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Understanding Rx Priority Points in POS Systems for Accurate Insurer Transmission

This agenda focuses on the definition and impact of Rx Priority Points in determining the insurer transmitted electronically via Point of Sale (POS) systems. Participants will learn troubleshooting techniques and how to effectively assign and calculate points for various insurers, including private and governmental entities. The session will address the selection criteria for insurers, including base points and specific rules, ensuring accurate claims processing. Resources such as worksheets and manuals will be reviewed to enhance understanding.

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Understanding Rx Priority Points in POS Systems for Accurate Insurer Transmission

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  1. RPMS POS and Rx Priority Points

  2. Agenda • Review definition of Rx Priority Points and how they impact the determination of which insurer is transmitted electronically via POS • Learn how to troubleshoot • REFERENCES: • ftp://ftp.ihs.gov/rpms/POS/ • POS User folder - Rx Priority Points worksheet • POS User folder – POS User Manual – page 35

  3. Definition • Rx Priority – points assigned (adding weight) to insurer. • Rx Priority points are added to BASE POINTS (located in the POS Set-Up Menu). • POS selects insurance to transmit electronically by determining which insurance has the most points assigned. • Points are assigned in various places in the POS package

  4. POS selection of Insurance • Not affected by Patient Registration package sequencing • Selection criteria: • Base points • Rules among private insurers • Points for particular insurers (POS / MGR / SET / INS / ADV) • Insurer added most recently to patient registration record

  5. Base Points Enter the base scores for each insurance type. For example, if Private insurance is usually primary, and Medicaid is secondary and Medicare is tertiary then you might give Private 900 points, Medicaid 600 points, Medicare and Railroad each 300 points and Self pay 100 points. INS BASE PRVT: 900// INS BASE CAID: 600// INS BASE CARE: 300// INS BASE RR: 300// INS BASE SELF: 100//

  6. Additional Insurance Rules • Birthday rule (2 parents) • Policy Holder is Self • Workers Comp Rule

  7. Insurer Points • Extra points for specific insurers • POS / MGR / SET / INS / ADV • Rx Priority Points • Insurer name used for Medical and Pharmacy Claims – 5 points • Insurer name used only for Pharmacy claims – 20 points • Medicare Part D insurer - >600 points; recommend 650 points if Medicare Part D is primary

  8. SEE Rx Priority Worksheet

  9. Calculate Points Assume base points have not been adjusted. However, it would be good to verify. • INS BASE PRVT: 900// • INS BASE CAID: 600// • INS BASE CARE: 300// • INS BASE RR: 300// • INS BASE SELF: 100//

  10. Calculate Points • Select INS RULE ORDER: 20// • INS RULE ORDER: 20// • INS RULE NAME: POLICY HOLDER IS SELF// • INS RULE POINTS PLUS: 10// • INS RULE POINTS MINUS:

  11. Calculate Points ----- Using electronic FORMAT: MEDICARE PARTD RXSOLUTIONS 5.1 BIN: 610097 D-PACIFICARE SAVER STANDARD 650.00 ----- Using electronic FORMAT: NATIONAL PHARM SVCS 5.1 BIN: 004758 NATIONAL PHARMACEUTICAL SER STANDARD ----- Using electronic FORMAT: PAID 5.1 BIN: 610014 GOVERNMENT EMPLOYEES HOSP ASSN STANDARD 5.00 MERCK-MEDCO RX SERVICES STANDARD 20.00 MEDCOHEALTH STANDARD 20.00

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