Summary of New Plans and Plan Sponsor changes Effective January 1, 2011

Transcription

1 Medco Health Solutions, Inc. 100 Parsons Pond Drive Franklin Lakes, NJ Summary of New Plans and Plan Sponsor changes Effective January 1, 2011 New Plan Sponsors Plan sponsor: See below Geographic area: See below Effective date: January 1, 2011 Number of lives: See below Announcement: Effective January 1, 2011, Medco will administer prescription drug benefits for the clients listed below. Action requested: For successful claim processing, effective January 1, 2011, process claims for sponsors listed below using the newly issued ID card. Provider must submit claims to Medco through the TelePAID System using: - Rx BIN number new Rx Group number - member's new ID number Sample ID cards: See next page. For claim adjudication or general questions: Contact the Pharmacy Services Help Desk toll-free at , or visit the Pharmacist Resource Center at Plan Sponsor Rx Group # ID number # of lives Geographic area Albuquerque Public APSNMRX 12-digit numeric 27,500 New Mexico Schools Avaya AVAYARX 12-digit numeric 36,000 Nationwide (conc. in NJ and CO) Carolina Care Plan MMODRUG 12-digit numeric 45,000 Nationwide Coventry PHS Preferred CVTYCOM 10-digit numeric 100,000 Nationwide (conc. in KS) Plus of Kansas Edward Jones EJRXPLAN 12-digit numeric 50,000 Nationwide (conc. in MO) Frontier Communications FRCOMM1 12-digit numeric 14,000 Nationwide Memphis Light, Gas and MLGWRXS 12-digit numeric 11,500 Tennessee Water Merck (adding lives from MEDMERCK 12-digit numeric 50,000 Nationwide Schering-Plough) National Elevator Industry NATLELV 9 digits numeric 82,000 Nationwide Health Benefit Plan Nucor NUCORRX 12-digit numeric 40,000 Nationwide Pitney Bowes PTNYBWS 12-digit numeric 40,000 Nationwide (conc. in CT) sanofi-aventis SANOFIRX 12-digit numeric 42,000 Nationwide URS Energy & URSECRX 12-digit numeric 19,000 Nationwide Construction URS Federal Services URSFSRX 12-digit numeric 10,000 Nationwide URS Federal Services URSFSRX 12 alphanumeric 3,000 Nationwide (CDH) URS Infrastructure & URSIERX 12-digit numeric 20,000 Nationwide Environment Walmart WALMARTRX 9 alphanumeric 1,200,000 Nationwide LT41068C Medco manages the prescription drug benefit for many of your customers employers or health plans.

2 Sample Prescription Identification Cards Albuquerque Public Schools Avaya Carolina Care Plan Coventry PHS Preferred Plus of Kansas Edward Jones Frontier Memphis Light, Gas and Water Merck National Elevator Industry Health Benefit Plan Nucor Pitney Bowes sanofi-aventis URS Energy & Construction URS Federal Services CDH URS Federal Services URS Infrastructure & Environment Walmart

3 Claim Submission Data Quality Plan Sponsor: All Plan Sponsors Geographic area: Nationwide All claims must be submitted accurately through Medco s TelePAID System for the Eligible Person for whom the prescription was written by the Prescriber. Each claim must contain complete and accurate information for member, prescriber, and drug. 1. Member and Dependent Data Accurate data entry at the time of dispensing ensures the accurate identification of the Member/Eligible Person. Ask the member for his/her current identification card. Submit accurate: Identification number (as listed on the ID card). It is important to confirm that the ID number that you are using is the most current active identifier. Rx Group number Date of birth Gender First name Relationship code Person code The Provider can contact the Pharmacy Services Help Desk to verify eligibility by calling and selecting option 1 or by visiting the Pharmacist Resource Center website at 2. Prescriber Identification The National Provider Identifier (NPI) is the required Prescriber Identifier for all claims submitted through the TelePAID system. Accurate data entry at the time of dispensing ensures the accurate identification of the Prescriber. Submit correct NPI information from the prescription identifying the Prescriber for each claim. Identifying an incorrect prescriber in the transmitted claim, upon audit, will result in a recoupment of the net amount paid if the prescriber contests writing the prescription. DO NOT submit the pharmacy s NPI number or the prescriber s DEA number in the Prescriber ID field. 3. Drug Data It is the Provider s obligation to submit claims using accurate drug information, including the NDC of the package size used, quantity, prescriber directions, and days supply of the product dispensed. NDC When submitting a claim, the NDC number of the package size dispensed or the package size used should be transmitted on the claim. Provider must dispense from the most cost-effective NDC with the lowest net cost to the member and plan, when appropriate. Days Supply Provider must clarify ambiguous dosage directions prior to dispensing. o A use as directed dosage should not be assigned an arbitrary days supply. o Provider must document in a retrievable manner the clarification of the dosage/instructions.

4 Claim Submission Data Quality (continued) 4. Quantity Dispensed The Quantity Dispensed transmitted via the TelePAID system for all Medco claims must reflect the exact quantity dispensed, including metric decimal amounts. There are three standard billing units to describe drug products: Eaches EA - Examples of EA drug forms can include tablets, capsules, transdermal patches, non-filled syringes and reconstitutable injectable vials. Milliliters ML - Examples of ML drug forms that are measured by liquid volume can include liquids, suspensions, solutions, IV solutions, irrigations, nasal sprays, and oral inhalers. Grams GM Examples of GM drug forms measured by weight can include ointments, creams, balms, bulk powders, and inhalers. Check the Pharmacy Services Manual for examples of exceptions to these designations. For more information: For additional helpful information, check the Medco Pharmacy Services Manual available on the Pharmacist Resource Center at

5 REMINDER Preventive Services Under the Affordable Care Act Announcement: Interim final regulations issued under the Patient Protection and Affordable Care Act identify four types of preventive services that must be covered by certain health plans at a $0 co-payment and not be subject to deductibles or other benefit limitations. Based on interpretation of the regulation, certain health plans are electing to cover five (5) drug product categories in the plan s prescription drug benefit coverage as either federal legend drugs or over-thecounter (OTC) items. Coverage for these products can begin as early as October 1, 2010, and each product will be subject to specific clinical and age guidelines in accordance with U.S. Preventive Services Task Force (USPSTF) guidance as interpreted by each plan. It is expected that approximately 20 Sponsors with plans administered by Medco will begin coverage October 1, 2010, with additional plans adding coverage for the Preventive Services in phases over time. Two of the larger plan Sponsors that are making changes for this coverage effective October 1, 2010, include some plans under HealthNow of New York, Inc., in upstate and western New York (Group number HNRXS) and some plans under BlueCross and Blue Shield of North Carolina (Group number BNCDRUG). As with other Covered Services, a valid prescription order is required for both legend and OTC items. The TelePAID System is updated to adjudicate claims from network provider pharmacies based on the NDCs of the specific legend or OTC product categories listed below. Product examples: Note: For more information: 1. Aspirin 2. Folic acid 3. Iron 4. Fluoride 5. Tobacco cessation use products (or interventions) Guidelines for coverage of the preventive service drug products, as adopted for plans administered by Medco, will be posted on the Pharmacist Resource Center ( website. Contact the Pharmacy Services Help Desk toll-free at or visit the Pharmacist Resource Center at

6 Medco s NCPDP Version D.Ø Highlights Pharmacies can look forward to many new enhancements included in the new HIPAA Transaction Standard NCPDP VERSION D.Ø. Some new features are listed below: Prescription number: is Expanding from a 7-digit field to a 12-digit field. Prescription Origin Code Values: A new value of 5 = Pharmacy. This value can be used for a pharmacy to pharmacy-transfer. Multi-Ingredient Compounds processing: Acceptance of up to 25 valid NDC s may be submitted for each compounded prescription claim. Medco will not be supporting Submission Clarification Code 8 for overriding (See separate communication). Additional Submission Clarification Codes for Long Term Care (LTC) Refill too soon override use: Five additional codes will be available for LTC pharmacies to use when supported by the clients benefit design. Patient Pay enhancements: Member co-payment amounts will include new clearly defined fields breaking out the total member responsibility into each field that went into the total dollar amount to be collected (i.e., formulary selection, product selection, coverage gap, etc.) New Improved Reject Codes: New reject codes have been added providing clearer reasons for the rejection. Several v5.1 reject codes have been replaced with the new enhanced reject codes (i.e., Reject code 7X, 9G, MR). New reject codes have been added for new processing situations and requirements. Note: Medco will follow industry standards and guidelines for rejections. The standard NCPDP rejection description text will no longer accompany the rejection number. In some instances, there may be supportive secondary messaging populated. Contact your software vendor for your software display ability. Consistent with the requirements listed in the Department of Health and Human Services final rule on HIPAA Electronic Transaction Standards (published in the January 16, 2009, Federal Register), Medco intends to begin accepting D.Ø claims from pharmacies through the TelePAID System starting January 1, Remember, all of 2011 is the transition year and Medco will accept both standards until the mandatory compliance date of January 1, 2012.

7 Medco NCPDP Version D.Ø Multi-Ingredient Compound Claim Processing, effective January 1, 2011 Compounded prescription claims are required to be submitted via the TelePAID System. Compound prescription claims transmitted using vd.ø must be submitted using the compound segment and will allow for the transmission of up to 25 individual ingredients to be submitted. Multi-ingredient compound claims and reversals must be submitted as a single transaction. Compound claims included in a multi-script transaction will cause the multiclaim transaction to reject. Multi-ingredient compound claims must be identified as a compound by submitting a Compound Code of 2 in the appropriate field. Each ingredient in the compound must be submitted with the NDC of the product used. The quantity of each specific ingredient, the cost of each individual ingredient and the basis of cost determination must also be submitted. It is important to submit the quantity dispensed to the member as the total metric quantity of the finished product. (not a total of the individual ingredients). Submit the sum of all individual ingredient costs, as the Provider s Ingredient Cost Submitted for the compounded prescription, and also submit the Provider s U&C price for the compounded prescription. For Plan Sponsors covering compound claims, if one ingredient submitted on a multiingredient compound claim is covered under the member s plan benefit design, then all the ingredients will be paid at the contracted rate. Certain exceptions may apply according to the member s plan benefit design. Medco will not reject individual ingredients in a compound unless the NDC submission represents an experimental drug, a recall drug, or it contains an invalid NDC. The NCPDP Submission Clarification Code of 8 to override the rejection of an individual ingredient will not be used. New Rejection codes associated with vd.ø multi-ingredient compound processing: 1. Compounds Not Covered = Reject 7Y 2. Duplicate Product ID (a duplicate product submitted) = Reject 9Z 3. Compound Requires at Least One Covered Ingredient (not all ingredients are covered) = Reject 8A Note: For Compounded Claims Submission Requirements, check the Claim Segment and Compound Segment in the Medco vd.ø Payer Sheets available on-line at

8 Version D.Ø Pharmacy Readiness Checklist for Implementation Medco will begin accepting the new NCPDP Version D.Ø HIPAA-compliant claims standard starting January As required by the HIPAA regulation, Medco will continue to accept v5.1 claim submissions during the 2011 year to permit all pharmacies time to transition to the new NCPDP Version D.Ø claims standard to meet the compliance date of January 1, In order to assure your pharmacy s readiness for a smooth transition to the new claims standard prior to the January 1, 2012, mandatory compliance date, we suggest creating a reminder check list. Some items to consider for your pharmacy s readiness checklist are: Check with your software vendor to ensure their vd.ø software will be certified by Medco Only software that is certified by Medco will be able to transmit claims successfully. Ask your software vendor for their vd.ø claim standard software roll-out schedule to determine when your pharmacy will be receiving the updated claim standard. Prepare your staff by providing training for the new fields and values for efficient claims processing during the vd.ø implementation process. Remember, the following PDF s are available for download at The Medco NCPDP vd.ø payer sheets which you can use to familiarize yourself and your staff with the new fields and requirements for the new claims standard. Current and historical pharmacy announcements and claims processing information related to the new vd.ø claims standard.