OptumRx pharmacy manual

Transcription

1 OptumRx 2014 pharmacy manual

2 Table of contents Click on any section or page below to go directly to that portion of the document. I. Introduction...4 II. How to contact us and how we contact you....6 Pharmacy help desk / customer service numbers... 7 Prior authorization (PA) department Electronic data interchange (EDI)... 8 Pharmacy network contracting department...8 Provider feedback forms...8 Pharmacy notification...9 III. Customer identification cards...10 Best available evidence (BAE) All pharmacy types EXCLUDING long-term care (LTC) providers Long-term care (LTC) providers ONLY IV. Claims process...15 A. General process...16 B. Required prescription information C. Dispense as written (DAW) D. Electronic remittance advice (ERA) program E. Electronic funds transfer (EFT) program F. Member/insured appeals and grievances G. Utilization management H. Concurrent drug utilization review ( cdur ) I. Retrospective drug utilization review ( rdur )/clinical programs...30 J. MAC review requests...32 V. Products...33 VI. Medicare product information and guidelines...35 Excluded drugs...36 Medicare Part A/B/D coordination of benefits...37 Medicare Part D coverage determinations...37 Time frames...38 OptumRx pharmacy manual: 7th edition 2

3 Table of contents Click on any section or page below to go directly to that portion of the document. Coverage limitations...38 Medication therapy management (MTM) program Medicare Part D transition policy...40 Medicare Part D transitioning long-term care (LTC) facility residents Long-term care facility information to be provided upon termination Short-cycle dispensing (SCD) processing for long-term care Daily cost share (DCS), a CMS requirement Medicare Part D sixty (60) day negative formulary change notice Medicare Part D annual notice of change for continuing members...45 Inform members of advance directives Provide timely notice of demographic changes...45 VII. Other general terms and conditions...46 A. Compliance...47 B. Pharmacy fraud, waste and abuse and general compliance training C. Pharmacy audits D. Credentialing E. Confidentiality and proprietary rights...58 F. Involuntary disenrollment by benefit plan or sponsor...58 G. State medicaid requirements H. Definitions Exhibit A...62 Exhibit B Exhibit C Exhibit D...66 Exhibit E Exhibit F...69 Exhibit G...70 OptumRx pharmacy manual: 7th edition 3

4 I. Introduction OptumRx pharmacy manual: 7th edition 4

5 The OptumRx Pharmacy Provider Manual (Manual) is intended to be a guide regarding the policies of OptumRx for pharmacies, Pharmacists and pharmacy staff (collectively, Network Pharmacy Providers ) who are parties to and serve customers pursuant to the Prescription Drug Services Agreement or the Pharmacy Network Agreement, as amended (the Agreement ) with OptumRx, formerly Prescription Solutions, Inc. Please note: The information in this Manual is current at the time of the Manual s publication. While efforts are made to keep the information current, this Manual is subject to change without notice. This Manual is not designed to cover all circumstances or issues, nor is it a replacement for sound clinical judgment. Online adjudication of Claims will reflect the most current benefit and takes precedence over printed information. For your convenience, the defined terms in this Manual have the same meaning as used in the Agreement and are listed in the last section of this Manual. In the event that this Manual and the Agreement have conflicting language, the Agreement will supersede the Manual. For specific details regarding the governing elements of the relationship between OptumRx and its participating pharmacies, please refer to the Agreement. You may request a copy of the latest version of the Manual by calling or via to pharmacynetwork@optum.com. While we hope that most of your day-to-day questions concerning the OptumRx pharmacy program are adequately addressed in this Manual, please contact us if you have any questions. The OptumRx Faxblast communications that have been previously sent and sent after the date of receipt of this Manual to Network Pharmacy Providers are hereby incorporated by reference into this Manual, which the Manual is incorporated into the Agreement. OptumRx pharmacy manual: 7th edition 5

6 II. How to contact us and how we contact you OptumRx pharmacy manual: 7th edition 6

7 OptumRx strives to ensure that Pharmacies receive prompt and courteous attention when questions arise. For assistance in processing a claim or questions concerning OptumRx pharmacy programs, please contact us at the telephone number identified on the Member s identification (ID) card or contact us as indicated below. Pharmacy help desk service numbers: Hours of operation: 24 hours a day, 7 days a week For information regarding Benefit Plan exclusions, Disease Therapy Management (DTM) programs, or other customer service issues, please contact us using the following telephone numbers: Pharmacy help desk for members with UnitedHealthcare Medicare Advantage Prescription Drug Plan ( MAPD ): Telephone: TDHI (for the hearing impaired): Pharmacy help desk for members with UnitedHealthcare Medicare Prescription Drug Plan ( PDP ): Telephone: TDHI (for the hearing impaired): Pharmacy help desk for members with UnitedHealthcare Medicaid plans: Telephone: TDHI (for the hearing impaired): Pharmacy help desk for members with UnitedHealthcare commercial plans: Telephone: TDHI (for the hearing impaired): Pharmacy help desk for members with OptumRx commercial plans or plans not listed above: Telephone: TDHI (for the hearing impaired): Website: optumrx.com Prior authorization ( PA ) department: Hours of operation: 7 a.m. 7 p.m., PT, Monday Friday For questions concerning utilization management requirements, Medicare Part D ( Part D ) decisions, coverage limitations and PAs, please contact: Telephone: Fax:(Oral): (Specialty): OptumRx pharmacy manual: 7th edition 7

8 Electronic data interchange (EDI): Hours of operation: 8 a.m. 5 p.m., PT, Monday Friday For questions concerning Electronic Data Interchange (EDI), contact your EDI vendor or call the EDI support line at: Telephone: Pharmacy network contracting department: Hours of operation: 8 a.m. 5 p.m., PT, Monday Friday For information on network participation for a particular OptumRx benefit plan sponsor, please call or contact our pharmacy network contracting department at the following: Pharmacy network contracting department Von Karman MS: CA Irvine, CA Monday through Friday Phone: Fax: address: pharmacynetwork@optum.com For MAC review requests only: address: rxreimbursement@optum.com Provider feedback forms: To facilitate feedback and comments from our Network Pharmacy Providers regarding the OptumRx Prior Authorization ( PA ) Guidelines and Outpatient Drug Formulary, the following forms are available: The Prior Authorization (PA) Guideline Change Request Form: The online submission for recommended change(s) in prior authorization guideline(s). The Formulary Change Request Form: Online submission for providers to submit a request related to recommendations for formulary change(s). Provider Feedback Forms are available at: optumrx.com/rxsolhcpweb/cmscontent.do?pageurl=/hcp/healthcareprovidertools/ FormsAndDocuments. Written requests can be submitted to the following: Prior authorization guideline change request form Clinical Programs OptumRx 2300 Main Street, CA Irvine, CA Fax: OptumRx pharmacy manual: 7th edition 8

9 Formulary change request form Clinical Formulary Management OptumRx 2300 Main Street, CA Irvine, CA Fax: New prescription fax form Fax: Please note: OptumRx is unable to accept incomplete Provider Feedback Forms. In order to avoid a delay in processing your request, please complete these forms in their entirety. Pharmacy notification: Faxblast communications Periodically, OptumRx communicates updates to procedures, formularies, pharmacy Manual, etc., via Faxblast communications. Faxblasts are sent electronically to the contracted network entity (independent pharmacy, retail chain (chain), Group Purchasing Organization (GPO) or Pharmacy Services Administration Organization (PSAO) corporate representative) via facsimile (fax) process. To request copies of previously sent Faxblasts, please contact: pharmacynetwork@optum.com. OptumRx pharmacy manual: 7th edition 9

10 III. Customer identification cards OptumRx pharmacy manual: 7th edition 10

11 Printed 12/16/13 This card does not guarantee coverage. Present your ID card along with your prescription when ordering your medication. If you have any questions regarding your pharmacy benefit program, please call Customer Service 7 days a week/24 hrs a day or check the website. For Members: optumrx.com Pharmacists: optumrx.com Claims: PO Box 29044, Hot Springs, AR Back The review and approval of health care services, based on medical necessity, does not guarantee coverage under your policy. Also, verification of eligibility for benefits and coverage does not guarantee coverage. Actual benefits and coverage will be determined under the terms and conditions of your policy when a claim is submitted. This Medical ID Card is to be used solely in connection with and is subject to the terms and conditions of your health or medical coverage issued or administered by UnitedHealthcare or its affiliates. UnitedHealthcare and its affiliates reserve all rights in the event of improper use. Gracias por elegirnos como proveedor de su plan de beneficios de atención de la salud. Adjuntamos su tarjeta de identificación del plan de salud de UnitedHealthcare. Empiece a usarla el día en que comience su cobertura. Administre su atención de la salud en línea en myuhc.com. Encontrará información y herramientas personalizadas para ayudarle a administrar reclamos y ver cuánto adeuda, encontrar un médico Gracias por sus elegirnos como proveedor de su plan de beneficios de u hospital, sus Adjuntamos costos de atención de de la salud, investigar de atención calcular de la salud. su tarjeta identificación deltemas plan de salud, y encontrar respuestas a sus preguntas atención la salud.su salud de UnitedHealthcare. Empiece a usarla elde día en que de comience Para obtener más ayuda, llámenosdeallanúmero que se encuentra en el cobertura. Administre su atención salud en línea en myuhc.com. reverso de su tarjeta. y herramientas personalizadas para ayudarle a Encontrará información The review and approval of health careyservices, based onadeuda, medical necessity, does notun guarantee coverage administrar sus reclamos ver cuánto encontrar médico u under your policy. Also, verification of eligibility benefits and coverage does not guarantee coverage. hospital, calcular sus costos de for atención de la salud, investigar temasactual de benefits and coverage will be determined under the terms and conditions ofatención your policy when ala claim is salud, y encontrar respuestas a sus preguntas de de salud. submitted. This Medical ID Card is to be used solely in connection with and is subject to the terms and Para obtener más ayuda, llámenos aladministered número by que se encuentra en el conditions of your health or medical coverage issued or UnitedHealthcare or its affiliates. reverso de su UnitedHealthcare andtarjeta. its affiliates reserve all rights in the event of improper use. Thank you for choosing us as your health care benefit plan provider. Manage your health care online at myuhc.com. You willbegin find using it on Attached is your UnitedHealthcare health plan ID card. personalized tools and starts. information to help you: the day your coverage Manage your claims and see how much you owe Find a doctor or hospital Manage your health care online at myuhc.com. You will find Estimate your health care costs personalized tools and information to help you: Research health topics Manage your claims and see how much you owe Find answers to your health care questions Find a doctor or hospital For more help, please call us at the number on the back of your card. Estimate your health care costs Research health topics Find answers to your health care questions For more help, please call us at the number on the back of your card. This card is for Pharmacy Benefits Administered by OptumRx 0000 A Thank you for choosing us as your health care benefit plan provider. Welcome to UnitedHealthcare Attached is your UnitedHealthcare health plan ID card. Begin using it on the day your coverage starts. Local Employee Benefit Fund Welcome to UnitedHealthcare UnitedHealthcare Ned Ruete CT A 185 Asylum Street Hartford CT UnitedHealthcare Ned Ruete CT A 185 Asylum Street Hartford CT LEBF SAM SAMPLE Download a free QR code reader and scan this code to learn about convenient Smartphone access to benefit and provider information with myuhc.com7 mobile. Rx BIN: Rx PCN: Rx GRP: Issuer (80840): Rx ID: Name: Download a free QR code reader and scan this code to learn about convenient Smartphone access to benefit and provider information with myuhc.com7 mobile. Important: Please register at myuhc.com to view your coverage and manage claims. Important: register myuhc.com to > Please at view your coverage EMPLOYEE SMITHand manage claims. 111 MAIN ST. > ANYTOWN ST EMPLOYEE SMITH 111 MAIN ST. ANYTOWN ST SAMPLE MEMBER ID CARDS: Next *114* *114* Below are samples of Member ID cards representing a couple of our Benefit Plan sponsors. This is a sampling only and is not an all-inclusive list. Member ID cards may be added, deleted or amended at any time. Contents Eligible Members ( Members ) receive an identification (ID) card containing information that helps our Network Pharmacy Providers submit Claims accurately and completely. Information may vary in appearance or location on the card due to employer, Benefit Plan, Sponsor or OptumRx requirements. However, cards display essentially the same information (e.g., Member Name, Subscriber Identification (ID), Group Number, Processor Control Number (PCN), Bank Identification Number (BIN), RxGroup Number (GROUP), and contact telephone numbers). RUN_DATE DATA_SEQ_NO CLIENT_NUMBER UHG_TYPE DOC_SEQ_ID DOC_ID NAME MAILSET_NUMBER CUSTCES_KEY _KEY0 CUSTCES_KEY2 CUSTCES_KEY3 CUSTCES_KEY4 CUSTCES_KEY5 CUSTCES_KEY6 CUSTCES_KEY7 CUSTCES_KEY8 CUSTCES_KEY9 RUN_DATE DATA_SEQ_NO CLIENT_NUMBER UHG_TYPE DOC_SEQ_ID DOC_ID NAME MAILSET_NUMBER CUSTCES_KEY _KEY0 CUSTCES_KEY2 CUSTCES_KEY3 CUSTCES_KEY4 CUSTCES_KEY5 CUSTCES_KEY6 CUSTCES_KEY7 CUSTCES_KEY8 CUSTCES_KEY9 SMITH SMITH DIG2CARD DIG2CARD EMPLOYEE HCAC/Medical ~00CARD ~01CARD ~02CARD ~03CARD ~04CARD ~00CARD ~01CARD ~02CARD ~03CARD ~04CARD ~00CARD ~01CARD ~02CARD ~03CARD ~04CARD ~00CARD ~01CARD ~02CARD ~03CARD ~04CARD EMPLOYEE HCAC/Medical ~00CARD ~01CARD ~02CARD ~03CARD ~04CARD ~00CARD ~01CARD ~02CARD ~03CARD ~04CARD ~00CARD ~01CARD ~02CARD ~03CARD ~04CARD ~00CARD ~01CARD ~02CARD ~03CARD ~04CARD CARD1 CARD :38:01 CARD1 CARD2 14:38:01,EMPLOYEE,EMPLOYEE Be sure to check the member s ID card at each visit especially the first visit of each new benefit year when information is most likely to change. Health Plan Health (80840) Plan (80840) EMPLOYEE EMPLOYEE SMITH SMITH HMO HMO Dependents Dependents SPOUSE SPOUSE SMITH SMITH CHILD1 SMITH CHILD1 SMITH CHILD2 SMITH CHILD2 SMITH CHILD3 SMITH CHILD3 SMITH Payer ID Payer ID Rx Bin: Rx Bin: Rx PCN: 9999 Rx PCN: 9999 Rx Grp: UHEALTH Rx Grp: UHEALTH Office: $30 Office:ER: $30$100 ER: $100 UrgCare: $20 UrgCare: $20 DOI-0501 DOI-0501 UnitedHealthcare UnitedHealthcare Choice Choice Underwritten Underwritten by [Appropriate by [Appropriate Legal Entity] Legal Entity] This card does This card not guarantee does not guarantee coverage.coverage. To verify benefits, To verifyview benefits, claims, view or claims, find or find a provider,a visit provider, the websites visit the or websites call. or call. For Members: For Members: Care24: Care24: Mental Health: Mental Health: For Providers: For Providers: Medical Medical Claims: Claims: PharmacyPharmacy Claims: OptumRx Claims: OptumRx PO Box PO Box Hot29044 Springs, Hot AR Springs, 71903AR For Pharmacists: For Pharmacists: Printed: 09/17/13 Printed: 09/17/13 This card does not guarantee coverage. Present your ID card along with your prescription when ordering your medication. If you have any questions regarding your pharmacy benefit program, please call Customer Service 7 days a week/24 hrs a day or check the website. Health Plan Health (80840) Plan (80840) For members: optumrx.com or Member ID: Member ID: Group Number: Group Number: Member:Pharmacists: Member: optumrx.com or HMO HMO EMPLOYEE EMPLOYEE SMITH SMITH Dependents Dependents Claims: Box 29044, Hot Springs, AR SPOUSE SPOUSE SMITH PO SMITH Payer ID Payer ID CHILD1 SMITH CHILD1 SMITH CHILD2 SMITH CHILD2 SMITH CHILD3 SMITH CHILD3 SMITH Rx Bin: Rx Bin: Rx PCN: 9999 Rx PCN: 9999 Office: $30 Office:ER: $30$100 ER: $100 Rx Grp: UHEALTH Rx Grp: UHEALTH UrgCare: $20 UrgCare: $20 OptumRx pharmacy manual: 7th edition This card does This card not guarantee does not guarantee coverage.coverage. To verify benefits, To verifyview benefits, claims, view or claims, find or find a provider,a visit provider, the websites visit the or websites call. or call. For Members: For Members: Care24: Care24: Mental Health: Mental Health: For Providers: For Providers: Medical Medical Claims: Claims: 11 Pharmacy Claims: OptumRx Claims: OptumRx PO Box PO Box Hot29044 Springs, Hot AR Springs, 71903AR UnitedHealthcare Choiceand Choice The information contained Underwritten in thisunitedhealthcare document isbyproprietary confidential to Pharmacy OptumRx. Underwritten by [Appropriate [Appropriate Legal Entity] Legal Entity] For Pharmacists: For Pharmacists: DOI-0501 DOI-0501 Exit Member ID: Member ID: Group Number: Group Number: Member: Member: Previous Printed: 09/17/13 Printed: 09/17/13

12 For instances when a Member does not have an ID card, please see the following: Situation: member does not have an ID card OptumRx UnitedHealthcare (UHC) skip to step 3 OptumRx UnitedHealthcare (UHC) skip to step 3 OptumRx UnitedHealthcare (UHC) Step 1 Step 2 Step 3 Step 4 UnitedHealthcare (UHC) Person is at the pharmacy, has no proof of coverage but states they are currently enrolled. Member may present generic marketing materials that were provided with the inquiry kits. 1) E1 transaction initiated to determine eligibility; this is done by the Pharmacist (a) Eligibility validated; Pharmacist processes prescription (b) Eligibility not validated or Pharmacist unable to access E1, move to step 2 Note: An E1 transaction can be initiated with the Member s Social Security Number (SSN) or Member s ID. Pharmacist contacts the OptumRx Pharmacy Help Desk using the contact information provided in Section II of this pharmacy Manual. (a) Pharmacy Help Desk validates eligibility and Claim is processed (b) Unable to validate eligibility, move to step 3 Pharmacy Help Desk completes transfer of Pharmacist to the UnitedHealthcare Call Center. Alternatively, the pharmacy may direct the Member to call their plan. 1) Call center confirms eligibility; Member eligibility entered real-time into OptumRx system; Pharmacist fills prescription. 2) Unable to confirm eligibility or eligibility has been denied; person pays retail for drug; fourteen (14) day window to allow for online processing at pharmacy when eligibility issue resolved or person to submit a paper Claim for reimbursement. 3) Person unwilling to pay retail, prescription not filled. Person is at the pharmacy, has an acknowledgement or confirmation letter with an enrollee number and states that they are enrolled. 1) E1 transaction initiated to determine eligibility or Pharmacist attempts to process Claim online; this is done by the Pharmacist (a) Eligibility validated; Pharmacist processes prescription online (b) Eligibility not validated or Pharmacist unable to access E1, move to step 2 Pharmacist contacts the OptumRx Pharmacy Help Desk using the contact information provided in Section II of this pharmacy Manual. (a) Pharmacy Help Desk validates eligibility and Claim is processed (b) Unable to validate eligibility, move to step 3 Pharmacy Help Desk completes transfer of Pharmacist to the UnitedHealthcare Call Center. Alternatively, the pharmacy may direct the Member to call their plan. 1) Call center confirms eligibility; Member eligibility entered realtime into OptumRx system; Pharmacist fills prescription. 2) Unable to confirm eligibility, eligibility pending, eligibility has been denied, or a disenrollment was processed; person pays retail for drug; fourteen (14) day window to allow for online processing at pharmacy when eligibility issue resolved or person to submit a paper Claim for reimbursement. 3) Person unwilling to pay retail, prescription not filled. OptumRx pharmacy manual: 7th edition 12

13 Best available evidence (BAE) All pharmacy types EXCLUDING long-term care (LTC) providers If a Member questions their copayment amount, or states that they qualify for federal subsidy or extra help, they must have valid supporting documentation in order to receive the lower copayment level amount. Any of the following documents are acceptable and meet the criteria as Best Available Evidence (BAE) to support a Member s qualification for federal subsidy: A copy of the beneficiary s Medicaid card that includes the beneficiary s name and eligibility date status during a month which occurred after June 30 of the previous calendar year; A copy of a State document that confirms active Medicaid status during a month which occurred after June 30 of the previous calendar year; A printed document from the State electronic enrollment file showing Medicaid status during a month which occurred after June 30 of the previous calendar year; A screen print from the State s Medicaid systems showing Medicaid status during a month which occurred after June 30 of the previous calendar year; Other documentation provided by the State or Centers for Medicare and Medicaid Services (CMS) showing Medicaid status during a month which occurred after June 30 of the previous calendar year; A copy of the Social Security Administration (SSA) award letter for those individuals who are not deemed eligible, but who apply for and are found to be Low Income Subsidy ( LIS ) eligible. To correct a member s subsidy level utilizing BAE, please secure one (1) of the above documents from the Member and contact Customer Service at the phone number provided on the back of the Member s ID card. Please note: Provided the documentation received meets the BAE criteria, the Member s copayment will be adjusted within forty-eight (48) to seventy-two (72) hours of receipt of BAE documentation. Reprocess the prescription(s) to capture the lower copayment amount. If you have any questions on BAE, please contact Customer Service at the phone number provided on the back of the Member s ID card. OptumRx pharmacy manual: 7th edition 13

14 Long-term care (LTC) providers ONLY If a Member questions their copayment amount, or states that they qualify for the institutional status zero (0) cost sharing, they must have valid documentation supporting this position in order to receive the zero (0) copayment amount. Any of the following documents are acceptable and meet the criteria as Best Available Evidence (BAE) supporting a Member s institutional status and qualification for zero (0) cost sharing: A remittance from the facility showing Medicaid payment for a full calendar month for the beneficiary during a month after June 30 of the previous calendar year; A copy of the state document that confirms Medicaid payment for a full calendar month for the beneficiary during a month after June 30 of the previous calendar year; A screen print from the State s Medicaid systems showing the beneficiary s institutional status for at least a full calendar month stay for Medicaid payment purposes during a month after June 30 of the previous calendar year. To correct a Member s subsidy level utilizing BAE, please secure one (1) of the above documents from the Member and contact Customer Service at the phone number provided on the back of the Member s ID card. Please note: Provided that the documentation received meets the BAE criteria, the Member s copayment will be adjusted within forty-eight (48) to seventy-two (72) hours of receipt of BAE documentation. Reprocess the prescription(s) to capture the lower copayment amount. If you have any questions on BAE, please contact Customer Service at the phone number provided on the back of the ID card. OptumRx pharmacy manual: 7th edition 14

15 IV. Claims process OptumRx pharmacy manual: 7th edition 15

16 A. General process The following describes the OptumRx processes and procedures for processing Claims. Complete claims OptumRx requires the submission of a Clean Claim, as described in pharmacy contract Section: Recitals/Defined Terms. Because a Member s level of coverage under his or her Benefit Plan may vary for different services, it is particularly important to correctly code, according to the National Council for Prescription Drug programs (NCPDP) standards, in order to submit pharmacy Claims for proper payment and application of deductibles, coinsurance or copayments. Pharmacies should use best efforts to submit complete and accurate claims at the point of sale, but must reverse and resubmit Clean Claims electronically within thirty (30) days of the original submission. Please note, for federal programs that we support: Federal regulations prohibit us from paying Claims for medications prescribed by providers that have been excluded from federal program participation as evidenced by listing of the prescriber within the Health and Human Services (HHS) Office of Inspector General (OIG) or General Services Administration (GSA) Excluded and Sanctioned Providers listings. These OIG or GSA lists are checked monthly and Claims for medications by excluded providers will be rejected. The Claim will reject with the NCPDP Rejection Code 71 MD NOT COVERED SANCTIONED PRESCRIBER. Claims may only be paid for prescriptions properly prescribed in accordance with Federal and State prescribing laws and regulations. Please ensure that pharmacy and pharmacy staff maintain up-to-date knowledge of Federal and State prescribing rules and that pharmacy will not submit a claim for a prescription not fully compliant with applicable Federal and State prescribing laws and regulations. Federal regulations for schedule II drugs Pursuant to Federal regulations in Title 21 of the Code of Federal Regulations (CFR) (a), Schedule II prescription drugs may not be refilled. A separate prescription is required if a physician wishes to authorize continuation of a patient s use of a Schedule II drug beyond the amount specified on the first prescription. The regulations at 21 CFR (b) allow for a prescription for a Schedule II drug written for a patient in a long-term care facility or for a patient with a medical diagnosis documenting a terminal illness to be filled in partial quantities to include individual dosage units. Under this provision, a Schedule II drug may be partially filled as long as the total quantity dispensed does not exceed the total quantity prescribed. The prescription is valid for a period not to exceed sixty (60) days from this date. The regulations at 21 CFR (a) also permit the partial filling of a prescription for a Schedule II drug if the pharmacist is unable to supply the full quantity prescribed. The remaining portion of the prescription may be filled within seventy-two (72) hours of the first partial filling; however, if the remaining portion is not or cannot be filled within the seventy-two (72) hour period, the pharmacist may not dispense any further quantity without a new prescription. According to 21 CFR , except in emergency situations or when dispensed directly by a practitioner other than a pharmacist to the ultimate user, Schedule II drugs may not be dispensed without a practitioner s written prescription. In the case of an emergency situation, a pharmacist may dispense Schedule II drugs upon receiving an oral authorization from a prescribing practitioner, provided that, among other things, the prescription is immediately reduced to writing by the pharmacists and contains all information required in 21 CFR , except for the signature of the prescribing practitioner. OptumRx pharmacy manual: 7th edition 16

17 Online Processing Window The Online Processing Window to submit electronic claims is as follows: Medicare Part D claims: One-hundred and eighty (180) days Commercial claims: Sixty (60) days Medicaid claims: Sixty (60) days Please note: OptumRx is unable to extend these time frames. Pharmacies that need to process claims outside the Online Processing Window time frame for submission of electronic claims will be required to submit a Universal Claim Form (UCF) and an explanation for the late submission. Submission of the UCF is not a guarantee claim(s) will be paid. Payment is determined on a case-per-case basis upon review of explanation of late submission and plan approvals. Please mail completed UCF and explanation for late submission request to: OptumRx P.O. Box Hot Springs, AR Pharmacy processing information and notices As a reminder, all claims, including Medicare Part D must be submitted using the Bank Identification Number ( BIN ), Processor Control Number ( PCN ) and Submitted Group ( Group ) that appears on the Member s ID card. Payer sheets The OptumRx D.0 Payer sheets are available on the health care professionals portal via the following: optumrx.com/rxsolhcpweb/cmscontent.do?pageurl=/hcp/healthcareprovidertools/formsanddocuments Submitting compounds A compounded prescription consists of two (2) or more solid, semisolid, or liquid ingredients one of which is a Federal Legend Drug that is weighed, measured, prepared, or mixed extemporaneously according to the prescription order to make a product that is not commercially available. The Network Pharmacy Provider is responsible for compounding preparations with approved ingredients only. Ingredients need to be of an acceptable strength, quantity and purity and must have the appropriate labeling and packaging in accordance with good compounding practices, official standards, and scientific information. The Network Pharmacy Provider is responsible for documenting the drug name, National Drug Code (NDC) of the package size used, and metric quantity of each component used to prepare the compounded prescription. Important points to remember when submitting multi-ingredient compounded prescriptions under version D.0 (applies to ALL BIN s): Single-ingredient compound billing will not be accepted. OptumRx pharmacy manual: 7th edition 17

18 Each individual ingredient should be represented by the NDC of the product(s) used, including: The total quantity of each specific ingredient The cost of each individual ingredient with basis of cost determination Up to twenty five (25) ingredients may be entered for each compounded prescription claim Submit the NDC number (Product/Service Identification) in the claim segment as 0 (zero) and the Product/Service Identification qualifier should be submitted as 00 (two zeros). Use the correct compound segment to identify each individual ingredient. Submit a Compound Code of 2 (two) in field 406-D6 in accordance with National Council for Prescription Drug Programs (NCPDP) standards as defined in the OptumRx payer sheets for Version D.0. A minimum of two (2) and a maximum of twenty-five (25) ingredients will be accepted. Submit the quantity dispensed as the total metric quantity of the finished product, including: Sum of all individual ingredient costs as the Pharmacy s Ingredient Cost Submitted for the compounded prescription Submit the Pharmacy s Usual & Customary (U&C) for the compounded prescription Members should be charged the applicable copayment indicated only. Prescription Drug Compensation for compounded medications dispensed to Members that are Covered Prescription Services will be at the Pharmacy s agreed upon Prescription Drug Contracted Rate for each approved ingredient submitted for the applicable network associated with the claim submission, plus a $7.50 compounding fee that is subject to change by Administrator. Please note the following exclusions: Reconstitution of an oral antibiotic or similar product is not considered to be a compounded prescription. Adding flavorings to a commercial product is not considered to be a compounded prescription. Charges for ancillary supplies, flavoring, equipment depreciation and/or labor are not eligible for reimbursement. Ingredients with missing or invalid NDC numbers are not eligible for reimbursement. Updated Payer Sheets related to Medicare Part D, Commercial and Medicaid can be located at the following: optumrx.com/rxsolhcpweb/cmscontent.do?pageurl=/hcp/healthcareprovidertools FormsAndDocuments National drug code (NDC) number Pharmacies should always submit the exact eleven (11) digit NDC number of the actual package size of the Drug Product dispensed. Vaccines The value of 2Ø in Submission Clarification Code (42Ø-DK) field Indicates that, prior to providing service, the pharmacy has determined the product being billed is purchased pursuant to rights available under Section 34ØB of the Public Health Act of 1992 including sub-ceiling purchases authorized by Section 34ØB (a)(1ø) and those made through the Prime Vendor Program (Section 34ØB(a)(8)). OptumRx pharmacy manual: 7th edition 18

19 National provider identification (NPI) number In compliance with Health Insurance Portability and Accountability Act of 1996 ( HIPAA ), the NPI is the required Pharmacy and Prescriber identifier. The NPI is a unique ten (10) digit identifier assigned to health care providers to use when submitting a HIPAA standard transaction. Pharmacy ID: OptumRx only accepts NPI as the pharmacy identifier for online Claims. Any Claims transmitted with a NCPDP or other ID number will be rejected. Although NPI numbers are required for Claims processing, we strongly encourage pharmacies to continue to register for an NCPDP ID and regularly update their information with NCPDP. Prescriber ID: The NPI of the prescribing physician is required for all Claims. At this time, OptumRx will not reject Claims transmitted with a legacy ID (unless instructed otherwise by a specific client). Although Claims will not be rejected, pharmacies should transmit the NPI whenever it is available. If the pharmacy does not have the prescriber s NPI on file, the pharmacy should make a reasonable attempt to obtain the NPI number. Please note: In order to avoid claims rejections, please ensure you carefully enter the correct prescriber DEA (Drug Enforcement Administration) and NPI numbers. Entering the correct prescriber DEA and NPI numbers also ensures that correspondence sent to providers based on pharmacy claims goes to the correct provider. Permissible prescriber identifiers for Medicare Part D claims For Medicare Part D and medicaid claims: Pharmacies should submit a prescriber ID on all Part D and Medicaid claim submissions. Claim submissions without a prescriber ID will result in a claim rejection with code EZ Missing/Invalid Prescriber ID. Organizational NPIs should not be submitted. NPI should be submitted using an individual NPI that is valid on the Date of Service (DOS) for the claim. Claims submitted without a valid individual prescriber NPI will reject with NCPDP Rejection Code 56 NPI EXISTS. PRESCRIBER ID INVALID/NOT ALLOWED and the corresponding NPI number will be provided for use when resubmitting the claim. We recognize that pharmacies cannot always obtain the prescriber s NPI at the point of service. If a prescriber s NPI absolutely cannot be obtained, a valid non-npi number (see below) will be allowed to prevent Member disruption (see below). However, we do encourage all pharmacies to use the prescriber s NPI when possible. The prescriber s DEA number will be accepted as an alternative to the NPI number only when there is no NPI number on file. If an invalid DEA is submitted, the claim will reject with Point of Service (POS) Messaging or NCPDP Rejection Code 25 MISSING OR INVALID PRESCRIBER ID. Invalid DEA number is defined as any expired DEA number or DEA numbers that are not registered with the DEA (i.e., default or pharmacy constructed DEA numbers). Prescribers with a current Health and Human Services Department (HHS) Office of Inspector General (OIG) sanction will be rejected. Prescriptions written for controlled substances: OptumRx will reject claims where the prescriber being submitted on the claim does not have the authority to write for the schedule drug being prescribed. Please note: In order to avoid claims rejections, please ensure you carefully enter the correct prescriber DEA (Drug Enforcement Administration) and NPI numbers. Entering the correct prescriber DEA and NPI numbers also ensures that correspondence sent to providers based on pharmacy claims goes to the correct provider. OptumRx pharmacy manual: 7th edition 19

20 Claim adjustments Members are responsible for applicable copayments, deductibles and coinsurance associated with their Benefit Plans. Medicare Part D Claim adjustments: Pharmacies will be unable to reverse Medicare Part D (Part D) claims that have been reprocessed internally by OptumRx. This is necessary because claim adjustments have been made and if a financial adjustment was owed to the member or Long-term care (LTC) pharmacy, then a reimbursement process has already been initiated. Pharmacies attempting to submit reversal requests on claims that have been reprocessed by OptumRx will receive a NCPDP Rejection stating CLAIM NOT ELIGIBLE FOR REVERSAL. CONTACT HELP DESK FOR ASSISTANCE. If there is a need to resubmit Claims due to incorrect Medicare Part D Low Income Subsidy (LIS) level, please contact Customer Service using the information provided in Section II of this pharmacy Manual. Manual changes to income subsidy levels may be overwritten by files received from CMS. This process would require monthly Manual updates until the Member s LIS level is transmitted by the appropriate Medicaid or Social Security Administration (SSA) office to CMS. Subrogation and coordination of benefits (COB) Benefit Plans are subject to subrogation and coordination of benefits (COB) rules: 1. Subrogation To the extent permitted under applicable law and the applicable Benefit Plan, we reserve the right to recover benefits paid for a Member s health care services when a third (3rd) party causes the Member s injury or illness. 2. COB Coordination of benefits (COB) is administered according to the Member s Benefit Plan and in accordance with applicable statutes and regulations. OptumRx is able to accept secondary Claims electronically. Retroactive eligibility changes Eligibility under a Benefit Plan may change retroactively if: The Benefit Plan, Sponsor or OptumRx receives information that an individual is no longer a Member; The Member s policy/benefit contract has been terminated; The Member decides not to purchase continuation coverage; or The eligibility information received by OptumRx is later determined to be incorrect. As determined by CMS, with respect to Medicaid, Medicare Prescription Drug Plan (MA-PD) or Prescription Drug Plans (PDP). Covered entities are health plans, health care clearinghouses, and those health care providers who transmit any health data in connection with a transaction for which the Secretary of Health & Human Services has adopted a standard (known as standard transactions). Most Medicare Organization health care providers send electronic Claims to Medicare (they are standard transactions), making them covered health care providers (covered entities). If a Network Pharmacy Provider has submitted Claim(s) that are affected by a retroactive eligibility change, a Claim adjustment may be necessary. OptumRx pharmacy manual: 7th edition 20

21 Average wholesale price ( AWP ), and wholesale acquisition cost ( WAC ) AWP shall mean the average wholesale price of medication drugs or ancillary supplies, as applicable, as dispensed and as set forth in the latest edition of the Medi-Span Prescription Pricing Guide (with supplements) or any other nationally recognized pricing source selected by Administrator (the Pricing Source ), as updated at least monthly. With respect to the term * Average Wholesale Price or * AWP as used in any exhibit or rate sheet that establishes compensation to Company or a Pharmacy, such *Average Wholesale Price or *AWP is derived by Administrator s adjusting AWP as follows to account for the September 26, 2009, rollback of AWP implemented by Medi-Span ( AWP Rollback ): (1) Administrator shall adjust the Medi-Span AWP Pricing Information for each of the Affected NDCs to reflect the markup factors utilized by Medi-Span immediately prior to the AWP Rollback. Affected NDCs shall mean all NDCs with adjusted markup factors by the Pricing Source pursuant to the AWP Rollback. (2) New NDCs with markup factors used by the Pricing Source shall be adjusted by Administrator to reflect a markup factor of New NDCs shall mean those NDCs first issued and listed on the Medi-Span AWP Pricing Information after the effective date of the AWP Rollback. WAC shall mean the average wholesaler acquisition cost of a Covered Prescription Service based on the Medi-Span Prescription Pricing Guide (with supplements) or any other nationally recognized pricing source selected by Administrator (the Pricing Source ), as updated at least monthly. Claims rejecting for high dollar limit Some plans may elect to implement a high cost dollar limit *. If the claim rejects for this reason, please contact the Pharmacy Help Desk using the contact information provided in Section II of this pharmacy Manual. * Amounts vary by plan. Vacation supply Some plans may offer a one-time vacation override. Please contact the Pharmacy Help Desk using the contact information provided in Section II of this pharmacy Manual to determine if the member s plan will allow for an override. B. Required prescription information For each Claim for a covered drug filled and dispensed by a Network Pharmacy Provider for a covered Member, all related Network Pharmacy Providers are required to transmit the following information to OptumRx: NCPDP D.0 format billing transaction. The payer/billing specification sheet which details all of the requirements for submitting a Claim using the NCPDP D.0 format is referred to as the Payer Sheet. Several fields are marked as situational and they will require data as needed under the defined situation in the comment section. Claims submitted that are missing data in mandatory or required fields, or where data is required under situational conditions, will be rejected. OptumRx pharmacy manual: 7th edition 21

22 With the NCPDP D.0 format change being able to handle the exact metric decimal quantity correctly, you will no longer need to adjust the quantity by rounding prior to submitting Claims. All Claims submitted in D.0 format MUST use the PCN of 9999 (or 8888 if a wrap plan Member refer to ID card) and a submitted group. We have not provided specifications for the American National Standards Institute (ANSI) 837 format, as we believe that the NCPDP D.0 is the correct format to use for pharmacy dispensed non-drug items. Other non-prescription products and pharmacy-related supply items should also be billed using the NCPDP or D.0 format. Pharmacy service type (PST) & patient residence code (PRC) requirements Effective January 1, 2014, OptumRx will accept Patient Residence Code (PRC) 01 and Pharmacy Service Type (PST) of 01 on claims from Retail Pharmacies in support of the Centers for Medicare and Medicaid Services (CMS) memo titled 2014 Requirements for Coding Patient Residence and Pharmacy Service Type on Claims Transactions. Below is a table of the PRC that OptumRx will accept based on the patient setting applicable to each circumstance: Patient setting Appropriate codes Not specified PRC of 00 Home PRC of 01 Home infusion (HI) PRC of 01 and place of service (POS) of 12 Skilled nursing facility PRC of 02 For Medicare Part B use only Nursing facility/long-term care (LTC) PRC of 03 Submission clarification code (SCC) required if for short-cycle dispensing Assisted living facility (ALF) PRC of 04 Custodial care facility PRC of 05 For Medicare Part B use only Group home PRC of 06 Intermediate care facility/mentally rtrd (ICFMR) PRC of 09 Hospice PRC of 11 Correctional institution PRC of 15 The pharmacy is required to choose the appropriate PRC and PST based on the circumstance of the point of sale claim. It would not be acceptable for the pharmacy to default to any PRC or leave this field blank. Claims submitted without an appropriate PRC, POS or PST code may be rejected. C. Dispense as Written (DAW) OptumRx supports the NCPDP standard DAW codes. To ensure accurate reimbursement, always include the correct DAW code when you submit a Claim. Claims submitted to OptumRx with DAW codes of three through six (3 thru 6) or eight through nine (8 thru 9) will be adjudicated similarly to a DAW 0. If necessary, contact your software vendor for needed alterations to your pharmacy system. OptumRx pharmacy manual: 7th edition 22

23 DAW codes: DAW 0 NO DISPENSE AS WRITTEN (substitution allowed) (or no product selection indicated) Use the DAW 0 code when dispensing a generic drug; that is, when no party (i.e., neither Prescribing Physician, nor Pharmacist, nor Member) requests the branded version of a multi-source product. Use the DAW 0 code when dispensing a multi-source generic, even if the Prescribing Physician indicates the DAW code for the generic product and does not specify a manufacturer. Use the DAW 0 code when dispensing single-source brands (e.g., Crestor ), because generic substitution is not possible. DAW 1 PHYSICIAN writes DISPENSE AS WRITTEN Use when the Prescribing Physician specifies the branded version of a drug on the hard copy prescription or in the orally communicated instructions. If the Member requests a Brand Name Drug, and it is not a Prescribing Physician-initiated instruction, transmit the DAW 2 code. (See following instructions.) DAW 2 PATIENT REQUESTED Use this code when the Member requests the Brand Name Drug even though the original prescription did not indicate DISPENSE AS WRITTEN. DAW 3 PHARMACIST SELECTED BRAND DAW 4 GENERIC NOT IN STOCK DAW 5 BRAND DISPENSED, PRICED AS GENERIC Use when dispensing a brand as a generic. Claims submitted with DAW 5 will be reimbursed at the generic price. DAW 6 OVERRIDE DAW 7 SUBSTITUTION NOT ALLOWED; BRAND MANDATED BY LAW DAW 8 GENERIC NOT AVAILABLE DAW 9 OTHER Please note: Most Members have a choice between Brand Name and Generic Drugs. However, in some programs the Member will pay the difference between the cost of the Brand Name Drug and the available Generic Drug. Accordingly, correct DAW submissions indicate if a penalty is applicable. D. Electronic remittance advice (ERA) 835 program OptumRx network pharmacy providers have the option to participate in the Electronic Remittance Advice (ERA) 835 program. This service provides improved analysis, reporting, and a cost-effective alternative to the traditional hard copy. OptumRx pharmacy manual: 7th edition 23

24 Enrollment requirements To use the OptumRx pharmacy ERA program, you must meet the following requirements: Be a current OptumRx network pharmacy provider. Have the ability to receive and read the Electronic Remittance Advice (ERA) 835 file. Check with your Information Technology support staff or pharmacy software provider to confirm that you have the ability to receive the encrypted claims information via File Transfer Protocol (FTP). The Centers for Medicare and Medicaid Services (CMS) also offer free software to view and print the Electronic Remittance Advice (ERA) 835 file for professional providers and suppliers. For more information on this software, Medicare Remit Easy Print (MREP), please access the CMS website at: cms.hhs.gov/. When converting from a paper remittance advice to an ERA, the paper remittance advice can be mailed to you upon your request. This can be done for up to thirty one (31) days once you are enrolled in the EFT payment process. Complete the Pharmacy ERA paper enrollment form containing your contact and banking information. Please allow four weeks for your enrollment to be processed. Claims received after your Pharmacy EFT enrollment has been processed will be paid electronically. Please see a copy of the ERA Enrollment Form attached as Exhibit A. Complete the server information section on the enrollment form. To complete the server information you will need to provide your PGP Key. This ensures the delivery of secure data. PGP (Pretty Good Privacy) Encryption is a computer program that provides cryptographic privacy and authentication. PGP and similar products follow the Open PGP standard for encrypting and decrypting data. You will need to get this information from your software vendor. Enrollment steps Follow these simple steps to enroll in the OptumRx pharmacy ERA program: Print, complete and return the enrollment form via fax or U.S. Mail to OptumRx. or Click on the online link (optumrx.com/rxsolhcpweb/cmscontent.do?pageurl=/hcp/healthcareprovidertools/ PharmacyERA) to complete the form online. This form will be used to set up the Electronic Remittance Advice (ERA) 835 file transfer. To Make Changes to or Cancel Your ERA Information: Print and complete the enrollment form. Be sure to circle Change or Cancel on the form. Return the form via fax or U.S. Mail to OptumRx. or Call the OptumRx Pharmacy HelpDesk at Completed forms may be returned via mail or fax: OptumRx P.O. Box 6104 Cypress, CA Fax: Once you are enrolled in the ERA program, you can call the Pharmacy Help Desk at if you have questions about a late or missing ERA. OptumRx pharmacy manual: 7th edition 24