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Maryland Pharmacy Programs Claims Processing Training PowerPoint Presentation
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Maryland Pharmacy Programs Claims Processing Training

Maryland Pharmacy Programs Claims Processing Training

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Maryland Pharmacy Programs Claims Processing Training

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  1. Maryland Pharmacy Programs Claims Processing Training January 2007

  2. Affiliated Computer Services (ACS) Agenda • Implementation Information • Coordinated ProDUR – MCO/PBM Information • Call Center Information • Operational Information (All Programs) • Operational Information (By Program) • Clinical Information (By Program) • Conclusion

  3. Program Learning Objectives • Understand and explain how the POS system works. • Know the differences between the old and new POS processing system • Be able to operate the system at Provider level and educate Providers Staff • Understand processing procedures on PDL, Mental Health drugs, HIV, and drugs requiring PA

  4. ACSPrescriptions Benefit Management (PBM) • Serve 32 programs nationwide – including Medicaid, senior programs, and workers’ compensation programs • Process more than 200 million pharmacy claims annually. • Manage States’ drug spend of more than $14 Billion. • Manage 14 million covered lives, or 1 in every 3 Medicaid eligibles nationwide.

  5. ACSPrescriptions Benefit Management (PBM) • Process over 2 million calls and faxes in our call centers annually • Process an average of 100,000 prior authorizations each month. • Manage a retail pharmacy network of 56,000 providers, approximately 80% of all pharmacies nationwide. • Administer federal and supplemental rebate programs and collect over $100 million in manufacturer rebates

  6. Implementation Information • February 4, 2007 is the official implementation date. • Down time – FH will cease processing at 11PM February 3, 2007. • ACS will be processing no later than 3 PM on February 4, 2007. • Follow internal downtime procedures during this outage

  7. Operational Program Changes General Information • Claims will only be accepted in the NCPDP Version 5.1 Claim Format via POS • There is no batch claim submissions accepted

  8. Coordinated ProDUR - MCO/PBM Information The ACS POS system has a mechanism, which at the pharmacy level, with one transmission, will electronically link the payer with all recipient drug information necessary to perform Coordinated ProDUR. • MCO Services • Specialty Mental Health Services • Medical Assistance Program Services • Providers will submit a single transmission only. • Coordinated ProDUR editing is “message only”

  9. Coordinated ProDUR • ACS will process claims for the Mental Health Carve-out drugs then send any drug that are denied to the MCO for processing. All claims MUST be sent to the following: • BIN: 610084 • PCN: Use current ACS code submitted • Group ID – Use current number submitted

  10. ACS Call Center All Programs • Call Center • PA Call Center number • Phone: 1-800-932-3918 • Fax: 1-866-440-9345 • Technical Call Center number • Phone: 1-800-932-3918 • Fax: 1-866-440-9345 • Hours of Operation: 24/7/365 • Henderson facility handles overflow and after hours

  11. ACS Call Center • Staffed by Customer Service Representatives and Pharmacy Technicians • Pharmacist on site 8:30 am to 5:00 pm and on call 24 hours per day • Includes multi-lingual support services Will Handle: • Claims inquiries • Clinical inquiries • Program specific and general inquiries • Prior Authorizations

  12. PAC Call Center • PAC Eligibility Services Call Center information • Call Center Number – (800) 226-2142 • General questions about the PAC Program • Maryland residents requesting an application • Maryland residents who have applied but no decision has been made - questioning status of application • Applicant questioning a determination decision

  13. Maryland Medicaid (OOEP)

  14. Medicaid Pharmacy Program Specific Information BIN 610084 PCN DRMAPROD Group ID MDMEDICAID Provider ID NCPDP Number Prescriber ID DEA Number Recipient ID Medicaid ID Number

  15. Copays • Fee for Service = $1.00 / 3.00 PAC copays = up to $2.50 for generics and up to $7.50 for brand name drugs NH = NO copays; • Pregnancy = NO copays (PA type = 4) • Family Planning medications = NO copay MMI State Funded Foster copay = $1.00 / 3.00 (no exceptions) • MCO/HMO copay - up to $1.00 for generics and up to $3.00 for brand name drugs

  16. Copay Exceptions • Patient is pregnant • Patient drug is a family planning medication. • Long Term Care (LTC) claims • Preferred Drug List (PDL) – 3 day emergency supply

  17. Dispensing Fees • Brand not on PDL: $2.69 • PDL and generic: $3.69 • LTC/Hospice Brand not on PDL: $3.69; PDL and generic: $4.69 • Partial Fills: • ½ dispensing fee at initial fill • ½ dispensing fee at completion fill • Copay paid on initial fill.

  18. Partial Fill Claim Submission Guidelines: • Dispensing status = P (partial) or C (complete) • Cannot submit a P and C transaction the same day • Cannot submit a C transaction before a P transaction • Quantity intended to be dispensed • Days supply intended to be dispensed • Quantity dispensed

  19. Compounds • Maryland Medicaid only accepts multi-line Compound claims. • If providers submit a compound claim with a single ingredient the claim will be denied. • The system will accept up to 40 line items (individual ingredients) in each compound claim. • The system will allow providers to use submission clarification code 8 (process compound for approved ingredients) to override denials for compound ingredients that are not covered.

  20. Generic Mandatory • The system will deny brand drugs when a generic is available • Edit 22 (M/I /DAW code) and the message text: “Generic Available – Physician to call State at 410-767-1755, Medwatch form required” • When submitted as Brand Medically Necessary (DAW = 1) with the exception of the following (pay at EAC): • Levothyroxine • Brimonidine eye drops

  21. Generic Mandatory • The system will cover brand drugs billed as generic with DAW=5 without preauthorization • Claims for brand drugs will be rejected with NCPDP edit 22 (M/I DAW code) and the message text: “Generic Available – Physician to call State at 410-767-1755, Medwatch form required” • The system will accept the following Dispense as Written (DAW) values (NCPDP field 408-D8): 0 - Default, no product selection 1 - Physician request 5 - Brand used as generic 6 - Override

  22. Coordination of Benefits (COB) ACS will process a claim for TPL when: • There is presence of COB on the Recipient Eligibility file • There is presence of COB submitted on a claim with an Other Payer Amt. Paid. • Claims that are submitted without COB information when there is presence of COB on the eligibility file will deny with NCPDP reject 41 – Submit claim to other payer. • Claims submitted with an Other Coverage Code 8 – Copay Only – are not accepted by Maryland Medicaid.

  23. LTC / Hospice The system will determine LTC claims by the following conditions: • Claim contains Patient Location Code = “04” (NCPDP field 307-C7) • Facility ID (NCPDP field # 336-8C) is on list of institutions • Pharmacy Provider ID is on the list of LTC providers • Note: Existing "NH" provider numbers = LTC providers / institutions

  24. LTC / Hospice The system will determine Hospice-Only claims by the following conditions: • Claim contains Patient Location Code = “11” (NCPDP field 307-C7) • Client Specific Reporting field on Recipient Eligibility file = "HI" • The Date of Service is within an active coverage span on the Recipient Eligibility file • Facility ID (NCPDP field # 336-8C) is on list of institutions (see appendix in Provider Manual) • Note: The system will deny Hospice claims that do not have both a Patient Location code = “11” and a Client Specific Reporting field on Recipient Eligibility file = "HI”

  25. LTC / Hospice ACS will determine RECIPIENTS with BOTH LTC/HOSPICE LTC/Hospice claims will be determined by the following distinct conditions: • Client SPECIFIC REPORTING field = "HI" on the recipient's enrollment record with a date span that includes DOS, AND • PATIENT LOCATION (NCPDP field # 307-C7) = "11", AND • FACILITY ID (NCPDP field # 336-8C) any value on the list of institutions, AND

  26. LTC / Hospice ACS will determine RECIPIENTS with BOTH LTC/HOSPICE LTC/Hospice claims will be determined by the following distinct conditions: (continued from previous slide) • Designated LTC providers in the SERVICE PROVIDER ID (NCPDP field # 201-B1) • The system will deny non-LTC claims for unit dose medications with certain exceptions; claims will deny with error 70 (drug not covered) and message text: “Unit Dose Package Size”

  27. Age Limitations Maryland Medicaid will enforce the following age restrictions: • Ferrous sulfate covered for recipients < 12 years • Non-legend chewable tablets of any ferrous salt when combined with vitamin C, multivitamins, multivitamins and minerals, or other minerals in the formulation • Topical Vitamin A Derivatives

  28. Prior Authorizations Methods to obtain a Prior Authorization: • Contact the Call Center or specified State office • Complete and fax a Prior Authorization request form • Smart PA

  29. Prior Authorizations • Maryland Medicaid Staff • Days supply exceeding maximums • Growth Hormones • Synagis (Palivizumab) • Female Hormones for a male and vice versa • Nutritional supplements (see MD PA form for clinical criteria) • Recipient Lock-In • Price (long-term PAs only) • OxyContin Quantity (during business hours) • Antihemophilic Drugs (claim pended in X2 and evaluated manually by State)

  30. Prior Authorizations • Maryland Medicaid Staff (continued) • Duragesic Patch excess quantity (during business hours) • Topical Vitamin A Derivatives • Opiate Agonists for Hospice and Hospice/LTC • Antiemetic excess quantities • Serostim • Botox • Orfadin • Revlimid • Revatio • Brand Medically Necessary

  31. Prior Authorizations • ACS ProDUR Call Center Prior Authorizations • Oxycontin, Duragesic Patch Qty (for after hours/weekends only) • Quantity Limits (except OxyContin & Duragesic Patch as noted above) • CNS Stimulants • Actiq • Anti-Migraine excess quantities • Atypical Antipsychotics (dosing quantity)

  32. Prior Authorizations • ACS Technical Call Center • PDL - Non-Preferred drugs • Early Refill • Maximum dollar limit per claim ≥ $2,500 • Age Restrictions • Maximum Quantity overrides

  33. Prior Authorizations • Maryland CAMP Office • Depo Provera • Lupron Depot

  34. SmartPA SmartPA New Clinical PA rules engine • ACS stores both medical and pharmacy claims history. • Claim is submitted, looks at both while reading the rule. Smart PA will issue a PA if claim and history meet criteria without pharmacy or physician intervention.

  35. Smart PA Exception Codes

  36. Smart PA Exception Codes

  37. SmartPA • Prior Authorizations handled by SmartPA • CNS Stimulants • Actiq • Anti-Migraine excess quantities • Atypical Antipsychotics (dosing quantity) • Serostim • Botox • Synagis • Growth Hormones

  38. SmartPA • Prior Authorizations handled by SmartPA • Anti-emetic • Topical Vitamin A • Orfadin • Revlamid • Revatio • Nutritional Supplements • Oxycodone

  39. Breast and Cervical Cancer Diagnosis and Treatment Program (BCCDT)

  40. BCCDT Program Specific Information BIN 610084 PCN DRDTPROD Group ID MDBCCDT Provider ID NCPDP ID Number Prescriber ID DEA Number Recipient ID BCCDT Recipient ID

  41. Copays / Dispensing Fee BCCDT Recipients do not have copays Dispensing fee structure: • BRAND products = $2.69 • Generic Products = $3.69 • Partial Fill • Dispensing fee will be paid ½ at the initial fill and ½ at the completion fill

  42. Generic Mandatory • BCCDT has a generic mandatory program in place. • The system will deny brand drugs when a generic is available with NCPDP Reject 22 (M/I Dispense As Written/DAW code) when submitted as Brand Medically Necessary (DAW = 1). • The system will accept the following Dispense as Written (DAW) values (NCPDP field 408-D8): • 0 - Default, no product selection • 1 - Physician request • 5 - Brand used as generic

  43. Coordination of Benefits / Copay Only Rules for copay only claim submission: • $60.00 maximum on all copay only claims. Amounts greater than $60.00 will have to be approved by BCCDT • BCCDT will pay copays for PAC recipients only if claims contain an "8" in NCPDP field 308-C8, Other Coverage Code. • The system will reject PAC claims where the Other Coverage Code is not equal to ‘8’ (Copay Only) with reject code edit 70 (Drug Not Covered) and the message text “BCCDT Only Reimburses Co-payments – Please bill PAC”

  44. Coordination of Benefits / Copay Only The following fields must be populatedwhen submitting a copay only claim: • Other Coverage Code (308-C8) = 8 • Other Amount Claimed Submitted Count = 1 • Other Amount Claimed Submitted Qualifier = 99 • Other Amount Claimed Submitted = copay amount and must equal the amount in Gross Amount Due • Gross Amount Due = copay amount and must equal the amount in the Other Amount Claimed Submitted • **No COB Segment is submitted with a Copay only claim.

  45. Coordination of Benefits /Qualified Medicare Beneficiary (QMB) • BCCDT will pay coinsurance for QMB recipients if claims contain an other coverage code of 3 or 4 for Med-B covered drugs only. • The system will reject claims for Medicare B covered drugs for QMB recipients where the other coverage code is not equal to “3 or 4”; the response will contain reject code edit 70 (Drug Not Covered) and the message text “BCCDT Only Reimburses Non-Covered Medicare B covered drugs"

  46. Coordination of Benefits / QMB & Medicare B • QMB recipients have pharmacy coverage except for drugs covered by Medicare B such as Xeloda- then BCCDT pays only denied claims. Pharmacies must bill Medicare and then Medicaid and BCCDT will be the payer of last resort for coinsurance. • ACS will deny COB claims for Medicare B covered drugs such as Xeloda, if the Other Coverage Code (OCC) is not equal to “2” with edit 41 (bill other insurance) and the message text: “Bill Medicare B”.

  47. Coordination of Benefits / Medicare D • BCCDT will cost avoid for Medicare D recipients • Providers are required to ensure COB claims for Medicare D to contain “77777” in the Other Payer ID (NCPDP field 340-7C). • The Other Payer ID is not required for non-Medicare D carriers

  48. Drug Coverage (BCCDT) • OTC drugs are generally not covered except for the drug listed in the grid in your Pharmacy Provider Manual. • Unit dose drugs are generally not covered except for noted exceptions. • Don't cover meds for pts in LTC facilities

  49. Prior Authorizations BCCDT providers can obtain prior authorizations from two sources: • BCCDT Office • ACS Technical Call Center

  50. Prior Authorizations The MD BCCDT staff will handle the following prior authorization requests: • Early Refill - For requests outside established criteria • PA/Medical Certification - authorization based on diagnosis • DME/DMS for HCFA 1500 billing - exception: needles, syringes that are paid through POS • PA denials handled by MD BCCDT will return the following message text in the response: “Prior Authorization Required, call MD BCCDT (410) 767-6787, M-F, 8:30 am – 4:30 pm”.