Solutions 

FIR Overview

What is a FIR Transaction?

FIR transactions are designed to facilitate the real-time transfer of beneficiary information and TrOOP and Drugs Spend dollars accumulated between all Part D plans the beneficiary may have had during a calendar year.

FIR transactions are NCPDP transactions.

There are three types of FIR transactions:

F1-Financial Information Reporting Inquiry

This transaction is sent to the very first plan for the beneficiary in a calendar year.

F2- Financial Information Reporting Update

This transaction is sent to the last plan on record during the calendar year as of the date of the FIR transaction. This is also called the current plan of record for the beneficiary.

F3- Financial Information Reporting Exchange

This transaction is sent to any additional plans between the first plan of record for the calendar year and the last or current plan of record for the calendar year. This transaction contains accumulators from any prior plans and allows for the plan(s) receiving the F3 to report their accumulators in addition to those reported by others in their response to this transaction.

Every time a beneficiary changes plans in a calendar year, there will be at minimum two FIR transaction types (F1 and F2) generated; however if the beneficiary has more than two plans in a calendar year, there will be three transaction types (F1, F2 and F3).

The entire process of sending FIR transactions to each of the beneficiary's plans is called a Sequence. Each FIR transaction is sent sequentially from the oldest (first plan in a calendar year) to the most current plan.  Each Sequence will contain at minimum an F1 and an F2, but may also include an F3 if more than two plans exist for a beneficiary in a calendar year.

What is the FIR Transaction Process?

  1. The Transaction Facilitator receives a nightly eligibility data file from CMS that indicates a new Part D plan for a patient.
    1. Transaction Facilitator determines if the new plan will become effective in the future or is already effective.  If the plan is already effective, the Transaction Facilitator sends an F1 to the first plan for the calendar year.
    2. If the plan will become effective in the future, the Transaction Facilitator schedules the delivery of the F1 to the first plan for the calendar year one day before the plan becomes effective.
     
  2. If the response to the F1 is a rejection, the Sequence stops. The rejection is reported on the rejecting plan's Daily Cumulative Exception Report. Until the rejection is resolved, the beneficiary's accumulators will not be transferred to any plans after the first plan in the calendar year.
  3. If the F1 is accepted, the Transaction Facilitator will send a FIR transaction to the next plan in line. If there is only one additional plan, that transaction will be an F2. If there is more than one additional plan, the transaction will be an F3. Specifically:
    1. There is only one additional plan.
      The Transaction Facilitator sends an F2 transaction. This transaction contains the accumulators from the prior plan. If the F2 is accepted, the plan receiving the F2 will update the beneficiary's accumulators with information provided by the prior plan.
    2. There is more than one additional plan
      The Transaction Facilitator sends all additional plans except the plan that caused the FIR sequence to be initiated (the most current plan of record), an F3 transaction. This transaction contains accumulators from all plans prior to the plan receiving the F3.

      If the F3 is accepted, the plan receiving the F3 will respond to the F3. The response will either mirror back what prior plans have reported (if receiving plan does not have a any dollars to report for the month) or will contain the sum of prior plans and current plan accumulators (if prior plans had dollars to report and receiving plan has dollars to report in the same month). Additionally, the Part D plan should update their systems to reflect any dollars provided from prior plans.

      Each additional plan except the plan that caused the FIR sequence to be initiated (the most current plan of record) will receive an F3.

      If there are no additional plans other than the most current plan of record the Transaction Facilitator will send an F2 containing all prior plan dollars to the most current plan of record.
     

What causes a FIR to be triggered?

  1. Any beneficiary that has a change in Contract ID during a plan year will initiate a new FIR series.
  2. Any beneficiary that has a change in PBP ID with a change in either BIN, PCN or both will initiate a new FIR series.
  3. Any beneficiary for which a proxy add was requested, by any plan that may have paid claims on behalf of the beneficiary, will always initiate a new series.
  4. Any beneficiary for which a proxy edit was requested will trigger a FIR Sequence if a series is already under way. However if there is not an active series for the beneficiary a new series will be initiated.
  5. A retrigger request, from any plan the beneficiary may have had during the plan year, will initiate a new sequence.
  6. A beneficiary that has a FIR series "in flight" that also has a 4Rx or DOB change will generate a one time, on demand, FIR sequence on the day prior to the effective date of the change or the date of receipt of the change (whichever is later) if a FIR sequence is not already in queue on that day.

How often are the FIR Sequences sent?

Many events can occur that result in a change to the way a claim originally processed. These events may occur even after the beneficiary has left (disenrolled)a plan.  For example, a plan may receive a retroactive change to the Low-Income Cost Sharing that requires claims to be adjusted. Other examples may be the receipt of latent supplemental payer information (N transactions), paper claims submitted by the beneficiary, reversal or non-coverage of claims previously paid, and end-of-year reconciliation. All of these can impact the beneficiary's accumulators.  To account for these changes, the Transaction Facilitator automatically submits FIR sequences multiple times, as defined in the schedule below, to all plans to communicate any changes to the beneficiary's accumulators.

FIR sequences are sent based on the following schedule, which is called a Series unless a new event (e.g. beneficiary moves to another plan) restarts the Series at which time the schedule restarts based on that new event. The specific timing of each sequence in a series is listed below:

  1. 1 day prior to effective date if eligibility is received prior to effective date
  2. Effective date (or receive date if received after effective date)
  3. Day 8 (7 days from effective date or receive date)
  4. Day 10
  5. Day 12
  6. Day 14
  7. Day 21
  8. Day 28
  9. Day 73
  10. Day 118
  11. December 1st
  12. February 1st  of subsequent year
  13. March 1st of subsequent year

If a Part D Plan continues to experience changes to the beneficiary's prior plan year accumulators between March 31 st and May 31st, the plan can request the Transaction Facilitator to initiate a FIR sequence.

For additional information on FIR timing and examples, please consult the FIR Timing Examples document located in the related documents section on the right side of this page.

For accumulator balance changes that occur after May 31st following a plan year, Part D Plans should have policies in place to determine when and how the balance information will be provided to downstream payers. Additionally, plans must continue to update their Prescription Drug Events (PDEs), even if the reconciliation period is closed, until CMS indicates that PDEs are no longer accepted.

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