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Veterans Health Administration Chief Business Office Business Development ePharmacy Team

Veterans Health Administration Chief Business Office Business Development ePharmacy Team. ePharmacy Update for Pharmacy Informatics. Agenda. ePharmacy Project Overview ePharmacy team and project information ePharmacy Statistics ePharmacy Enhancements

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Veterans Health Administration Chief Business Office Business Development ePharmacy Team

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  1. Veterans Health AdministrationChief Business OfficeBusiness DevelopmentePharmacy Team ePharmacy Update for Pharmacy Informatics

  2. 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

  3. 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

  4. 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

  5. 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.

  6. 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

  7. ePharmacy Rejections OverviewCalendar 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. 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.

  8. 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

  9. 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.

  10. 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

  11. ePharmacy Future

  12. 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

  13. 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

  14. Phase 5/D.0 – Additional Reject Information 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 OVR Submit Override Codes MP Medication Profile RES Resubmit Claim CSD Change Suspense Date Select: Quit// ?? The following actions are also available: COM Add Comments DN Down a Line PS Print Screen CLA Submit Clarif. Code UP Up a Line PT Print List ED Edit Rx FS First Screen SL Search List PA Submit Prior Auth. LS Last Screen ADPL Auto Display(On/Off) + Next Screen GO Go to Page QU Quit - Previous Screen RD Re Display Screen ARI View Addtnl Rej Info

  15. Phase 5/D.0 – Additional Reject Information Cont. Reason : ID (INGREDIENT DUPLICATION) +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 OVR Submit Override Codes MP Medication Profile RES Resubmit Claim CSD Change Suspense Date Select: Quit//ARI 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

  16. Phase 5/D.0 – Multiple Clarification Codes 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 OVR Submit Override Codes MP Medication Profile RES Resubmit Claim CSD Change Suspense Date Select: Quit// ?? The following actions are also available: COM Add Comments DN Down a Line PS Print Screen CLA Submit Clarif. Code UP Up a Line PT Print List ED Edit Rx FS First Screen SL Search List PA Submit Prior Auth. LS Last Screen ADPL Auto Display(On/Off) + Next Screen GO Go to Page QU Quit - Previous Screen RD Re Display ScreenARI View Addtnl Rej Info

  17. Phase 5/D.0 – Multiple Clarification Codes cont. 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 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//

  18. 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.

  19. 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

  20. 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.

  21. Reject Information Screen Changes Reject Information(UNRESOLVED)Apr 06, 2011@08:30:37 Page: 1 of 1 Division : ECMETEST DIV NPI#: 130689XXXX Patient : PATIENT, TESTONE(###-##-####) Sex: M DOB: MMM, ##, ####(##) Rx# : #####713I/3 ECME#: ####202 Fill Date: MMM ##, #### CMOP Drug: DIAZEPAM 10MG TAB NDC Code: 67544-0020-30 REJECT Information Reject Type : 88 - DUR Reject Error- received on APR 06, 2011@00:44:26 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 OVR Submit Override Codes MP Medication Profile RES Resubmit Claim CSD Change Suspense Date Select: Quit// Select: Quit// Select: Quit// OVR Submit Override Codes Reason for Service Code : DD DRUG-DRUG INTERACTION Professional Service Code:

  22. 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...

  23. 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

  24. 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

  25. Pop Quiz – DUR Reject Reject Information(UNRESOLVED)Apr 06, 2011@08:30:37 Page: 1 of 1 Division : ECMETEST DIV NPI#: 130689XXXX Patient : PATIENT, TESTONE(###-##-####) Sex: M DOB: MMM, ##, ####(##) Rx# : #####713I/3 ECME#: ####202 Fill Date: MMM ##, #### CMOP Drug: DIAZEPAM 10MG TAB NDC Code: 67544-0020-30 REJECT Information Reject Type : 88 - DUR Reject Error- received on APR 06, 2011@00:44:26 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 OVR Submit Override Codes MP Medication Profile RES Resubmit Claim CSD Change Suspense Date Select: Quit// Select: Quit//

  26. Pop Quiz – DUR Reject - answer VW View Rx IGN Ignore Reject OVR Submit Override Codes MP Medication Profile RES Resubmit Claim CSD Change Suspense Date Select: Quit// CLA CLA Clarification Code: 2 OTHER OVERRIDE When you confirm, a new claim will be submitted for the prescription and this REJECT will be marked resolved. Confirm? YES//

  27. Billing Methodology Change

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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 

  33. 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

  34. 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.

  35. 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

  36. 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

  37. 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

  38. 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

  39. Pharmacy Actions to Maximize Revenue

  40. 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

  41. 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

  42. 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

  43. 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

  44. ePharmacy Menu Screen IR Ignored Rejects Report MP ePharmacy Medication Profile (View Only) NV NDC Validation PF ePharmacy Medication Profile Division Preferences SP ePharmacy Site Parameters VP Third Party Payer Rejects - View/Process WL Third Party Payer Rejects - Worklist TC 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//

  45. ePharmacy Site Parameter Screen Division: ECMETEST DIV ...OK? Yes// (Yes) ALLOW ALL REJECTS: NO// REJECT WORKLIST DAYS: 7// Previously defined override reject codes: Code Description Auto Send ----- ---------------------------------- ------- 22 M/I Dispense As Written (DAW)/Product Selection Co YES M5 Requires Manual Claim YES 99 Host Processing Error 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

  46. Reject Transfer Screen Code Description Auto Send ----- ---------------------------------- ------- 22 M/I Dispense As Written (DAW)/Product Selection Co YES M5 Requires Manual Claim YES 77 Discontinued Product/Service ID Number NO 50 Non-Matched Pharmacy Number NO 19 M/I Days Supply NO EU M/I Prior Authorization Type Code YES 21 M/I Product/Service ID NO EV M/I Prior Authorization Number Submitted YES 75 Prior Authorization Required NO 54 Non-Matched Product/Service ID Number NO E7 M/I Quantity Dispensed YES 55 Non-Matched Product Package Size YES 25 M/I Prescriber ID NO E4 M/I Reason For Service Code YES E5 M/I Professional Service Code YES E6 M/I Result Of Service Code YES

  47. Reject Information Screen – E4 Reject Reject Information(UNRESOLVED)Mar 28, 2011@08:58:27 Page: 1 of 2 Division : ECMETEST DIV NPI#: 130689XXXX Patient : PATIENT,ECME ONE(###-##-####) Sex: M DOB: MMM 24,####(##) Rx# : ####1594A/1 ECME#: ###0914 Fill Date: Mar 25, 2011 CMOP Drug: ALBUTEROL 90MCG (CFC-F) 200D ORAL INHL NDC Code: 59310-0579-20 REJECT Information Reject Type : E4 - M/I Reason For Service - received on MAR 25, 2011@19:45:35 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, 2011@19:45:35 - 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 OVR Submit Override Codes MP Medication Profile RES Resubmit Claim CSD Change Suspense Date Select: Next Screen//

  48. 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

  49. Reject Information Screen – Valtrex Reject Information(UNRESOLVED)Mar 28, 2011@08:58:27 Page: 1 of 2 Division : ECMETEST DIV NPI#: 130689XXXX Patient : PATIENT,ECME ONE(###-##-####) Sex: M DOB: MMM 24,####(##) Rx# : ####8819B/3 ECME#: 6662743 Fill Date: Mar 30, 2011 CMOP Drug: VALACYCLOVIR HCL 500MG TAB NDC Code: 00173-0933-08 REJECT Information Reject Type : 88 - DUR Reject Error- received on MAR 21, 2011@10:41:14 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 IGN Ignore Reject OVR Submit Override Codes MP Medication Profile RES Resubmit Claim CSD Change Suspense Date Select: Next Screen//

  50. ePHARMACY TRAINING

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