About Financial Information Reporting (FIR)

When a patient changes to a new Part D plan during a plan year, the previous Part D plan is no longer the plan of record that is responsible for maintaining the current overall True Out-Of-Pocket (TrOOP) and Gross Covered Drug Cost balance for the patient for that plan year. The new plan then becomes the current plan that is responsible for maintaining the overall TrOOP and Gross Covered Drug Cost balance for the patient.

Based on a same-year change in Part D plan being detected in the eligibility data imported from CMS, RelayHealth will, as the TrOOP Facilitator, initiate the real-time capture of TrOOP-related data from the disenrolling plan (old plan) and real-time forwarding to the new plan (enrolling plan). The data requested and forwarded includes the total TrOOP costs and gross covered drug spending for each month that the beneficiary was covered by the disenrolling plan.

RelayHealth has worked closely with the appropriate NCPDP workgroups and task forces to assist in the creation of the following new transaction types to support the electronic exchange of TrOOP-related data:

“F1” Financial Information Reporting Inquiry
Initiated by RelayHealth to request and receive from a plan the TrOOP and Gross Covered Drug Cost (by month) for a specified beneficiary.

“F2” Financial Information Reporting Update
Initiated by RelayHealth to forward to the current plan the TrOOP and Gross Covered Drug Cost (by month) for a specified beneficiary.

“F3” Financial Information Reporting Exchange
Used in the infrequent case where a beneficiary has more than two Part D plans in the same calendar year. Initiated by RelayHealth to forward to a plan the TrOOP and Gross Covered Drug Cost (by month) for a specified beneficiary and also retrieve that plan’s TrOOP and Gross Covered Drug Cost (by month) for that same beneficiary.

Certification Testing for FIR

• Certification Testing (described in the FIR Certification section) is mandatory. FIR transactions will not be routed to plans that have not been certified.
  
  
• In Certification Testing, each Transmission Test (Request and Response set) is independent from the others, but they will be executed in the order presented. Failure of some tests may preclude continuation of testing until remedies are implemented.
  
  
• All Transmission Tests are initiated by the Facilitator based on a testing request from a processor. The processor will need to test certify each of their systems used for Part D primary plans. However, if multiple plans are supported on a single system, it not necessary to run separate tests for each plan on the system; certification of the system will certify all plans supported by that system.