MEDICAL ASSISTANCE BULLETIN

Transcription

1 ISSUE DATE April 8, 2011 EFFECTIVE DATE April 8, 2011 MEDICAL ASSISTANCE BULLETIN NUMBER , , , , , , SUBJECT Electronic Prescribing Internet-based Application for Enrolled Medicaid Prescribers BY Izanne Leonard-Haak, Acting Deputy Secretary Office of Medical Assistance Programs Purpose: The purpose of this bulletin is to notify providers that effective April 8, 2011 enrolled Medical Assistance (MA) prescribers will have the option to electronically transmit outpatient drug prescriptions and renewals using a new Internet-based electronic prescribing (eprescribing) application accessible through the existing PROMISe provider Internet portal. Scope: This bulletin applies to all licensed pharmacies, including pharmacy providers serving residents of long term care facilities and prescribers (physicians, certified registered nurse practitioners, optometrists, dentists, podiatrists, and certified nurse midwives) enrolled in the MA program and providing services in the fee-for-service (FFS) delivery system, including ACCESS Plus. Providers that participate in the managed care delivery system should address any questions related to (eprescribing) to the appropriate managed care organization. Background/Discussion: The Centers for Medicare and Medicaid Services (CMS) has identified eprescribing as an important element in improving the quality of patient care. The adoption and effective utilization of eprescribing has also been recognized by the Office of the National Coordinator (ONC) for Health Information Technology as a means to reduce medication errors and enhance patient safety. Section 4201 of the American Recovery and Reinvestment Act of 2009 established a program for incentive payments to providers who adopt and become meaningful users of certified electronic medical records (EMR) technology. The adoption of eprescribing will promote improved accuracy in prescribing practices, enhance patient safety, and embrace technology to promote efficiency. On August 16, 2010, the Department of Public Welfare (Department) implemented eprescribing transactions allowing providers currently using stand-alone point of care (POC) COMMENTS AND QUESTIONS REGARDING THIS BULLETIN SHOULD BE DIRECTED TO: The appropriate toll free number for your provider type Visit the Office of Medical Assistance Programs Web site at

2 eprescribing software or EMR software to obtain eligibility and medication history information and to submit prescriptions electronically for MA FFS recipients. On April 5, 2011, the MA program will offer a new Internet-based eprescribing application accessible through the existing PROMISe provider Internet portal. This application will enable MA enrolled prescribers who do not have EMR software or stand-alone POC eprescribing software the option to prescribe electronically for MA FFS recipients. eprescribing is the real-time transmission of prescription or prescription-related information through electronic media. The Department uses Surescripts, which operates an eprescribing network, to manage this functionality. The Surescripts network currently processes the majority of all eprescribing transactions in the country, and it connects to major chain pharmacies and many payers, pharmacy benefit managers and independent pharmacies nationwide. The Surescripts network is linked to PROMISe TM enabling recipient eligibility information, medication history, and pharmacy benefit information to be electronically transmitted to the prescriber at the point of prescribing. Prescribers may access a patient s eligibility information and medication history as part of the eprescribing transaction for treatment purposes only. Providers must continue to comply with all relevant state and federal laws and regulations, including the Health Insurance Portability and Accountability Act (HIPAA) and the accompanying regulations. MA enrolled prescribers utilizing the new PROMISe eprescribing application will be able to transmit prescriptions electronically to a Surescripts participating pharmacy designated by the MA recipient. The transmission occurs through the network connections between the prescriber s office, Surescripts, and the pharmacy. As part of this process, prescribers will have access to the MA preferred drug list (PDL) and prior authorization requirements. In order for the Surescripts participating pharmacy to be eligible for payment, the pharmacy must be enrolled in the MA Program. Procedure: Providers must be enrolled in the MA program and have a National Provider Identifier (NPI) on file with the MA program in order to use the eprescribing application. To access the Internet based eprescribing application, providers must be registered to use the PROMISe Internet portal at There are some types of prescriptions that cannot be transmitted electronically. The Generic Equivalent Drug Act requires the prescriber to handwrite brand necessary or brand medically necessary on a prescription in order for a brand name product to be dispensed by the pharmacist(35 P.S ). Prescribers must therefore continue to use paper prescriptions for brand medically necessary drugs. 2

3 Prescriptions for controlled substances also cannot be transmitted electronically. Therefore, prescribers must continue to use paper prescriptions for controlled substances. The Drug Enforcement Administration issued a rule that allows electronic prescribing of controlled substances provided that specified security requirements are met (75 Fed. Reg , March 31, 2010); however, Surescripts is not permitting controlled substances to be eprescribed through its network at this time. In addition, Pennsylvania state law requires that Schedule II drugs contain the manual signature of the prescriber (49 Pa. Code 27.18). The following information highlights the PROMISe eprescribing application. Prescriber Registration - Providers intending to prescribe electronically via the PROMISe Internet portal must register separately within the portal by using the eprescribe secure portal page the first time they access the application. The prescriber must provide his or her state license number for registration in addition to other provider information. The provider must create a unique user Personal Identification Number (PIN) to use in the submission of an electronic prescription. Prescribers who are already registered with Surescripts to use stand-alone POC eprescribing software or other EMR software that has renewal/request capabilities will not be able to finalize the PROMISe eprescribe registration process until they complete the Surescripts Prescriber Vendor Release Form. This form may be obtained by contacting the PROMISe Provider Assistance Center (PAC) at The completed form must be faxed to Surescripts for processing. Providers who register to prescribe electronically have the option to allow all of their PROMISe Internet portal registered alternate user(s) to access the eprescribing application to perform functions such as establish patient profiles, check eligibility, and obtain medication history. It is important to note that only prescribers registered to use the eprescribing application are permitted to submit electronic prescriptions; therefore, the prescriber must manually enter his or her unique PIN to finalize the eprescribing process. Patient Information After completing the prescriber registration process, prescribers are required to create a profile for each patient that includes the patient s first name, last name, birth date, gender, and address. This information will be used by Surescripts to verify the patient s eligibility with the payer(s). When establishing a patient profile, the prescriber must select from the Patient Consent drop down list to confirm the prescriber has obtained patient consent to view the patient s medication history. If the prescriber does not indicate that patient consent has been obtained, medication history will not be available for display. As part of the patient profile creation, the PROMISe eprescribing application will also allow the prescriber to manually enter patient reported medications, disease conditions and allergies. 3

4 The patient s Preferred Pharmacies to be used for the electronic prescription can also be selected and stored in the Patient Profile section of the application. Pharmacy Benefit Coverage Eligibility The PROMISe TM eprescribing application performs a pharmacy benefit coverage verification check as the first step of the prescribing process. Using information from the patient profile, an eprescribing eligibility transaction is initiated to determine the patient s type of prescription coverage and associated payers. The eprescribing application will automatically send a pharmacy coverage eligibility request to Surescripts if it has been more than 24 hours since the last request. If eligibility is confirmed, the application will display pharmacy benefit coverage information from all payers that verify the patient is eligible. If a prescriber does not receive validation of a patient s pharmacy coverage during the eprescribing process, it does not necessarily mean that the patient is not enrolled in MA FFS. It may be that the Surescripts system is unable to match the patient information transmitted by the PROMISe TM eprescribing application. In addition, a recipient who is eligible in MA FFS may initially show as ineligible because updates are sent to Surescripts on a weekly basis. If current eligibility cannot be confirmed, pharmacy benefit plan information will not be returned and medication history will not be available. However, the provider may continue to prescribe within the eprescribing application. Before rendering any services, providers should verify the patient s MA FFS program eligibility for the date of service through the Department s Eligibility Verification System (EVS). Eligibility information obtained during the eprescribing process is not a guarantee of payment. Medication History If the patient is currently enrolled in MA FFS, the prescriber can view the patient s medication history. Medication history supports the Prospective Drug Utilization Review (ProDUR) process by providing information from all available payers for consideration by the prescriber at the point of prescribing. Medication history will be available from any payer that participates in the Surescripts network and with whom the Surescripts network has verified that the patient currently has active coverage. Surescripts allows payers to return up to two years of medication history. MA makes available up to one year of medication history information for MA patients currently enrolled in the FFS delivery system. Please note medication history from the MA managed care delivery system will not be available for a recipient currently enrolled in the FFS delivery system because Surescripts considers the FFS and managed care delivery systems to be different payers. Medication history is only returned from payers in which the patient currently has active coverage. The Confidentiality of HIV-Related Information Act limits the release of HIV-related identifying information without the patient s specific written consent (35 P.S ). Therefore, such information will not be included in the patient s MA medication history. 4

5 eprescribing - Before the actual electronic prescription is entered, the prescriber is required to choose the patient s primary payer coverage. This is an important step when the patient has drug benefits through more than one payer. Medicaid should only be selected as the primary payer if the patient does not have any other drug coverage. Once the coverage is selected, the prescriber enters the medication. If the medication prescribed is Non Preferred, which Surescripts refers to as Non Formulary, the Preferred medication, which Surescripts refers to as Formulary Alternatives will be displayed. After the medication is chosen the prescriber enters the directions and the quantity. The prescriber also has the ability to provide additional comments to the dispensing pharmacist. Coverage limitations such as prior authorization required will be displayed. The prescriber must acknowledge any major Drug Utilization Review (DUR) alerts to complete the prescription. Please note that DUR alerts resulting from the eprescribing process are based on the medication history returned from Surescripts, and therefore may, be different than alerts received by the dispensing pharmacist from the PROMISe claims processing system. The final step in the eprescribing process is the entry of the prescriber s PIN. This security feature requires the prescriber to confirm the prescription before the prescription is electronically transmitted to the patient s pharmacy of choice. Note that only the prescribers registered to use the PROMISe eprescribing application via the PROMISe Internet portal are permitted to submit electronic prescriptions. Compound drugs, requiring more than one drug, may not be submitted via the application. The NCPDP transaction does not allow for the designation of compound drugs. It is not possible to select two pharmaceutical ingredients. Prescriptions for controlled substances may not be transmitted electronically to the dispensing pharmacy; however, the application does allow the prescription to be entered, stored and printed for the recipient to hand carry to the pharmacy. A printed image of the prescription information that is electronically transmitted will satisfy the requirements of 55 Pa. Code a and a, provided that any such images contain the elements specified by these regulations. The pharmacy should either maintain a hard copy of the image of the prescription or have an image of the prescription information readily retrievable. If the recipient s preferred pharmacy does not participate in the Surescripts network, a hard copy of the prescription may be printed, manually signed by the prescriber, and given to the recipient. For the prescriber s use, the hard copy prescription information is available for reference using the eprescribing application Confirmation page. A summary of historical 5

6 prescription information is also available for printing via the application s View Prescriptions page. The application also supports the prescription renewal process. Pharmacies can initiate requests regarding prescriptions renewals. Prescribers can review, approve, or deny an electronic request from a pharmacy for the renewal of a prescription. The prescriber s PIN must be submitted before transmitting a response to a renewal request. The prescriber has the ability to retrieve Medication History prior to processing renewals and are encouraged to do so. While renewal requests are supported by the PROMISe eprescribing application, MA providers must continue to comply with all relevant laws such as the number of refills permitted. Training on the use of the PROMISe eprescribing application will be available to providers who will have access to this application. Please watch your RA banner pages for specific dates, times and information regarding the registration process. An online help demonstration and User s Manual will be posted to the PROMISe website to assist in using the application at Additional information regarding eprescribing can be found at the DPW website under rmation/index.htm. 6