Carolyn explores how access to BIN/PCN/Group (BPG) data—the three key identifiers on pharmacy benefit cards—can shape the benefit verification process for patient support services programs. By linking this data to claims systems and APIs, companies may be able to accelerate verification, reduce regulatory complexity, and better align financial assistance with patient needs.
Click here to learn about MMIT’s Bridging as Service solution for benefit verification.
Read on for Carolyn’s insights.
Cracking the Code of BIN/PCN/Group Data for Faster Benefit Verification
By Carolyn Zele, Advisor, Solution Consulting, MMIT.
Unlocking the power of BPG data can transform claims bridging and streamline early benefit verification, helping pharma companies provide support to more patients in need.
What Is BPG Data, and Why Is It Elusive?
A patient’s drug benefit insurance card features their name, member ID, and plan group name—which is assigned by the payer, and does not necessarily correspond to PBM naming conventions. Three essential numbers are also encoded in the card’s magnetic strip:
- Rx BIN (prescription Bank Identification Number): This six-digit number identifies the specific insurance company or PBM processing the claim.
- Rx PCN (Processor Control Number): This alphanumeric code identifies the specific benefit package within a payer.
- Rx Group Number: This identifier points to the plan benefit structure within the payer, which indicates the correct coverage and pricing. Typically, this number identifies an employer, but it can also be a contract number for Medicare and Medicaid patients. Neither of these identifiers are easy to find or map, as CMS does not publish its contract ID numbers.
As there is no master database of all BPG numbers, many duplicates exist among adjudication systems and PBMs, which means that the same Rx Group number can be associated with several different BIN/PCN combinations. This complicates the plan matching process—especially for manufacturers, hubs, and support teams working directly with patients.
The Need for Preliminary Benefit Verification
For complex and high-cost therapies, many pharma companies offer Patient Support Services (PSS) to help with education and access. When a potential patient reaches out, PSS first needs to know if their insurance will cover the drug. As full benefits verification requires processing a test claim, PSS teams often prefer to do a “dirty” or preliminary benefit verification, which costs much less and does not involve protected health information (PHI).
However, it does cost time—and lots of it. Many PSS teams spend up to two days per patient to find the correct coverage data. After a manual Google search to find the patient’s likely Rx BIN number, the PSS rep then contacts the patient’s PBM to determine the patient’s Rx PCN and Rx Group number. Unfortunately, the PBM may not be able to interpret the patient’s BPG data and plan name to arrive at the correct pharmacy coverage and pricing information—leaving the PSS team (and the patient) in the dark.
Given this unwieldy process, PSS teams are often unclear on which patients truly need their financial support. Many pharma companies run out of PSS funding much earlier than expected, because they end up enrolling patients who already have full or partial insurance coverage for their brand.
Mapping Claims Data to Coverage Details
As pharma knows all too well, the primary challenge of integrating claims data with other datasets is the difficulty of mapping non-standardized terminology, as payers use their own coding and naming systems. Typically, an analyst may be able to identify the payer associated with a particular claim, but not the exact plan: the patient could be a member of any one of hundreds of plans.
When claims data is augmented with unique BPG fields, however, that data can be linked to plan-level hierarchies within payer coverage data—enabling fast identification of a patient’s plan. For example, MMIT’s Bridging as a Service solution can map BPG data from various source IDs to our coverage and restriction data. Clients are provided with their own custom-built databases, crosswalk tables, and API services for more powerful analysis.
Using an API to Speed Benefit Verification
Once the power of BPG data is unlocked, a pharma company’s PSS team can verify coverage at a much faster rate, reducing call times. When a patient provides their member ID, the manufacturer can use its claims database to identify the correct BPG data for that patient.
The PSS team can then send that BPG data to a third-party vendor via an API, receiving the patient’s coverage details for the specific therapy in return. Importantly, the use of an API means that the vendor in this scenario does not have to collect PHI, as the member’s ID is only used to find the BPG data. This removes the regulatory risk of sharing PHI with a third party.
The pharma company now has the information it needs to verify coverage details and determine which patients are good candidates for its financial assistance program. BPG data helps manufacturers fully evaluate access hurdles for every potential patient—before they spend their precious PSS dollars.
Learn how MMIT can help you streamline benefit verification by bridging coverage, claims and Rx BIN/PCN/Group data.
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