Submission clarification code
For beneficiaries living in long-term care (LTC) facilities, this variable indicates how many days' supply of the medication was dispensed by the long-term care pharmacy and provides some details about the dispensing event.
This variable is only populated when beneficiary lives in an LTC facility (i.e., when the PTNT_RSDNC_CD variable equals 03).
CMS requires Part D plans to have drug utilization management programs to encourage compliance with the formulary; this variable is designed to make it easier to monitor how well LTC pharmacies comply with formularies by making it easier to aggregate LTC prescriptions into 31-day equivalent prescriptions and thus compare pricing.
Note that this variable is different than the days supply of the medication on the PDE (the DAYS_SUPLY_NUM variable).
This variable was new in 2013 and required for all PDEs beginning on February 28, 2013.
This variable is coded, and will contain one of the following values.
| Value | Description |
|---|---|
00 |
(Unknown value – rarely populated) |
05 |
Therapy change. Physician determined that a change in therapy was required – either the medication was used faster than expected, or a different dosage form is needed. |
07 |
Emergency supply of non-formulary drugs (or formulary drugs which typically require step therapy or prior authorization). Medication has been determined by the physician to be medically necessary. |
08 |
Process compound for approved ingredients |
14 |
LTC leave of absence – short fill required for take-home use |
16 |
LTC emergency box (e box) /automated dispensing machine |
17 |
LTC emergency supply remainder (remainder of drug from the emergency supply) |
18 |
LTC patient admit/readmission indicator. This status required new dispensing of medication. |
19 |
Split billing. The quantity dispensed is the remainder billed to a subsequent payer after Medicare Part A benefits expired (partial payment under Part A). |
21 |
LTC dispensing rule for <=14 day supply is not applicable due to CMS exclusion or the fact that the manufacturer’s packaging does not allow for special dispensing |
22 |
LTC dispensing, 7-day supply |
23 |
LTC dispensing, 4-day supply |
24 |
LTC dispensing, 3-day supply |
25 |
LTC dispensing, 2-day supply |
26 |
LTC dispensing, 1-day supply |
27 |
LTC dispensing, 4-day supply, then 3-day supply |
28 |
LTC dispensing, 2-day supply, then 2-day supply, then 3-day supply |
29 |
LTC dispensing, daily during the week then multiple days (3) for weekend |
30 |
LTC dispensing, per shift (multiple medication passes) |
31 |
LTC dispensing, per medication pass |
32 |
LTC dispensing, PRN on demand |
33 |
LTC dispensing, other <=7 day cycle |
34 |
LTC dispensing, 14-day supply |
35 |
LTC dispensing, other 8-14 day dispensing not listed above |
36 |
LTC dispensing, outside short cycle, determined to be Part D after originally submitted to another payer |
42 |
The prescriber ID submitted has been validated and is active (rarely populated) |
43 |
For the prescriber ID submitted, the associated DEA number has been renewed or the renewal is in progress (rarely populated) |
44 |
(Unknown value – rarely populated) |
45 |
For the prescriber ID submitted, the associated DEA number is a valid hospital DEA number with suffix (rarely populated) |
Null |
Not applicable, beneficiary not in an LTC setting (or in the first two months of 2013, the presumption is there was greater than a 14-day supply) |
Some additional information on this variable: