings or failures,
the data verification result email will include details on the identified issues:
The Issue Description describes the warning or error encountered
in the detailed data file.
The Issue Instance lists the first place in the detailed data file
where the warning or error was encountered.
This is provided to give a specific example of the identified issue.
The Issue Count details the number of occurrences for the warning or error
across the data set submitted. At any point during the specified
submission window timeframe, you can edit an existing submission,
if the submission is not pending data verification.
Submissions can be edited whether the previous data verification status was failed
or successful. To edit the data in an existing submission,
select Edit next to the submission on the PBM Submission Issuer List page.
For each submission listed on the PBM Submission Issuer List page,
you can also access the submission status history by selecting History.
This information allows you to review the workflow of status changes,
including which user initiated the status change
and when the status change occurred.
Selecting View lets you review a read-only version of a previous submission,
including information about the attachments submitted.
Only the issuer-level attestation form can be downloaded
while viewing a previous submission;
the detailed data file is only accessible to CMS once submitted.
After reviewing a submission, CMS may determine corrections are needed
and reject the submission in HIOS.
Submitters will receive an email informing them of the submission’s rejection,
and the submission will have a status of Correction Needed.
The submission will also become editable, even outside of the submission window,
until the submitter is able to resubmit a new submission that passes data verification.
If you have questions regarding the QHP PBM DPR2,
including data submission requirements,
please contact the Marketplace Service Desk
at CMS_FEPS@cms.hhs.gov, or 855-CMS-1515.