Part D Transaction Facilitator

• PIA Validation (PIA Refresh/Annual Review)
• New Public Access
• Other - Added the MediFacD website, which was omitted on the previous PIA.

The purpose of the Medicare Part D Transaction Facilitator (PDTransFac) system is to meet the statutory requirement outlined in the Medicare prescription drug benefit, authorized in the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) and ensures routing of claim information so that Medicare Part D Plans can accurately calculate True Out of Pocket (TrOOP) expenditures and non-Medicare Payer payments.

Non-Medicare payments do not count toward the Medicare Beneficiary’s TrOOP expenditures. Therefore, the PDTransFac system is used to determine, capture, and route claims data at the beginning of the process (when a Medicare Beneficiary fills the prescription) which minimizes errors and adjustments.

NDCHealth Corporation DBA RelayHealth, as the PDTransFac Contractor, supports the TrOOP Facilitation Process by:

Providing Medicare Part A, B, or D Beneficiary Plan eligibility information to the pharmacy in real-time using the HIPAA mandated National Council for Prescription Drug Programs (NCPDP) Eligibility Inquiry (E1) transaction standard.

Capturing supplemental claim data for routing to the appropriate Medicare Part D Plan in real-time using the HIPAA mandated NCPDP Information Reporting (Nx) transaction standard.

Determining when a Medicare Beneficiary has been enrolled into a new plan and requests the TrOOP balance information from the previous plan(s) and provides this data to the new plan using the NCPDP Financial Information Reporting (FIR) transaction standard.

The Medicare Part D Transaction Facilitator (PDTransFac) system receives Medicare Beneficiary enrollment data files that include the following data elements: Medicare Beneficiary ID (MBI), Social Security Number (SSN), date of birth, sex, name, mailing address, entitlement status and coverage dates in Medicare Part A, Part B and Part D, and plan coverage information (including plan ID number and supplemental plan information). The Medicare Beneficiary enrollment data file is received daily via a secure electronic file transfer from the Medicare Beneficiary Database (MBD), without direct user input.

PDTransFac passes or transfers Medicare beneficiary enrollment information in the form of

Financial Information Reporting (FIR) transactions
Eligibility Inquiry (E1) transactions
Information Reporting (Nx) real-time standard transactions

There are no external users of the system; PII is used only in HIPAA named NCPDP transactions. External users cannot access the system.

Part D sponsors receive mandatory compliance reporting from RelayHealth for FIR and Nx rejections via CMS required secure emails.

PDTransFac passes or transfers Medicare beneficiary enrollment information in the form of National Council for Prescription Drug Programs (NCPDP) HIPAA standard financial information reporting (FIR) real-time transactions. The enrollment information is provided to pharmacies via NCPDP HIPAA standard eligibility inquiries (E1) transactions and NCPDP HIPAA standard information reporting (Nx) real-time standard transactions to Part D Sponsors. There are no external users of the system, just transactions. Part D sponsors receive mandatory compliance reporting for FIR and Nx rejections via CMS required secure file transfer protocol (SFTP). External users cannot access the system.

Access to the PDTransFac Systems is only granted to RHP Support Administrators. All access to the PDTransFac Environment is conducted through the PDTransFac Virtual Private Network (VPN) which ensures communication integrity. The VPN is used to access the PDTransFac system and utilizes a native access control software solution. The VPN collects administrator usernames, password, and email information.

RHP maintains PII internally via a limited group of credentialed users with multi-factor authentication. Medicare beneficiaries' PII in the form enrollment information only is maintained and transferred to Medicare Part D plans as CMS direct contractors. Enrollment information is shared with Pharmacies who are under contract with Medicare Part D plans via NCPDP HIPAA standard real-time transactions.

The purpose of the Medicare Part D Transaction Facilitator (PDTransFac) system is to meet the statutory requirement outlined in the Medicare prescription drug benefit, authorized in the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) and ensures routing of claim information so that Part D Plans can accurately calculate True Out of Pocket (TrOOP) expenditures and non-Medicare Payer payments. Personally Identifiable Information (PII) is provided to the contractor and is used to create and respond to transactions required for Part D coordination of benefits. The data is maintained for 10 years.  All information is passed via HIPAA mandated NCPDP transaction standards.

Relay Health Plan (RHP) maintains Personally Identifiable Information (PII) that is accessible internally via a limited group of credentialed users with multi-factor authentication.

Enrollment information is shared for processing of:

Financial Information Reporting (FIR) transactions between Part D plans

Eligibility Inquiry (E1) transactions with contracted pharmacies Information Reporting (Nx) real-time standard transactions sent to Part D plans.

The system also checks user credentials- username, passwords, and emails for users who access the system.

Plans can accurately calculate True Out of Pocket (TrOOP) expenditures and non-Medicare Payer payments. Personally Identifiable Information (PII) is provided to the contractor and is used to create and respond to transactions required for Part D coordination of benefits. The data is maintained for 10 years.  All information is passed via National Council for Prescription Drug Programs (NCPDP) Health Insurance Portability Act (HIPAA) transactions only.

Relay Health Plan (RHP) maintains Personally Identifiable Information (PII)is retrieved by internally via a limited group of credentialed users with multi-factor authentication. Medicare beneficiaries' PII in the form enrollment information only is maintained and transferred to Medicare Part D plans as CMS direct contractors. Enrollment information is shared with Pharmacies who are under contract with Medicare Part D plans via NCPDP HIPAA standard real-time transactions.  PII is retrieved based on the beneficiary's last name, date of birth, Medicare Beneficiary ID and home address, HICN, MBI, Plan coverage information including plan ID number. The system also checks user credentials- username, passwords, and emails for users who access the system.

• Social Security Number
• Name
• Date of Birth
• Other - MBI, Plan coverage information including plan ID number. User credentials- username, passwords, and emails.

Personally Identifiable Information (PII) is used to: respond to pharmacy transactions to ascertain enrollment in Medicare and to create transactions for transfer of Part D drug spend balances and records of supplemental coverage.

User credentials are used for authentication into the system to support operations and maintenance.

The Medicare Modernization Act (MMA), Section 1860D-23(a)(4) of the Social Security Act.

The statutory authority for this system is given under Part D of Title XVIII of the Social Security Act, as amended by the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.

Medicare, Medicaid, and State Child Health Insurance Program (SCHIP) Extension Act of 2007 (Section 111 of P.L. 110-173), E.O. 9397.

09-70-0557, True Out-of-Pocket (TrOOP) Expenditures System

09-07-0536, Medicare Beneficiary Database (MBD)

• Within the OPDIV

• Private Sector: Pharmacies submit Personally Identifiable Information (PII) via the National Council of Prescription Drug Programs (NCPDP) eligibility transaction standard and received Medicare Part D plan enrollment in return. Medicare Part D sponsors receive NCPDP Financial Information Reporting (FIR) and Information Reporting (Nx) transactions to meet coordination of benefits (COB) requirements.
• State or Local Agency/Agencies: State Pharmaceutical Programs (SPAPs) and AIDS Drugs Assistance Programs (ADAPs), and other local agencies may need assistance determining why their coordination of benefit (COB) information is not being accepted by Medicare Part D plans. In this instance, the agency provides Personally Identifiable Information (PII) from within their system to compare to CMS data within the Relay Health Plan (RHP) system.

There is no process to notify individuals that their personal information is collected because the Medicare Part D Transaction Facilitator (PDTransFac) system does not collect Personally Identifiable Information (PII) directly. Data provided to RHP is from another CMS system, Medicare Beneficiary Database (MBD), which has its own PIA.

Relay Health Plan (RHP) maintains PII internally via a limited group of credentialed users with multi-factor authentication. Medicare beneficiaries' PII in the form of enrollment information only is maintained and transferred to Medicare Part D plans as CMS direct contractors. Enrollment information is shared with Pharmacies who are under contract with Medicare Part D plans via NCPDP HIPAA standard real-time transactions.

When an individual enrolls in Medicare Part D their PII is recorded in MBD so that CMS can administer the benefit.

Relay Health Plan (RHP) has implemented a policy that limits the use and disclosure of Personally Identifiable Information (PII) to the minimum necessary to accomplish the purposes for which PII is needed. RHP conducts an annual Part D Transaction Facilitator (PDTransFac) System Protected Health Information (PHI) and PII Holdings review which involves an examination of data received by, stored in, or generated by the system to ensure data integrity. This review involves discussion and decisions regarding appropriateness of storage of the data considering data use and contractual obligations to maintain system integrity. The data must be available to pharmacies who need it when the patient presents to them for a prescription. Pharmacy responses are returned as required by the national standards organization, (NCPDP). These standards are real-time transactions, and the infrastructure employed (high availability) supports the real time mandate. As for relevancy, the NCPDP standard is used in transactions to ensure that the system supplies relevant (standard) use cases. 

RHP maintains Personally Identifiable Information (PII) internally via a limited group of credentialed users with multi-factor authentication. Medicare beneficiaries' PII in the form enrollment information only is maintained and transferred to Medicare Part D plans as CMS direct contractors. Enrollment information is shared with Pharmacies who are under contract with Medicare Part D plans via the National Council of Prescription Drug Programs (NCPDP) Health Insurance Portability Accountability Act (HIPAA) standard real-time transactions.

• Users: A limited group of Relay Health Plan (RHP) users and administrators will have access to and maintain personally identifiable information (PII), internally, via multi-factor authentication. Level of access is determined by the role of the user, which is limited to only the users who support the help desk and administrators of the system. Medicare beneficiaries' PII (in the form enrollment information only) is maintained and transferred to Medicare Part D plans as CMS contractors. Enrollment information is shared with Pharmacies who are under contract with Medicare Part D plans via the National Council of Prescription Drug Programs (NCPDP) Health Insurance Portability Accountability Act (HIPAA) standard real-time transactions.
• Administrators: A limited group of Relay HealthPlan (RHP) users and administrators will have access to and maintain personally identifiable information (PII), internally, via multi-factor authentication. Level of access is determined by the role of the user, which is limited to only the users who support the help desk and administrators of the system. Enrollment information is shared with Pharmacies who are under contract with Medicare Part D plans via the National Council of Prescription Drug Programs (NCPDP) Health Insurance Portability Accountability Act (HIPAA) standard real-time transactions.
• Contractors: A limited group of Relay HealthPlan (RHP) users and administrators, direct contractors, will have access to and maintain personally identifiable information (PII), internally, via multi-factor authentication. Level of access is determined by the role of the user, which is limited to only the users who support the help desk and administrators of the system. Medicare beneficiaries' PII (in the form enrollment information only) is maintained and transferred to Medicare Part D plans as CMS contractors. Enrollment information is shared with Pharmacies who are under contract with Medicare Part D plans via the National Council of Prescription Drug Programs (NCPDP) Health Insurance Portability Accountability Act (HIPAA) standard real-time transactions.

If the data resides on the server database that is still in use and the data needs to be purged, the information which is encrypted is deleted off the database. When servers are decommissioned or if data is stored on tapes, there is an on-site shredding service that provides a certificate of destruction for tapes and server hard drives that are shredded.

According to the Medicare Advantage and Rx Plan Operations (MARPO) disposition authority N1-440-09-04, Item 1b1, beneficiary enrollment records must be cutoff annually and deleted/destroyed 6 years and 3 months after cutoff. 

According to the Medicare Advantage and Rx Plan Operations (MARPO) disposition authority N1-440-09-04, 1b3, prescription drug records must be cutoff annually and deleted/destroyed 10 years after cutoff.

Administrative

Relay Health Plan (RHP) has policies and procedures designed to manage development, implementation, and maintenance of the security measures designed to protect Protected Health Information (PHI) and the conduct of those with access to the PHI. These information security policies provide an essential and coherent framework for protection information resources.

Technical

RHP Systems reside within multiple levels of boundary security controls.  The network boundaries around RHP Systems are protected by firewalls configured to meet control requirements at each egress point in addition to an intrusion detection system (IDS). The RHP WAN is mainly comprised of private point-to-point connections. Two-factor authentication is required to remotely access RHP Systems.

Physical

There are diverse protect-in-depth physical controls in place to validate the identity of everyone which include perimeter and access controls.

Medicare Part D Transaction Facilitator

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