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Idaho Medicaid Pharmacy Program

Idaho Medicaid Pharmacy Program. Provider Training. Presenter Title/Department Date. Objectives. Upon completion of this training, participants will be able to

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Idaho Medicaid Pharmacy Program

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  1. Idaho MedicaidPharmacy Program Provider Training Presenter Title/Department Date

  2. Objectives • Upon completion of this training, participants will be able to • Describe changes to pharmacy claims processing implemented on January 30, 2010 by Magellan Medicaid Administration in support of the Idaho Medicaid Program. • List contact numbers that assist in processing pharmacy claims or answer questions regarding claims processing.

  3. Magellan Medicaid Administration Proudly presents…. The Idaho Medicaid Pharmacy Program Point-of-Sale (POS) Implementation

  4. Idaho Medicaid Pharmacy Program • On Saturday, January 30, 2010, Magellan Medicaid Administration began processing claims for the Idaho Medicaid Pharmacy Program. • Magellan Medicaid Administration performs the following functions: • Claims processing • Operations support for the POS system • Technical support for providers • Education and outreach for providers • Magellan Medicaid Administration’s Idaho Pharmacy Support Center • 1-800-922-3987

  5. Idaho Medicaid Pharmacy Program, cont. Clinical Prior Authorizations • For initiating Prior Authorizations (PA), contact the Idaho Department of Health and Welfare (IDHW) • Monday – Friday, 8:00 a.m. – 5:00 p.m. MT • 1-208-364-1829 (Local) • 1-866-827-9967 (Toll free) • 1-208-364-1864 (Fax)

  6. About Magellan Medicaid Administration • 30+ years of experience serving public sector health care programs • Medicaid • State drug program for seniors • Mental health agencies • Administers more Medicaid pharmacy benefit programs than all the competitors combined • National leader in Medicaid rebate administration • 970 employees nationwide • Headquartered in Glen Allen, VA, with offices in over 40 states

  7. Provider Electronic Solutions (PES) • If you use the PES software provided by Hewlett-Packard Enterprise Services to submit claims, verify eligibility, or submit claims solely on paper, then you need to send an email with “PES” in the subject line to idahommis@dhw.idaho.gov immediately. • These processes changed in January 2010 and IDHW will need to discuss the options that will be available to you. • As of January 30, 2010 you are able to access Web Claims Submission.

  8. Online 5.1 Claims Submission • On January 30, 2010, Magellan Medicaid Administration began accepting claims submissions.

  9. Plan Effective Date for POS Transition Implementation • On January 29, 2010, the current pharmacy vendor (HP-formally known as EDS) shut down claims processing at 8:00 p.m. MT. • On Saturday, January 30, 2010, Magellan Medicaid Administration began claims processing at 7:00 a.m., PT, 8:00 a.m., MT; 10:00 a.m., ET.

  10. Availability • Magellan Medicaid Administration will provide system availability for submitting claims • Daily, 24/7/365 • Except • Saturday down at 9:00 p.m., MT • Sunday up at 4:00 a.m., MT

  11. Readiness Documents and Resources • Pharmacy Claims Submission Manual • Payer Specification document • User Administration Console User Guide • Web Claims Submission User Guide • All documents and resources will be located on the following website: • https://idaho.fhsc.com *This site became available on January 4, 2010

  12. Modes of Claim Submission • POS Claims Submission • Batch Claims (National Council on Prescription Drug Programs (NCPDP) Batch 1.1 FTP) • Web Claims Submission • Provider Submitted Paper Universal Claim Form (this is a change)

  13. POS Technical Readiness

  14. Technical POS Submission Readiness • Ensure your software vendors are certified to send NCPDP 5.1 (most vendors are already certified). • For questions, contact Dorothea Roane at 1-804-217-7900. • Ensure that the routing information • Banking Identification Number (BIN) • Processor Control Number (PCN) are changed

  15. Necessary Data Elements for Initial Set-Up • All transactions require the following: • Version/Release# 5.1 • BIN Number* 014864 • Processor Control #* P043014864 • Group ID* IDMEDICAID • Software Vendor/Certification ID: Assigned when vendor is certified with Magellan Medicaid Administration. • Claims will reject if the new data elements (denoted with asterisks) are missing and if versions other than NCPDP 5.1 are used.

  16. Additional Necessary Data Elements for Initial Set-Up On Claim Segment • Number of Refills will be a required field. • Prescription Origin Code will be a required field. This field is used as a mechanism for providers to validate that written prescriptions have been submitted in accordance with tamper resistant guidelines. On Patient Segment • Pregnancy Indicator will be a new field that will be populated with a value of • Blank = Not Specified • “1” = Not Pregnant • “2” = Pregnant

  17. Additional Necessary Data Elements for Initial Set-Up, cont. On Clinical Segment • Diagnosis Code Count will be a required field when submitting diagnosis information on the claim. • Diagnosis Code Qualifier will be a required field when submitting diagnosis information on the claim. • Diagnosis Code will be a required field when submitting diagnosis information on the claim. • These fields are required for all hospice patient claims.

  18. Client Eligibility Determination • For participant eligibility determination, Magellan Medicaid Administration matches on • Patient first name = First 3 bytes • Patient last name = First 5 bytes

  19. Claims Submission Timely Filing Limits • Date Rx Written = should be the original date the prescription was written • Date of Service = should be the actual DOS • The Date Rx Written is used as a factor in refill editing logic

  20. Claims Submission Timely Filing Limits, cont. • POS claims are generally submitted at the time of dispensing. If a claim is submitted after a drug is dispensed due to mitigating circumstances the following guidelines apply: • For all original claims, the timely filing limit from the Date of Service (DOS) is 366 days. • For all reversals, the timely filing limit from the DOS is Unlimited. • For all rebill claims, the timely filing limit from the DOS is 732 days. • For all paper claims, it will be 365 days from date written. • Claims that exceed the timely filing limit will deny with the NCPDP Error Code 81, “Timely Filing Exceeded.” Providers may request an override following IDHW guidelines. This edit uses the Adjudication Date and Date of Service.

  21. Date Rx Written to Date of Service Edits • Claims that exceed the maximum Date Rx Written to Date of Service limit as indicated below will deny with NCPDP Error Code M4/“Prescription number/time limit exceeded.” This edit uses the Date Rx Written and the Date of Service. • Date Rx Written to First Fill Date = 366 days from the date written for non-controlled drugs. • Date Rx Written to First Fill Date = 183 days from date written for CIII, CIV, and CV drugs. • Date Rx Written to First Fill Date = 90 days from date written for CII drugs. • Date Rx Written to Refill Limit Durations for Controlled Substances = 183 days from date written for CIII, CIV, and CV drugs.

  22. NCPDP 5.1 • All submitted fields will be edited for valid format. • All submitted fields will be edited for valid values. • If you send optional data, the values must be valid and any supporting/associated fields must be sent.

  23. NCPDP 5.1, cont. • The following transactions will be accepted and processed Claim Type Original Claims B1 Reversals B2 Rebills B3 Eligibility E1

  24. NCPDP 5.1, cont. • HIPAA Compliance: there are requirements for privacy regulations regarding the use of claim data elements. • Data element conditions are detailed in the Payer Specification Sheet, including • Mandatory (NCPDP designation – required at all times) • Situational (NCPDP designation – required in specific circumstances) • Other (Repeating, Not Supported, and Not Used)

  25. NCPDP 5.1, cont. • In NCPDP 5.1, data is grouped together in segments. • Designated segments are needed to support specified transactions. • Refer to the Payer Specifications Sheet for identification of all required segments. • For the most current version, always check the website: • https://idaho.fhsc.com

  26. Example: Payer Specification Segment Detail Example

  27. Dispensing Limitations – Days Supply • 34-day supplyper Rx maximum. • Exceptions: Maintenance List cannot exceed 100 day supply. • Maintenance List • Cardiac Glycosides • Thyroid Replacement hormones • Prenatal Vitamins • Nitroglycerin Products, oral or sublingual • Fluoride and vitamin/fluoride combination products • Non-legend oral iron salts • Oral Contraceptives

  28. Dispensing Limitations – Refills • DEA = 0: original + up to 99 refills within 366 days from original Date Rx Written • DEA = II: No refills • DEA = III–V: original + 5 refills within 183 days from original Date Rx Written

  29. Dispensing Limitations • Number of Refills Authorized • Magellan Medicaid Administration’s POS logic uses this to validate on refill status. • New for claims submission on January 30, 2010. • Values • 0-99

  30. Early Refills • Early refills tolerance periods • Tolerance = 75 percent for all products • NCPDP Error Code “88” will display for an early refill • If the drug is a controlled substance, the IDHW Pharmacy Unit will handle all overrides.

  31. Early Refills, cont. • For initiating prior authorizations, contact IDHW Monday – Friday, 8:00 a.m. – 5:00 p.m., MT • 1-208-364-1829 (Local) • 1-866-827-9967 (Toll free) • 1-208-364-1864 (Fax)

  32. Unit of Measure • Unit of Measure • EA = Each • GM = Grams • ML = Milliliters • NCPDP Field # 600-28 • If you are submitting a paper claim, please write this in on the Universal Claim form.

  33. Durable Medical Equipment (DME) • Magellan Medicaid Administration will not be processing DME claims. • For questions about DME or Nutritional Supplements and DME PA Requests contact the DME Specialist at: • 1-800-685-3757 (Toll free) • 1-208-332-7280 (Fax) or • 1-800-352-6044 (Fax) • Hours are 8:00 a.m. – 5:00 p.m. MT Monday – Friday • PES claims are still accepted for DME products.

  34. Coordination of Benefits (COB) • Providers are required to fully pursue all third-party coverage before billing Medicaid. • Providers must comply with all policies of a patient’s insurance coverage, including, but not limited to, prior authorization, quantity, and days supply limits. • Magellan Medicaid Administration will assist IDHW in monitoring this process for compliance on all claims.

  35. Coordination of Benefits On Pricing Segment • Patient Paid Amount Submitted will be a required field when submitting an Other Coverage Code (OCC) of a “2.” The claim will reject if it is not submitted with the OCC of a “2” or submitted on claims where OCC is NOT equal to a “2.” On COB Segment • Other Payer Reject Count will be a required field when submitting an OCC of a “3.” • Other Payer Reject Code will be a required field when submitting an OCC of a “3.”

  36. Member Lock-In Members can be locked into • A pharmacy • A pharmacy and physician(s) • Specific drug by a specific physician

  37. Emergency Override Procedure • Medicaid will pay for a 72-hour emergency supply of medications that require a PA if the doctor has not submitted a prior authorization request and it is after hours, a weekend, or a IDHW designated holiday. • The appropriate PA process must be utilized during regular business hours. All of the following conditions must be met for an emergency supply: • The cardholder is Medicaid eligible on the date of service. • The prescription is new to the pharmacy. • The medication requires PA. • The days supply for the emergency period does not exceed three days.

  38. Emergency Override Procedure • The override codes for billing for a 72-hour emergency supply are • DUR REASON FOR SERVICE (NCPDP Field # 439-E4):TP (Payer/processor question) • DUR PROFESSIONAL SERVICE (NCPDP Field # 440-E5): MR (Medication review) • DUR RESULT OF SERVICE (NCPDP Field # 441-E6) 1F (Filled, with different quantity) • In order for the cardholder to get the remainder of their fills or subsequent refills, a completed PA request must be faxed to the Medicaid Pharmacy Unit at 1-208-364-1864 (Local).

  39. Compound Processing • Compounds are processed using the Multi-Ingredient Compound functionality as provided by NCPDP 5.1. • All compounds must contain at least two ingredients, and at least one ingredient must be a covered product. • If total cost is not equal to the sum of the ingredients’ cost, the claim will deny. • Single ingredient compound claims are not accepted.

  40. Compound Processing, cont. • Submission Clarification Code (SCC) = 8 may be submitted at POS to override and pay only covered ingredients within the compound. SCC = 8 does not override obsolete date of drug or existing PA requirements. • Multiple instances of a National Drug Code (NDC) within a compound will not be allowed. • Dispense fee for compounds is the standard dispense fee with additional amounts added based on the Route of Administration. • If the claim rejects for a non-covered drug, the NCPDP Error Code 70-NDC Not Covered, will be returned.

  41. Fields Required for Submitting Multi-Ingredient Compounds On Claim Segment • Enter COMPOUND CODE (NCPDP Field # 406-D6) of “2” • Enter PRODUCT CODE/NDC (NCPDP Field # 407-D7) as “00000000000” in the claim segment to identify the claim as a multi-ingredient compound • Enter QUANTITY DISPENSED (NCPDP Field # 442-E7) of entire product • SUBMISSION CLARIFICATION CODE (NCPDP Field #420-DK) • Value “8” should only be used for compounds with both covered and non-covered ingredients. This value allows the provider to be reimbursed for covered ingredients only. This field is not available on the Universal Claim Form (UCF) used for paper claim submission.

  42. Fields Required for Submitting Multi-Ingredient Compounds, cont. On Pricing Segment • Enter GROSS AMOUNT DUE (NCPDP Field # 430-DU) for entire product (this is required when entering SCC of “8”) On Compound Segment • COMPOUND DOSAGE FORM DESCRIPTION CODE (NCPDP # 450-EF) • COMPOUND DISPENSING UNIT FORM INDICATOR (NCPDP # 451-EG) • COMPOUND ROUTE OF ADMINISTRATION (NCPDP # 452-EH) • COMPOUND INGREDIENT COMPONENT COUNT (NCPDP # 447-EC) (Maximum of 25)

  43. Fields Required for Submitting Multi-Ingredient Compounds, cont. For Each Line Item • COMPOUND PRODUCT ID QUALIFIER (NCPDP Field # 488-RE) of “3” (NDC) • COMPOUND PRODUCT ID (NCPDP Field # 489-TE) • Product ID = NDC • COMPOUND INGREDIENT QUANTITY (NCPDP # 448-ED) • COMPOUND INGREDIENT DRUG COST (NCPDP # 449-EE)

  44. Summary of Changes • BIN Number: 014864 • Processor Control #: P043014864 • Group ID: IDMEDICAID • Software/Vendor Certification: TBD • Pregnancy Indicator • Blank = Not Specified • “1” = Not Pregnant • “2” = Pregnant • Number of Refills Authorized is Required

  45. Summary of Changes, cont. • Prescription Origin code is Required • 0 = Not Specified • 1 = Written • 2 = Telephone • 3 = Electronic • 4 = Facsimile

  46. Summary of Changes, cont. On Pricing Segment • Patient Paid Amount Submitted is a required field when submitting an OCC of a “2.” The claim will reject if it is not submitted with the OCC of a “2” or submitted on claims where OCC is NOT equal to a “2.” • Patient Paid Amount Submitted must be greater than $0.00 on a POS claim with an OCC of a “2.” On COB Segment • Other Payer Reject Count is a required field when submitting an OCC of a “3.” • Other Payer Reject Code is a required field when submitting an OCC of a “3.”

  47. Summary of Changes, cont. On Clinical Segment • Diagnosis Code Count is a required field when submitting diagnosis information on the claim • Diagnosis Code Qualifier is a required field when submitting diagnosis information on the claim • Diagnosis Code is a required field when submitting diagnosis information on the claim • These fields are required on all Hospice claims

  48. Contact Information • Idaho Medicaid Eligibility (Magellan Medicaid Administration) • 1-800-922-3987 (Toll free) • 24/7/365 • For initiating prior authorizations contact IDHW Monday – Friday, 8:00 a.m. – 5:00 p.m. MT • 1-208-364-1829 (Local) • 1-866-827-9967 (Toll free) • 1-208-364-1864 (Fax) • Paper Claims Mailing Address Magellan Medicaid Administration, Inc.Post Office Box 85042Richmond, VA 23261-5042

  49. Contact Information, cont. • Magellan Medicaid Administration’s Idaho Pharmacy Support Center Line • 24/7/365 • 1-800-922-3987 (Toll free) • Magellan Medicaid Administration’sWeb Support Help Desk • 6:00 a.m. – 6:00 p.m. MT, Monday – Friday • 1-800-241-8726 (Toll free) • The Web Support Help Desk can assist you with navigation, password management, and general questions.

  50. Contact Information, cont. • If you have questions regarding the Idaho Medicaid Management Information System (MMIS) transition, send an email to: idahommis@dhw.idaho.gov or visit the website at: www.idaho.mmis.dhw.idaho.gov • If you have questions regarding Provider Record Update, call Unisys at 1-866-686-4272 or email Unisys at idproviderenrollment@unisys.com.

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