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RPMS POS Pharmacy Billing

RPMS POS Pharmacy Billing. May 17, 2006. Agenda. POS Basics Patient Registration, the Eligibility Transaction (E1) & Medicare Part D Reports Correcting Common Rejections Upcoming sessions. POS Basics. References: ftp://ftp.ihs.gov/rpms/POS/ Current patches: POS v1 patch 16

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RPMS POS Pharmacy Billing

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  1. RPMS POS Pharmacy Billing May 17, 2006

  2. Agenda • POS Basics • Patient Registration, the Eligibility Transaction (E1) & Medicare Part D • Reports • Correcting Common Rejections • Upcoming sessions

  3. POS Basics • References: ftp://ftp.ihs.gov/rpms/POS/ • Current patches: • POS v1 patch 16 • APSA (AWP monthly patch) • Patient Reg v7.1 patch 1 • RPMS Support Desk: rpmshelp@ihs.gov

  4. ftp://ftp.ihs.gov/rpms/POS/

  5. ftp://ftp.ihs.gov/rpms/POS/POS%20User%20Information/

  6. http://home.ihs.gov/ITSC-CIO/CSMT/SRCB/patchtbl.pdf

  7. APS AWP/PMI UPDATE STATUS • Select IHS-Specific Pharmacy Options Option: APS AWP/PMI UPDATE STATUS • AVERAGE WHOLESALE PRICE (AWP) • >>> UPDATE STATUS <<< • Last AWP monthly update occurred on..................MAY 3,2006 • Most recent 'manual' AWP update was ran on...........MAY 15,2006@13:40:07 • Total number of DRUGS updated with AWP...............547 • >>> ACTIVE DRUGS STATUS <<< • The Total Number of Active Drugs.....................571 • PATIENT DRUG EDUCATION DATABASE (PDED) • >>> UPDATE STATUS <<< • The last quarterly PDED update occurred on...........APR 3,2006 • PATIENT DRUG EDUCATION DATABASE WILL EXPIRE ON.......JUL 5,2006

  8. POS Basics • Maintenance • Check for stranded claims • POS / RPT / CLA / STR • START WITH START TIME: FIRST// • If there are stranded claims; resubmit via POS Claims Data Entry Screen (User Screen) • Know the RPMS Insurers that are set to transmit via POS • POS / RPT / SET / SUMI • Review Rx Priority Points

  9. ******************************************** • * PHARMACY POINT OF SALE V1.0 * * Pharmacy electronic claims reports * • ******************************************** CLA Claim results and status ... SET Setup (Configuration) reports ... SURV Surveys of RPMS database ... ELIG Medicare Part D Eligibility Check OTH Other reports ...

  10. SUMI Report PHARMACY ELECTRONIC CLAIMS INSURERS MAY 17,2006 01:17 PAGE 1 Grace Ins. Disp Fee Per Sel. Insurer Pricing Formula Override Override Pts. -------------------------------------------------------------------------------- ===== DIAL OUT to: ENVOY DIRECT VIA T1 LINE ----- Using electronic FORMAT: ADVANCE RX MGT SILVERSCRPT 5.1 BIN: 004336 D-SILVERSCRIPT STANDARD 650.00 ----- Using electronic FORMAT: EXPRESS SCRIPTS 5.1 BIN: 003858 BENEFIT PLANNERS, INC. STANDARD 5.00 EXPRESS SCRIPTS,INC. STANDARD 20.00 EXPRESS SCRIPTS STANDARD 20.00 ----- Using electronic FORMAT: GEHA 5.1 BIN: 610014 GEHA/RX STANDARD 20.00 ----- Using electronic FORMAT: PAID 5.1 BIN: 610014 PAID PRESCRIPTIONS, L.L.C. STANDARD 20.00 PAID PRESCRIPTIONS, INC. STANDARD 20.00

  11. ******************************************** • * PHARMACY POINT OF SALE V1.0 * * Pharmacy electronic claims reports * • ******************************************** CLA Claim results and status ... SET Setup (Configuration) reports ... SURV Surveys of RPMS database ... ELIG Medicare Part D Eligibility Check OTH Other reports ...

  12. EXAMPLE OF SURVEY BY INSURER Count Name Now sending format 10909 SOUTH DAKOTA MEDICAID(`442) 1315 FIRST HEALTH(`1012) MAILHANDLERS 5.1 901 BC/BS FEDERAL EMPLOYEE PROG(`953) 519 D-HUMANA STANDARD(`1121) CAREPLUS HP HUMANA PDP 5.1 381 PAID PRESCRIPTION DRUG PROGRAM(`951) PAID 5.1 319 D-SILVERSCRIPT(`1133) ADVANCE RX MGT SILVERSCRPT 5.1 301 D-ADVANTAGE FREEDOM(`1124) MEDICARE PARTD RXAMERI PDP 5.1 284 D-YOURX PLAN(`1138) MEDCO MEDICARE PDP 5.1 259 D-PACIFICARE SAVER(`1130) MEDICARE PARTD RXSOLUTIONS 5.1 259 D-WELLCARE SIGNATURE(`1137) WELLCARE MEDICARERX 5.1 216 D-COMMUNITY CARE RX(`1128) MEMBER HEALTH BASIC PDP 5.1 190 D-UNITED HEALTHRX(`1135) PRIMARY MEDICARE PARTD WHI 5.

  13. Medicare Part D – Getting Started 1. Verify patches have been installed (Patient Reg v7.1, patch 1 and POS v1 patch 16) 2. Enter Insurers (use recommended naming convention, i.e. D-PLAN NAME) in 3PB Table Maintenance Insurer File. 3. Tie Medicare Part D POS format to appropriate Insurer 4. Enter patient with Medicare Part D in Patient Registration Determine duel-eligible members Can Run E1 to determine BIN, PCN & Group number which correlates to a Plan Name. 4. Backbill 180 days

  14. Using the Eligibility Check (E1) • ******************************************** • * PHARMACY POINT OF SALE V1.0 * * Pharmacy electronic claims reports * • ******************************************** • CLA Claim results and status ... • SET Setup (Configuration) reports ... • SURV Surveys of RPMS database ... • ELIG Medicare Part D Eligibility Check • OTH Other reports ...

  15. Eligibility Check (E1) • Generate eligibility chk (Med Part D) for which patient? DEMO PATIENT • M 04-20-1940 154459999 WE 59999 • On: • Patient Name: DEMO PATIENT • Status: A • Authorization #: • Insurance Level: PRIMARY • BIN: 012304 • PCN: MPD • GROUP: PDA23 • CARDHOLDER ID: 123456789 • PERSON CODE: 1 • PHONE NUMBER: 8005551212

  16. POS Medicare Part D formats – sorted by BIN

  17. Medicare Part D formats sorted by Plan

  18. Linking Insurer to POS format ******************************************** * PHARMACY POINT OF SALE V1.0 * * * * Edit Pharmacy POS Insurance settings * ******************************************** SYS Insurance selection parameters (system-wide) INS Quick setup of insurer ADV Advanced setup of insurer RPMS Enter/edit RPMS Insurance file RX settings SUMI POS Setup - Summary of Insurers

  19. SUMI Report PHARMACY ELECTRONIC CLAIMS INSURERS MAY 17,2006 01:17 PAGE 1 Grace Ins. Disp Fee Per Sel. Insurer Pricing Formula Override Override Pts. -------------------------------------------------------------------------------- ===== DIAL OUT to: ENVOY DIRECT VIA T1 LINE ----- Using electronic FORMAT: ADVANCE RX MGT SILVERSCRPT 5.1 BIN: 004336 D-SILVERSCRIPT STANDARD 650.00 ----- Using electronic FORMAT: EXPRESS SCRIPTS 5.1 BIN: 003858 BENEFIT PLANNERS, INC. STANDARD 5.00 EXPRESS SCRIPTS,INC. STANDARD 20.00 EXPRESS SCRIPTS STANDARD 20.00 ----- Using electronic FORMAT: GEHA 5.1 BIN: 610014 GEHA/RX STANDARD 20.00 ----- Using electronic FORMAT: PAID 5.1 BIN: 610014 PAID PRESCRIPTIONS, L.L.C. STANDARD 20.00 PAID PRESCRIPTIONS, INC. STANDARD 20.00

  20. Medicare Part D insurers set up to POS format • POS / RPT / CLA / MPD • MPD TOTALS – MEDICARE PART D INSURERS • Any insurers/plans listed on this report are tied to a format that is “tagged” as Medicare Part D.     PAYABLE      ADJUSTED      PAPER       REJECTED    RX CNT ------------------------------------------------------------------------------- ------------------------------------------------------------------------------- D-PACIFICARE SAVER            283.10        77.87         0.00           0.00         6 ------------------------------------------------------------------------------- D-PRESCRIPTION PATHWAY             15.54         5.01          0.00       10.75         2

  21. Entering Information on Page 4 of Patient Registration

  22. Adding Medicare Part D Plan on page 4

  23. Completed Patient Reg page 4

  24. ******************************************** • * PHARMACY POINT OF SALE V1.0 * * Pharmacy electronic claims reports * • ******************************************** • CLA Claim results and status ... • SET Setup (Configuration) reports ... • SURV Surveys of RPMS database ... • ELIG Medicare Part D Eligibility Check • OTH Other reports ...

  25. Reports: Claims Results and Status ******************************************** * PHARMACY POINT OF SALE V1.0 * * Claim results and status * ******************************************** PAY Payable claims report REJ Rejected claims report CAP Captured claims report PAP Paper claims report UN Uninsured claims report DUP Duplicate claims report (should be none) MISS Find prescriptions missed by POS NRV Reversals needed URM Update Report Master File for a date range REC Recent transactions STR List possibly stranded claims DAY TOTALS - by RELEASED DATE INS TOTALS - by INSURER MPD TOTALS - MEDICARE PART D INSURERS

  26. REPORTS • Before running any reports, run the Update Report Master File (URM). • If backbilling, run report at least as far back as claims were being re-submitted. • Corrected claims will display on the Release date (equivalent to fill date) • Recommended schedule of running reports: • Rejection – daily • Payable – daily – to review how much plans are paying. • URM – after correcting rejections; before running rejection report. • Stranded Claim – weekly or if POS “not working” • Management reports – monthly • DAY – totals by release date • MCD – totals by medicare Part D insurer;

  27. Rejection Codes • Complete list of rejection codes is located on the ftp site (NCPDP folder) • M/I = Means Missing/Invalid • Rejection codes are NCPDP standard codes used by processors. • Not all processors use the codes the same way.

  28. Rejection codes

  29. Rejection – M/I BIN PCN Group REJECTION: MAR 28,2006 10:20 P06-610468-100173 `1050039/0 12345123412 123456789 150 185.80 CARBAMAZEPINE 04:M/I Processor Control Number 06:M/I Group Number 01:M/I Bin To Correct: If commercial plan – contact processor help desk to verify BIN/PCN and group number. For Medicare part D plan – try E1

  30. Rejection – M/I BIN PCN Group • Patient Name: DEMO PATIENT • Status: A • Authorization #: • Insurance Level: PRIMARY • BIN: 610468 • PCN: UAFC • GROUP: 8310000 • CARDHOLDER ID: 123456789 • PERSON CODE: 1 • PHONE NUMBER: 8006988394

  31. Rejection – M/I BIN PCN Group

  32. Rejection – M/I Transaction Code • Ø3: M/I Transaction Code • If this is a Medicare Part D insurer, this usually means that a non-Medicare Part D format is being used. Refer to Part D plans by BIN to find a different POS format.

  33. Rejection – M/I Birth Date • 09:M/I Birth Date • Contact processor to determine which birthdate they have in their system. • For Medicare Part D patients – enter birthdate information on page 4 of Medicare Part D page. • To over-ride birth date field: • POS / N / Override / Field 304 • Enter birthdate as: YYYYMMDD

  34. Rejection – 85: Claim not processed MAR 23,2006 10:00 P06-610459-108961 `104700/1 00093067005 0123456 60 75.74 GEMFIBROZIL 600MG TAB 85:Claim Not Processed NN:Transaction Rejected At Switch Or Intermediary 98:ConnectionTo Payer Is Down These type of rejections are more common with some of the processors with the implementation of Medicare Part D. Try Resubmitting the claim – POS / U / EV / 3 – Single Patient / RES

  35. Upcoming WebEx Sessions • Registration required – up to 30 in each class • https://ihs-training.webex.com/ • May 25 – Set up Insurers to POS format • May 26th – Rx Priority Points • June 14th – Using the Claim Data Entry Screen • June 28 – Establishing a Pharmacy Billing Program • Welcome additional topics • Train-the-Trainer – Area experts actively using POS – refer to Elmer

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