Routing Supplemental Transactions to the Transaction Facilitator

The Switches deliver the following claims to the Facilitator:

Claims with a BIN/PCN listed in the BIN_PCN_Switch_YYYY_MM_DD.txt file for the Date of Service on the claim.

NCPDP Telecommunication vD.0, B1, B2, and B3 transactions with a Response status in Field # 112-AN of:

• ‘A’ APPROVED,
• ‘C’ CAPTURED,
• ‘D’ DUPLICATE of PAID,
• ‘P’ PAID,
• ‘Q’ DUPLICATE OF CAPTURED, and
• ‘S’ DUPLICATE OF APPROVED.

Note: Duplicates are included to ensure that transaction that timeout are accounted for with the retransmission.

Claims are delivered in a composite format that contains a wrapper and claims detail. Read more information on the wrapper specification.

RelayHealth Message Header Specifications (Wrapper for Switch Composite Transaction for Supplemental Claims):

• Message Header Specifications
• Reject Response Examples for Switch transactions

Multiple Switches

If multiple Switches are involved in routing a transaction from the pharmacy to a payer, only the Switch that receives the transaction from the pharmacy receives payment for sending the Request/Response.

Threading

The Facilitator supports multi-threading (up to 32 transactions at a time) and single threading of transactions. If the Switch sends more than 32 transactions at a time for multithreaded applications, the Facilitator rejects the transactions after 32 and returns those transactions back to the Switch.

Supplemental Routing/Processing rules for Switches:

If BIN-PCN is on table based on date rules below and date is April 1, 2012 (or later if HIPAA compliance date is changed) only forward transactions (request and response) if response to request is accepted/paid and Claim is D.0.

• Date of Fill on Claim is not more than 3 years prior to receive date
• Claim DOS meets the date driven logic below:

Date of Service Driven Logic:

• Claim received on 1-8-2012 for DOS of 1-2-2012 will be forwarded to TrOOP
• Claim received on 1-8-2012 for DOS of 1-8-2012 will NOT be sent to TrOOP
• Claim received on 1-15-2012 for DOS of 1-8-2012 will NOT be sent to TrOOP
• Claim received on 1-15-2012 for DOS of 1-15-2012 will be forwarded to TrOOP
• Claims received in the gap will not be retrospectively forwarded as this is consistent with current process. Retrospective pulls would require extra development work for all switches (extremely costly). Alternative options are that the plan can send an N batch for missing transactions or can request ad hoc pulls from all switches at their cost.

On 4-1-2012:

• All GHI only BIN-PCNs will have effective dates of 1-1-2006 and term dates of 3-31-2012
• Combined GHI/NDCHEALTH BINPCNs will have effective dates of 1-1-2006 and open-ended termination dates
• All NDCHEALTH only BIN-PCNs will have 1-1-2012 effective dates and open-ended termination dates.
• Claims will be processed using DOS to determine which date driven BIN-PCN should be applied.