Solutions 

Switches Overview

A switch is an entity that routes claims from the pharmacy to the plan/payer.

Switches work with the Transaction Facilitator to help support the success of the Medicare Part D program. They also provide Medicare Part D-related services to their customers.

This section defines the business and technical relationship between Switches in the pharmacy industry and the Medicare Part D Transaction Facilitator.

Transaction Flow for Supplemental Payer Claims

The image below illustrates the transaction flow between Switches and the Medicare Part D Transaction Facilitator (Facilitator). During this process the Facilitator creates TrOOP Reporting transactions (N Transactions) and sends them to the Part D Plans.

This transaction flow accomplishes the following goals:

  • Minimizes the development to switches
  • Avoids switch service level to customers
  • Ensures that reject transactions are not sent to the Facilitator

Switch Process Flow

Switch Transaction Flow

  1. The Pharmacy sends the Request to the Switch.
  2. The Switch receives and then sends the Request to the Supplemental Payer.
  3. The Supplemental Payer receives the Request and then sends a Response to the Switch.
  4. The Switch receives the response.
  5. The Switch checks the Supplemental Payer BIN/PCN Routing table to determine if record of the Supplemental Payers payment should be forwarded to the Transaction Facilitator. If the BIN/PCN is on the forwarding list:
  6. The Switch sends the Request and Response in one transaction (called a Composite Transaction) to the Facilitator within five seconds of receiving the Response from the Payer.
  7. The Facilitator acknowledges the Request/Response from the Switch and sends a captured response to the Switch within five seconds.
  8. The Switch may send the Response to the Pharmacy at any time before, during, or after steps 4 or 5. This flexibility allows the Switch to control the timing of the delivery of the Response to the Pharmacy.

Note: If multiple Switches are involved in routing a transaction from the pharmacy to a Supplemental Payer, only the Switch that receives the transaction from the pharmacy (the originating Switch) should send the transaction to the Transaction Facilitator.

Switches Payer Sheets

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