6414 - Administrative Servies Only (ASO) for Medical and Pharmacy Benefits, 4.Drawings/ Plans (9)Pharmacy Claims Pricing & Network Analysis
After receipt and initial evaluation of the vendor quotes, finalists will be requested to provide data for a claims pricing and network analysis. McGriff, Seibels & Williams will provide
a claim file to all finalists to calculate costs, as well as network status of the providers and claims.
THE FOLLOWING ONLY APPLIES IF YOU ARE SELECTED AS A FINALIST
Due to differences in the way carriers, TPAs and other vendors handle their reprising process, McGriff, Seibels and Williams has developed an independent methodology for analyzing potential
savings and network disruption. It is important that you follow the procedures in this document. Failure to submit a complete detailed pricing file will be taken into consideration
during the decision-making process. If you have any questions, please speak with your McGriff contact as soon as possible.
We recognize the sensitive nature of detailed pricing and network data. This information will only be used in a summary format by McGriff and its clients. No detailed information will
be shared with any outside parties. We also understand that network membership and contracts are subject to change at any time and the data you return represents a best estimate only.
Please re-price the claims and determine network participation and formulary tier on a prospective basis. The service and admission dates are provided for your reference only. You should
handle the claim as if it were happening with current network participation, rates and formulary in place. To avoid confusion due to differing uses of terms such as “eligible” and “allowed”,
we use the phrases PostDiscount. PostDiscount refers to the amount of the claim after all discounts have been applied and before member cost sharing is applied. Assume no coordination
of benefits or Medicare payments to be applied.
The accompanying tab-delimited file contains the following fields:
Field
Description
RecordID
Unique record identifier (created internally)
ClaimantID
Unique claimant identifier (created internally)
NABP Pharmacy Number
From claim dump
Pharmacy Name
From claim dump, extra white space removed to standardize format
Pharmacy City
From claim dump
Pharmacy State
From claim dump
Pharmacy ZIP
From claim dump
TransactionID
ClaimID from claim dump
NDC Number
From claim dump
Generic Indicator
From claim dump
DAW Indicator
From claim dump
Metric Quantity
From claim dump
Days Supply
From claim dump
Brand Name
From claim dump
Label Name
From claim dump
Mail/Retail Indicator
From claim dump
Date Filled
From claim dump, CCYYMMDD
Records with adjustments and $0-charge amounts are included in order to identify any bundling opportunities.
The file you return must also be a line-by-line file. Do not delete any records from the file. At minimum, the return file should contain the following fields:
Field
Description
RecordID
Retain from incoming file. Used to cross-reference
Considered
Y/N - Indicate if re-pricing and disruption were completed for this record
DiscountPct
Discount percentage applied to claim line
ProviderNetworkStatus
In/Out. Indicate if provider is a member of the proposed network.
NetworkClaimIndicator
In/Out. Indicate if claim would be processed in-network or out-of-network.
If you prefer, you may append these fields onto the original file layout. Please submit your return file in either Excel or tab-delimited text format, with headers included. Feel free
to compress the file into .zip format if you wish.
If you mark any records as not considered, please attach a note explaining the reason for the exclusions.
Thank you for your assistance with this project. Please contact us if you have any questions regarding the file layouts or data.