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Medicare Part D Reporting Requirements

Medicare Part D is an optional plan that covers prescription drug care for Medicare recipients. The drug plan was established in 2003 when Congress passed the Medicare Prescription Drug Benefit, Improvement and Modernization Act (MMA). All participating providers are required to report certain information to Medicare each year related to the cost of providing services, patterns of utilization, availability and accessibility of services and certain fiscal information. Data must be reported on a quarterly basis.

  1. Enrollment

    • As a provider, you must report certain enrollment data for your plan. You must report the total number of applications for your plan. You must then break this information down and separately report the number of persons rejected due to ineligibility, those denied because the required enrollment information was not received in the proper timeframe, the number of enrollment requests that were incomplete but on time, number of enrollments using the Special Enrollment Period (SEP) option, further broken down by the reason that option was used and again tallied as the total number of successful enrollees using the SEP option.

    Pharmacy Access

    • Pharmacy access reporting is related to retail, home infusion and long term care enrollments. You must report the number of enrollees living within two miles of a network pharmacy in an urban area, within five miles in a suburban area or within 15 miles in a rural area. You must also report the total number of network pharmacies in your plan's service area.

    Prescriptions

    • All of a provider's pharmacies are not required to be contracted for Medicare Part D. As a provider, you must report the total number of prescriptions filled by all of your pharmacies, and you must provide the same data for all contracted pharmacies. Further, if you supply extended-day prescriptions, defined as providing a prescription that contains more drugs than is defined by Medicare to be a one month supply for that particular drug, you must report the number of those prescriptions separately.

    Payment

    • As a Medicare Part D provider, you must report the number of claims for drugs paid under your program. This number must further be broken down by the number paid electronically, non-electronically and those paid on time or late, electronically and non-electronically. You must also report the amount of interest paid on untimely payments, again broken down by claims generated electronically or non-electronically. You must also report the number of pharmacies you contract with that can accept electronic prescriptions.

    Miscellaneous

    • Numerous other reporting requirements exist ,such as number of grievances, appeals for denial of benefits, prescription requests outside of the contracted formulary, rebates, discounts and price concessions granted to you by the pharmaceutical companies, utilization by long term care facilities and financial soundness of your organization, which is effectively a mini financial statement.

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