ePharmacy Update (2011)

Report
Veterans Health Administration
Chief Business Office
Business Development
ePharmacy Team
ePharmacy Update for Pharmacy Informatics
1
Agenda
• ePharmacy Project Overview
• ePharmacy team and project information
• ePharmacy Statistics
• ePharmacy Enhancements
• Billing Methodology Change - Potential Impact
• Pharmacy actions to maximize revenue
• ePharmacy Training
• TRICARE Processing differences & Business Rules
• Questions
2
ePharmacy Project Overview
• ePharmacy is the e-business initiative enabling real-time
electronic prescription claims to the PBM/payer.
– All pharmacies have been submitting claims to 3rd party
PBM/payers since September 2008
– ePharmacy is not involved with billing for the provision of
Pharmacy services, for example medication management
programs
– ePharmacy is not the same as ePrescribing, which is the
electronic transfer of prescription information from prescriber
to pharmacy
– ePharmacy is sometimes mistakenly referred to as eBilling,
a term that can refer to other types of electronic billing
3
ePharmacy Project Overview
cont.
• The ePharmacy Implementation team is responsible for
ensuring the project is functional and meets goals etc.
– Connie Meeker is Project Manager
– Ellen Giglia is an ePharmacy Implementation manager for
revenue related issues
– Deb Wistuba is an ePharmacy Implementation manager for
revenue related issues
– Gwyn Smith is CBO Liaison
– Greg Laird is an ePharmacy Implementation manager for
Pharmacy related issues
4
ePharmacy Fill Volume
Calendar Year 2010
A fill is an instance of a single prescription prepared for a patient and
electronically submitted to a Pharmacy Benefit Manager (PBM)/payer.
Volume
7m
2010 Total Fills
Fill Count
6m
6,043,357
5m
4m
3m
2m
2010 Average Fills per Month
1m
0m
Fill Count
2004
0.02m
2005
0.17m
2006
0.37m
2007
0.70m
2008
2.74m
2009
5.25m
2010
6.04m
503,613
5
ePharmacy by the Numbers
• There were a total of 136,695,024 prescriptions filled by
VA facilities in CY 2010
• ePharmacy fills accounted for 6,043,357 of those
136,695,024 prescriptions or 4.4% of total fills
Prescription Fills CY 2010
ePharmacy Fills CY 2010
6
ePharmacy Rejections Overview
Calendar Year 2010
2010 Claim Rejection Categories
This pie chart compares the percent of claims initially rejected in 2010 by rejection category. The percent
values represent the rejection rate as a percent of total claims. A claim is used to submit a prescription fill
to a PBM/payer for reimbursement.
Refill too
Soon
3.67%
90-Day
11.19%
NDC
2.41%
Paid or
Accepted
65.16%
Rejected
34.84%
Communications
Issue
1.06%
DUR Reject Error
0.92%
Other Rejections
16.45%
Missing or Invalid
Package Size or
Quantity
0.57%
Dispense As Written
0.41%
When rejected,
claims are returned
to VHA with one or
more rejection
codes that indicate
why a claim was
rejected. Similar
rejection codes are
grouped together
into rejection
categories. A claim
can be rejected for
multiple reasons
and counted under
multiple categories.
Therefore, the sum
of the rejection
rates by category
may overstate the
overall rejection
rate.
2010 Total Claims
2010 Rejected Claims
2010 Overall Rejection Rate
8,709,575
3,034,204
34.84%
7
NDC Rejects
• About 2.4% of overall rejects are for product related
(NDC) reasons
• The overwhelming majority of our NDC rejects have to do
with some sort of repackaged drug
• About 64% of our NDC rejects are for Aphena Pharma
Solutions (PrePak Systems) products
• Repackaged drug products need to be registered with the
major drug information databases First DataBank and
Medispan, to be recognized by the third parties
8
NDC Rejects
• Most of our Aphena Pharma Solutions product rejects are
due to the product being re-packaged, then sent back to
the CMOP and used before the registration is complete
• Some third party plans do not reimburse for re-packaged
products
• One of our ePharmacy business rules is to transmit the
NDC used to fill the prescription
• Facilities should not change the NDC to some other NDC
just to get reimbursed.
9
90 Day Fill Rejects
• There has been recent interest from some VAs with the system
to capture revenue lost as a result of 90 day fill rejects
• Some of the methods proposed have been:
• Designate VA CMOPs as mail-order pharmacies
• Pursue legislation to mandate reimbursement for 90 day fills
• Change 90 day fill prescriptions to 30 day fills to be reimbursed
• The CBO and PBM have extensively researched and evaluated
the issue
• For various reasons, none of the methods listed above are
recommended at this time
• The CBO will continue to pursue methods to reduce the
number of 90 day fill rejects
10
ePharmacy Future
11
Phase 5/D.0
• Phase 5 will be the next release - sometime this summer
• Will bring us into compliance with D.0, which is the NCPDP
communication standard that replaces 5.1
• Very involved process
• Testing has to be done with external partners, e.g. Emdeon and
insurance companies
• Some payers require our software be certified
• Need to maintain backwards compatibility - capability to
transmit claim in both 5.1 and D.0 during transition period
• Mostly changes that affect the revenue side of ePharmacy
• No major Pharmacy changes
12
Phase 5/D.0 cont.
• ECME numbers (prescription number that is transmitted to
the third party) expanded from 7 to 12 characters
• All screens that display ECME number are being changed.
• Pharmacy screens:
• Rx View screen from View Prescription [PSO VIEW]
• The Reject Information screen from the Third Party Payer Rejects –
Worklist [PSO REJECTS WORKLIST]
• Third Party Payer Rejects – View/Process [PSO REJECTS
VIEW/PROCESS]
• Additional information will be available from the Reject
Information screen to assist with reject resolution
• Submit Clarification Code (CLA) action modified so up to
three submission clarification codes may be entered
13
Phase 5/D.0 – Additional Reject
Information
Reject Status
Payer Message
Reason
+DUR Text
: OPEN/UNRESOLVED
: 1-ABOVE GERIATRIC MAX QTY/DAY,MAX DAILY QTY 2.0,DUR REJECT ERRO
R
: HD (HIGH DOSE ALERT )
: 1-ABOVE GERIATRIC MAX QTY/DAY
INSURANCE Information
Insurance
: MEDCO HEALTH DIRECT CLAIMS
Contact
: (800) 555-1557
Group Name
: ECME TEST INS
Group Number
: GROUP
Cardholder ID : #############
Enter ?? for more actions
VW View Rx
IGN Ignore Reject
MP Medication Profile
RES Resubmit Claim
Select: Quit// ??
The following actions are
COM Add Comments
CLA Submit Clarif. Code
ED
Edit Rx
PA
Submit Prior Auth.
+
Next Screen
Previous Screen
also
DN
UP
FS
LS
GO
RD
available:
Down a Line
Up a Line
First Screen
Last Screen
Go to Page
Re Display Screen
OVR Submit Override Codes
CSD Change Suspense Date
PS
PT
SL
ADPL
QU
ARI
Print Screen
Print List
Search List
Auto Display(On/Off)
Quit
View Addtnl Rej Info
14
Phase 5/D.0 – Additional Reject
Information Cont.
Reason
+DUR Text
: ID (INGREDIENT DUPLICATION)
: 1-ABOVE GERIATRIC MAX QTY/DAY
INSURANCE Information
Insurance
: MEDCO HEALTH DIRECT CLAIMS
Contact
: (800) 555-1557
Group Name
: ECME TEST INS
Group Number
: GROUP
Cardholder ID : #############
Enter ?? for more actions
VW View Rx
IGN Ignore Reject
MP Medication Profile
RES Resubmit Claim
Select: Quit//ARI
OVR Submit Override Codes
CSD Change Suspense Date
DUR Response: 1
Reason Code: TD (THERAPEUTIC )
Clinical Significance Code: MINOR
Other Pharmacy Indicator: OTHER PHARMACY
Previous Date of Fill: MAR 30, 2011
Quantity of Previous Fill: 0000090000
Database Indicator: OTHER
Other Prescriber Indicator: OTHER PRESCRIBER
DUR Text:
DUR Add Text: ALPRAZOLAM
TAB 0.5MG
15
Phase 5/D.0 – Multiple
Clarification Codes
Reject Status
Payer Message
Reason
DUR Text
: OPEN/UNRESOLVED
: 1-ABOVE GERIATRIC MAX QTY/DAY,MAX DAILY QTY 2.0,DUR REJECT ERRO
R
: HD (HIGH DOSE ALERT )
: 1-ABOVE GERIATRIC MAX QTY/DAY
INSURANCE Information
Insurance
: MEDCO HEALTH DIRECT CLAIMS
Contact
: (800) 555-1557
Group Name
: ECME TEST INS
Group Number
: GROUP
Cardholder ID : #############
Enter ?? for more actions
VW View Rx
IGN Ignore Reject
MP Medication Profile
RES Resubmit Claim
Select: Quit// ??
The following actions are
COM Add Comments
CLA Submit Clarif. Code
ED
Edit Rx
PA
Submit Prior Auth.
+
Next Screen
Previous Screen
also
DN
UP
FS
LS
GO
RD
available:
Down a Line
Up a Line
First Screen
Last Screen
Go to Page
Re Display Screen
OVR Submit Override Codes
CSD Change Suspense Date
PS
PT
SL
ADPL
QU
ARI
Print Screen
Print List
Search List
Auto Display(On/Off)
Quit
View Addtnl Rej Info
16
Phase 5/D.0 – Multiple
Clarification Codes cont.
Reject Status
Payer Message
Reason
DUR Text
: OPEN/UNRESOLVED
: 1-ABOVE GERIATRIC MAX QTY/DAY,MAX DAILY QTY 2.0,DUR REJECT ERRO
R
: HD (HIGH DOSE ALERT )
: 1-ABOVE GERIATRIC MAX QTY/DAY
INSURANCE Information
Insurance
: MEDCO HEALTH DIRECT CLAIMS
Contact
: (800) 555-1557
Group Name
: ECME TEST INS
Group Number
: GROUP
Cardholder ID : #############
Enter ?? for more actions
VW View Rx
IGN Ignore Reject
OVR Submit Override Codes
MP Medication Profile
RES Resubmit Claim
CSD Change Suspense Date
Select: Quit// CLA
CLA
Submission Clarification Code 1: 2
OTHER OVERRIDE
Submission Clarification Code 2: 3
VACATION SUPPLY
Submission Clarification Code 3: 5
THERAPY CHANGE
When you confirm, a new claim will be submitted for
the prescription and this REJECT will be marked
resolved.
Confirm? YES//
17
D.0 v2
• Development and testing for D.0 V2 will be combined
with our Phase 6 enhancements
• Testing is expected to start in September and Phase
6/D.0 V2 software expected to be released in February
2012
• Expand electronic transmissions to include CHAMPVA
pharmacy claims.
• Submit all mandatory NCPDP fields, required NCPDP
fields, and situational required NCPDP fields to
PBMs/Payers regardless of payer sheet specifications.
• Accurately utilize NCPDP fields for pricing of VHA
outpatient pharmacy claims. Include capability to allow
for this pricing on paper claims as well.
18
Phase 6
• Field names that display on both the Third Party Payer
Rejects - Worklist Pharmacy Worklist) and ECME User
screen (OPECC Worklist) will be standardized
• Information that shows on the Pharmacy Reject
Information screen will also show on the ECME User
screen log
• The BIN number will be added to the Pharmacy
Worklist Reject Information and View/Process
Information screens
19
Phase 6 cont
• The ‘Reason For Service’ field of the Submit Override
Codes action of the Reject Information screen will be
editable
• Users will be able to enter multiple Reject Action codes
from the Reject Information screen if needed.
• A new action will be added to the Reject Information
screen that will calculate the next date of fill based on
the last ePharmacy date of service and days supply.
• ePharmacy screens using ‘Fill Date’ labels will be
changed to ‘Date of Service’ when appropriate.
20
Reject Information Screen
Changes
Reject Information(UNRESOLVED)Apr 06, [email protected]:30:37
Division : ECMETEST DIV
Patient : PATIENT, TESTONE(###-##-####) Sex: M
Rx#
: #####713I/3
ECME#: ####202
CMOP Drug: DIAZEPAM 10MG TAB
Page:
1 of
1
NPI#: 130689XXXX
DOB: MMM, ##, ####(##)
Fill Date: MMM ##, ####
NDC Code: 67544-0020-30
REJECT Information
Reject Type
: 88 - DUR Reject Error- received on APR 06, [email protected]:44:26
Reject Status : OPEN/UNRESOLVED
Payer Addl Msg : 1-ABOVE GERIATRIC MAX QTY/DAY,MAX DAILY QTY 2.0,DUR REJECT ERROR
Reason Code
: HD (HIGH DOSE ALERT )
+ DUR Text
: 1-ABOVE GERIATRIC MAX QTY/DAY
INSURANCE Information
Insurance
: MEDCO HEALTH DIRECT CLAIMS
Contact
: (800) 555-1557
BIN Number
610014
Group Number
: GROUP
Cardholder ID : ############
Enter ?? for more actions
VW View Rx
IGN Ignore Reject
MP Medication Profile
RES Resubmit Claim
Select: Quit// Select: Quit// Select: Quit// OVR
Reason for Service Code : DD
Professional Service Code:
OVR Submit Override Codes
CSD Change Suspense Date
Submit Override Codes
DRUG-DRUG INTERACTION
21
Reject Information Screen
Changes cont
INSURANCE Information
Insurance
: MEDCO HEALTH DIRECT CLAIMS
Contact
: (800) 555-1557
Group Name
: ECME TEST INS
Group Number
: GROUP
Cardholder ID : #############
Enter ?? for more actions
VW View Rx
IGN Ignore Reject
OVR Submit Override Codes
MP Medication Profile
RES Resubmit Claim
CSD Change Suspense Date
Select Item(s): Quit// SDC
Suspense Date Calculation
LAST DATE OF SERVICE: Jan 01, 2011//
LAST DAYS SUPPLY: 60//
NEW SUSPENSE DATE: Feb 15, 2011//T+4
(FEB 11, 2011)
When you confirm, this REJECT will be marked resolved. A
new claim will be re-submitted to the 3rd party payer
when the prescription label for this fill is printed
from suspense on Feb 11, 2011.
Note: THE LABEL FOR THIS PRESCRIPTION FILL WILL NOT BE
PRINTED LOCAL FROM SUSPENSE BEFORE Feb 19, 2011.
Confirm? ? YES//
[Closing...OK]
Please wait...
22
Phase 6 cont
• The ¾ days supply hold calculation will round up for
any partial day
• Fill Date will no longer be used to determine the date of
service – only Current Date and Release Date will be
used
• A screen reminder to obtain a signature when
prescriptions are picked-up will be provided when
ePharmacy window prescriptions are released
• A reminder to obtain signature will also be provided
when removing a patient’s name from the Bingo Board
23
Phase 6 cont
• An indicator for ePharmacy prescriptions will be
provided via OPAI
• A new option ‘View ECME Rx’ will be available that will
provide a user all the information regarding an
ePharmacy prescription
• The Issue Date transmitted on claims for ePharmacy
prescriptions entered with a future ‘Issue Date’ will be
changed to the current date
• Claims submitted by the OPECC using the Process
Secondary/TRICARE Rx to ECME option, will reflect
that in the Prescription activity log
24
Pop Quiz –
DUR Reject
Reject Information(UNRESOLVED)Apr 06, [email protected]:30:37
Division : ECMETEST DIV
Patient : PATIENT, TESTONE(###-##-####) Sex: M
Rx#
: #####713I/3
ECME#: ####202
CMOP Drug: DIAZEPAM 10MG TAB
Page:
1 of
1
NPI#: 130689XXXX
DOB: MMM, ##, ####(##)
Fill Date: MMM ##, ####
NDC Code: 67544-0020-30
REJECT Information
Reject Type
: 88 - DUR Reject Error- received on APR 06, [email protected]:44:26
Reject Status : OPEN/UNRESOLVED
Payer Message : 1-ABOVE GERIATRIC MAX QTY/DAY,MAX DAILY QTY 2.0,DUR REJECT ERRO
R
Reason
: HD (HIGH DOSE ALERT )
DUR Text
: 1-ABOVE GERIATRIC MAX QTY/DAY
INSURANCE Information
Insurance
: MEDCO HEALTH DIRECT CLAIMS
Contact
: (800) 555-1557
Group Name
: ECME TEST INS
Group Number
: GROUP
Cardholder ID : ############
Enter ?? for more actions
VW View Rx
IGN Ignore Reject
MP Medication Profile
RES Resubmit Claim
Select: Quit// Select: Quit//
OVR Submit Override Codes
CSD Change Suspense Date
25
Pop Quiz –
DUR Reject - answer
VW View Rx
MP Medication Profile
Select: Quit// CLA CLA
Clarification Code: 2
IGN Ignore Reject
RES Resubmit Claim
OVR Submit Override Codes
CSD Change Suspense Date
OTHER OVERRIDE
When you confirm, a new claim will be submitted for
the prescription and this REJECT will be marked
resolved.
Confirm? YES//
26
Billing Methodology Change
27
Why the Change?
VA published a rule in the Federal Register to implement a new billing
methodology to provide VA with a more accurate billing methodology in
relationship to the actual cost of prescription drugs.
The new billing methodology is more in line with the way the private sector
bills.
Key points to remember are:
• The new billing methodology requires VA to bill the actual cost of the
drug plus an administrative fee
• The new billing methodology was implemented with prescriptions filled
beginning March 18, 2011
The rule was published in the Federal Register on October 6, 2010 and is
available at: http://edocket.access.gpo.gov/2010/pdf/2010-25043.pdf
28
Administrative Fee Calculation
The administrative fee will be calculated annually based on experience
from a prior fiscal year (October through September)
Drug Indirect Costs + Dispensing Costs
Total RX Fills
Updates to the administrative fee will be implemented and updated via a
patch in January of each year with the exception of this year
For example:
• The administrative fee of $11.40 (calculated for FY09) will apply to
prescriptions filled beginning March 18, 2011 through December 2011
• The administrative fee calculated for FY10 will apply to prescriptions filled
for the calendar year January to December 2012
29
Drug File Cost Methodology
• Here is how the prescription cost will be determined:
• For original fills, the UNIT PRICE OF DRUG field (#17) of
Prescription File (#52) will be used for the drug cost
• For refills, the CURRENT UNIT PRICE OF DRUG field
(#1.2) of the Prescription File REFILL multiple (#52.1) will be
used for the drug cost
• The administrative charge (currently $11.40) will be added to
these costs and used for the ePharmacy claim
• The Prescription file fields mentioned above will obtain their
costs from the Drug File entry for the item
30
Drug File Cost Methodology Cont.
• The drug cost that will be transmitted to the third party will
be the drug file cost for the NDC chosen for the
prescription when the claim is submitted
• In most cases the NDC chosen by the software will be the
Last Local NDC, or Last CMOP NDC
• For local fills, if the NDC chosen for the prescription is the
default NDC (Drug file field #31 NDC):
• The drug cost used will be the value of the PRICE PER
DISPENSE UNIT field (#16) of DRUG file (#50)
• If the NDC selected is a synonym:
• The PRICE PER DISPENSE UNIT field (#404) of the
SYNONYM multiple (#9) of the DRUG file (#50) will be used
31
Drug File Cost Methodology Cont.
• In the case of CMOP fills, the default NDC price will be
used, which is taken from PRICE PER DISPENSE UNIT
field (#16) of DRUG file (#50)
• Functionality currently doesn’t exist to allow CMOP drug
costs to be shared between VistA and CMOP.
• Drug cost values are stored at the same time as drug file
updates to the NDC occur, for example through the Drug
Accountability process
32
Reimbursement by PBMs and TPPs
• Impact of PBM Agreements
• PBMs will continue to pay under the terms and conditions of
their current agreements with VA
• Some agreements are written with “lesser of” logic using
reimbursement methodologies such as:
• Average Wholesale Price (AWP) less a discount
• Maximum Allowable Cost (MAC) pricing
• Usual and Customary (U&C) pricing
33
Reimbursement by PBMs and TPPs
cont.
Example of PBM reimbursement to facilities:
The PBMs agreement is written that they will pay the lower of:
(a) the pharmacy Usual & Customary (U&C) charge which
combines the drug cost and administrative fee; or
(b) the AWP less a discount
For this example, the AWP less a discount is lower than the U&C.
The payment returned to VHA will be the lower amount, which in
this example is the AWP less the discount and not the U&C billed
by VHA.
34
Potential for Additional Revenue
• A high level analysis completed prior to the publication of
the billing methodology rule indicated that it would result
in approximately a 3% increase in revenue
• The new methodology of billing the actual cost of the
prescription plus an administrative fee will provide
potential for increased revenue with regard to high cost
medications
• Instead of a maximum of $51 per prescription, VA has the
potential of receiving a much larger payment amount on
some high-end prescriptions
• Facilities who are the most successful at ensuring
prescriptions are billed and claims are approved will
benefit the most
35
Need for Prior Authorizations
• Many high cost medications require prior authorizations
• Most third party prior authorization rejects are returned
with reject code 75 : Prior Authorization, and are followed
up by the OPECC
• Some rejects for prior authorization are returned as 88:
DUR and are seen on the Third Party Payer Rejects –
Worklist
• These are usually Ignored by the pharmacists with an
appropriate comment back to the OPECC
• Proper follow-up on prior authorizations rejects is a must
to maximize revenue for prescriptions
36
Prior Authorization Process
• Prior Authorization processes are determined at the
facility level and vary from facility to facility
• Most sites currently have a method to follow-up on claims
that need Prior Authorization
• Prior Authorization process at many facilities pre-dates
ePharmacy, as a process was needed when the VA billed
prescription claims on paper as well
• At some facilities Revenue is in charge of following up on
Prior Authorizations
• Some facilities have Utilization Review nurses handle the
process
• Still other processes involve Pharmacy
37
ECME returned status:
Cannot find price for Item
• Facilities started reporting this problem shortly after the
Billing methodology change went into effect.
• Claims are not generated when the above error is returned
• Reported for prescriptions for drug with very low prices, e.g.
HCTZ 25/TRIAMTERENE 37.5MG TAB, GLYBURIDE
2.5MG TAB
• It appears the Price Per Dispense unit calculated field value
for some of these is less than $0.00, and the Integrated
Billing software needs a price of at least $0.01 to bill the
prescription
• At this time the issue is still being investigated, but a fix will
be implemented
38
Pharmacy Actions to Maximize Revenue
39
Pharmacy Actions to Maximize
Revenue
• Ensure all prescriptions are billed
• Make sure pharmacy and medical staff understand that
service designation is not only important for VA copay
determination but also determines whether we bill for
prescription or not.
• any prescription that is not service connected can be billed
• Encourage prescribers to accurately mark prescriptions
as SC or NSC
• Ensure prescriptions are properly marked as SC or
NSC when finishing prescription
40
Pharmacy Actions to Maximize
Revenue
• Take an active role in Reject Resolution
• Remember that Rx reimbursement is important to the
veteran as well because of VA copay reduction
• Work closely with your OPECC
• Even the best OPECCs do not have the overall
knowledge of products and medication therapy required
to evaluate some prescription rejects they receive
• Consider setting up additional rejects to transfer to your
Pharmacy Worklist
41
Pharmacy Actions to Maximize
Revenue cont.
• Ensure you have your parameters set-up to generate the
ePharmacy - OPEN/UNRESOLVED REJECTS LIST
messages
• Ensure appropriate staff are enrolled in theG.PSO
REJECTS BACKGROUND MESSAGE so the messages will
be received
• Periodically evaluate the ‘Ignored Rejects Report’ too ensure
staff are only ‘Ignoring’ appropriate rejects
• Ensure that the quantity dispensed for ePharmacy
prescriptions is appropriate for the days supply
42
Pharmacy Actions to Maximize
Revenue cont.
• Billing for AIDS medications is more lucrative now
because of their high cost
• Ensure drugs used exclusively for the sensitive
conditions are properly marked in your drug file
• Work with your OPECC to ensure patients on these
drugs have ROI’s entered into VistA
• Some pharmacies are interested in billing for
medications administered in the clinic
• If the patient picks up the prescription from the Pharmacy and
brings it to clinic it can be billed through ePharmacy
• If Pharmacy delivers the medication to the clinic the prescription
is billed as part of the clinic visit
43
ePharmacy Menu Screen
IR
MP
NV
PF
SP
VP
WL
TC
Ignored Rejects Report
ePharmacy Medication Profile (View Only)
NDC Validation
ePharmacy Medication Profile Division Preferences
ePharmacy Site Parameters
Third Party Payer Rejects - View/Process
Third Party Payer Rejects - Worklist
TRICARE Bypass/Override Report
Select ePharmacy Menu Option: sp
ePharmacy Site Parameters
Regardless of any parameters defined, Refill-Too-Soon, Drug Utilization
Review(DUR) and Tricare rejects will always be placed on the Third Party
Payer Rejects - Worklist, also known as Pharmacy Reject Worklist. These
parameters are uneditable and are the default parameters.
Division: ECMETEST DIV
...OK? Yes//
44
ePharmacy Site Parameter
Screen
Division: ECMETEST DIV
...OK? Yes//
(Yes)
ALLOW ALL REJECTS: NO//
REJECT WORKLIST DAYS: 7//
Previously defined override reject codes:
Code
Send
----22
M5
99
Description
Auto
---------------------------------M/I Dispense As Written (DAW)/Product Selection Co
Requires Manual Claim
Host Processing Error
------YES
YES
YES
Select REJECT CODE: 75
Prior Authorization Required
CODE: 75//
AUTO SEND: ??
Enter Yes for auto update or No for requires OPECC intervention.
Choose from:
0
NO
1
YES
AUTO SEND: 0 NO
45
Reject Transfer Screen
Code
Send
----22
M5
77
50
19
EU
21
EV
75
54
E7
55
25
E4
E5
E6
Description
Auto
---------------------------------M/I Dispense As Written (DAW)/Product Selection Co
Requires Manual Claim
Discontinued Product/Service ID Number
Non-Matched Pharmacy Number
M/I Days Supply
M/I Prior Authorization Type Code
M/I Product/Service ID
M/I Prior Authorization Number Submitted
Prior Authorization Required
Non-Matched Product/Service ID Number
M/I Quantity Dispensed
Non-Matched Product Package Size
M/I Prescriber ID
M/I Reason For Service Code
M/I Professional Service Code
M/I Result Of Service Code
------YES
YES
NO
NO
NO
YES
NO
YES
NO
NO
YES
YES
NO
YES
YES
YES
46
Reject Information Screen –
E4 Reject
Reject Information(UNRESOLVED)Mar 28, [email protected]:58:27
Division : ECMETEST DIV
Patient : PATIENT,ECME ONE(###-##-####) Sex: M
Rx#
: ####1594A/1
ECME#: ###0914
CMOP Drug: ALBUTEROL 90MCG (CFC-F) 200D ORAL INHL
Page:
1 of
2
NPI#: 130689XXXX
DOB: MMM 24,####(##)
Fill Date: Mar 25, 2011
NDC Code: 59310-0579-20
REJECT Information
Reject Type
: E4 - M/I Reason For Service - received on MAR 25, [email protected]:45:35
Reject Status : OPEN/UNRESOLVED
Payer Message : USE VENTOLIN HFA OR OV 5555/08,M/I REASON FOR SERVICE CODE, REQ
UIRED ON DUR/PPS BILLING
Reason
: PP (PLAN PROTOCOL )
DUR Text
: FOR LOWER COPAY OPTION
COMMENTS
- MAR 25, [email protected]:45:35 - Automatically transferred due to override for reject
code. (RPH,ONE)
INSURANCE Information
Insurance
: MEDCO HEALTH DIRECT CLAIMS
+
Enter ?? for more actions
VW View Rx
IGN Ignore Reject
MP Medication Profile
RES Resubmit Claim
Select: Next Screen//
OVR Submit Override Codes
CSD Change Suspense Date
47
DUR Reject for Valtrex cont
• Prescription rejected because we were using brand name
Valtrex when a generic is available
• Changing the DAW from 0 NO PRODUCT SELECTION
INDICATED, to 5 SUBSTITUTION ALLOWED-BRAND DRUG
DISPENSED AS A GENERIC, produced a payable claim
• We billed the default cost of $3.1897 X 180 = $574.15 + $11.40
= $585.55
• The insurance reimbursed the following way:
• Ingredient cost pd $548.05
• Patient copay $25.00
• Dispensing fee $1.25
• Total amt pd $524.30
48
Reject Information Screen –
Valtrex
Reject Information(UNRESOLVED)Mar 28, [email protected]:58:27
Division : ECMETEST DIV
Patient : PATIENT,ECME ONE(###-##-####) Sex: M
Rx#
: ####8819B/3
ECME#: 6662743
CMOP Drug: VALACYCLOVIR HCL 500MG TAB
Page:
1 of
2
NPI#: 130689XXXX
DOB: MMM 24,####(##)
Fill Date: Mar 30, 2011
NDC Code: 00173-0933-08
REJECT Information
Reject Type
: 88 - DUR Reject Error- received on MAR 21, [email protected]:41:14
Reject Status : CLOSED/RESOLVED
Payer Message : TRY VALACYCLOVIR FIRST.DRUG IS NON-COMPLIANT WITH STEP THERAPY.
TO DISPUTE CLAIM, CALL 800-238-6279 FOR FORMS/INSTRUCTIONS
Reason
:
DUR Text
:
INSURANCE Information
Insurance
: AETNA PHARMACY MANAGEMENT
Contact
: (800)238-6279
Group Name
: ECME TEST INS
Group Number
: GROUP
Cardholder ID : ############
VW View Rx
MP Medication Profile
Select: Next Screen//
IGN Ignore Reject
RES Resubmit Claim
OVR Submit Override Codes
CSD Change Suspense Date
49
ePHARMACY TRAINING
50
ePharmacy Training
• ePharmacy for Pharmacists 101 training were presented
in June 2011
• ePharmacy for Pharmacists 201 and 301 sessions are
being planned
• Similar training is being provided to the OPECCs
• TRICARE training will be provided to new facilities prior to
implementation
• ePharmacy Support Calls are held the second Monday of
each Month
• Please visit our ePharmacy Training Page
51
Pharmacy Section of ePharmacy
Training Site
• List of ePharmacy VISN Points of Contact (POCs) (April 2011)
• ePharmacy Helpful Hints (updated January 2011)
• ePharmacy Issue Reporting Form (updated July 2009)
• ePharmacy Issue Reporting Form Instructions (June 2009)
• ePharmacy Checklist for New ePharmacy Site Managers (02/10)
• Advanced Pharmacy Reject Resolution Training (February 2010)
• Advanced Training – ePharmacy Options & Bulletins (February 2010)
• DEA Special Handling Field Instructions (August 2010)
• NCPDP Dispense Unit and Quantity Multiplier Instructions (updated May
2010)
• Pharmacy Benefits Management Services Clinical INFORMatics Share
Point Site
• Click on NCPDP Document folder to access the NCPDP Disp Unit & Qty
Mult Exceptions List spreadsheet.
52
Pharmacy Section of ePharmacy
Training Site cont
• e-Pharmacy NDC Validation (06/13/06)
• ePharmacy Quick Reference Card for finishing & releasing staff (01/08)
• ePharmacy Quick Reference Card for ePharmacy Site Manager
• e-Pharmacy Rejects & Resolutions Guide v6 (revised Nov 2010 )
• Pharmacy Roles & Responsibilities (03/08)
• List of Drugs Used for Sensitive Diagnoses (08/09/09)
• Third Party Audits (01/10)
• VeHU 2007 - e-Pharmacy - Basic Training (08/07)
• VeHU 2007 - e-Pharmacy - Advanced Training (08/07)
• The National Council for Prescription Drug Programs (NCPDP) web site
NCPDP Provider ID application form
• Dispensing Pharmacy Information Spreadsheet (06/14/06 ) (To be
completed only when a pharmacy is obtaining a new NCPDP number. )
• How to Identify and Resolve Stranded ePharmacy Claims (Sep 2009)
53
TRICARE
54
TRICARE Implementation
• The only pharmacies currently authorized to process
TRICARE prescriptions are Dallas, Louisville, Loma
Linda, Long Beach, Palo Alto and Topeka.
• Other facilities will need to be approved for processing.
• Facilities must follow the national VA Memorandum of
Understanding (MOU) with the Department of Defense
(DoD) in order to process TRICARE prescription claims.
• Express Scripts, the PBM for TRICARE, has system
checks in place that will reject TRICARE claims submitted
by any VA pharmacy that has not been authorized
through the ePharmacy Implementation Team.
55
ePharmacy TRICARE Processing
Rules
• TRICARE claims are submitted electronically in real-time
when …
• The patient’s only eligibility is TRICARE, Sharing
Agreement, or Active Duty.
• The patient has separate active TRICARE insurance plan
entry with pharmacy coverage set to yes (no other Rx plans)
• TRICARE claims are submitted manually by the
TRICARE OPECC when …
• The patient has dual eligibility (e.g., Veteran and TRICARE
or TRICARE and Employee, etc.)
-- or -• The TRICARE beneficiary has Other Health Insurance (OHI)
primary to TRICARE.
56
Processing differences
Veteran 3rd Party Claims
TRICARE Claims
Submitted charge equals drug cost
plus admin fee ($11.40 for 2011)
Submitted charge equals drug cost
plus dispensing fee (currently $8)
Only time Prescription label will not
print is if claim rejects for DUR/RTS
Prescription label will NOT print if
claim rejects for any reason
Prescription processed and dispensed
to veteran even if claim rejects
Any reject must be resolved to a
payable status or Ignored before
prescription can be filled
Pharmacy staff are not notified of nonDUR/RTS rejects
Pharmacy staff given choice to
Discontinue, Quit or Ignore processing
for non-DUR/RTS rejects
DUR/RTS & site-defined rejects are
only rejects on Pharmacy Worklist
ALL TRICARE rejects appear on
Pharmacy Worklist (Non-DUR/RTS
rejects appear in a separate section)
57
TRICARE Rules for Pharmacy
Processing OTC & Supplies
• Certain medications (most OTC and supply items) are not
covered under the TRICARE contract (will not reimburse).
• Facilities lose money by filling TRICARE prescriptions for
these products.
• Pharmacy should notify patient and/or provider if a
prescription can not be filled due to limitations of
TRICARE contract (i.e., OTC and supplies).
• Per the patient’s TRICARE policy, the patient is
responsible for buying these items at a retail pharmacy.
• Pharmacy finishing & releasing staff will see new
“TRICARE - NON-BILLABLE” message.
58
Non-Billable TRICARE products
• The DEA, Special HDLG field of the Drug file is used to
determine which products can be dispensed to TRICARE
patients.
• Drug file entries at facilities should already be marked for
ePharmacy claims processing and therefore no additional updating
is required.
• Prescriptions for non-billable OTC and supply items will
not be allowed to be processed by Outpatient Pharmacy
software.
• Pharmacy staff holding the PSO TRICARE security key can
Override a TRICARE reject if there is an immediate medical need
to dispense the medication.
• TRICARE Bypass/Override Report tracks TRICARE Ignore
actions
59
TRICARE Non-Billable Rejects –
Non TRICARE Sites
• Sites should have at least one or more staff with the PSO
TRICARE key
• For example:
• Cannot print a label to fill a prescription for a non-billable
product, e.g. a vaccine marked with M or 0
• Check with local revenue staff - patient Insurance may not
be entered correctly
• If insurance is correct and you still want to fill the
prescription, the reject can be Ignored and the Rx filled
• Need the PSO TRICARE to Ignore a TRICARE claim and fill
Rx
60
ePharmacy TRICARE Processing
Rules – Dual Eligibility
• TRICARE sites have reported challenges surrounding
Dual Eligibility
• Pharmacy does not know veteran is using TRICARE
eligibility until Rx rejects
• Patient could receive prescription if using veteran eligibility,
but Rx not covered by TRICARE
• Guidance at this time is to process under TRICARE billing
rules
• If the prescription reject cannot be resolved to payable,
TRICARE will not pay, and the site needs to make a
decision to provide the prescription or not.
61
Outpatient Rx for TRICARE
Inpatients
• Outpatient medications for TRICARE inpatients:
• The software will not create an ePharmacy claim for a
Outpatient Rx filled for a TRICARE eligible who is an
inpatient. (e.g. patient is on a self-medication, a “pass” med
or the provider has written a discharge medication order)
• These prescriptions are not billable per the VA/DoD
TRICARE MOU, and are billed as part of the inpatient stay
• Since no claim is sent, no rejects will be received and
prescriptions are always allowed to be filled.
• TRICARE Bypass/Override Report tracks these TRICARE
Inpatient “bypassed” prescriptions. This report is locked with
the PSO TRICARE MGR security key.
62
Pop Quiz – TRICARE
True or False?
• Any facility that wants to process TRICARE
prescriptions can do so right now.
63
Pop Quiz Question – TRICARE answer
Answer: _________
The answer is false. Only 6 facilities are currently
approved for TRICARE prescription processing.
Others will need to be approved.
64
Educational Resources
• ePharmacy TRICARE Support Calls – VANTS 82429
• 3rd Wednesday of each month @ 2 pm Eastern
• VistA University – ePharmacy Training Page
•
•
•
•
•
http://vaww.vistau.med.va.gov/VistaU/e-bp/e-pharmacy.htm
Live Meeting Sessions
e-Pharmacy Checklists
Show-Me videos
Reject & Resolution Guide
• ePharmacy Simulation Training located on VA LMS
• How to access ePharmacy web courses on VA LMS
• Link to VA LMS
• The TRICARE Eligibility instructions are in Procedure Guide
1601D.01: TRICARE, Chapter 2:
65
Questions?
Send your questions to the
VHA ePharmacy Implementation Team
mail group in Outlook
66

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