2013 Pharmacy Manual

Transcription

1 2013 Pharmacy anual Office: Plaza Drive, Rocklin, CA Fax: Office Fax info@americanhealthcare.com

2 Table of Contents Section 1 Section 2 Section 3 Section 4 Section 5 Section 6 Claim Submission Audit Product Selection Dispensing Limitations iscellaneous D.0 Implementation

3 Pharmacy anual This American Health Care Provider anual is designed to answer your questions regarding online claim submission for American Health Care. The Provider anual is an extension of the Participating Provider Agreement and is incorporated into the Participating Provider Agreement with American Health Care. The provider must adhere to the provisions and terms set forth in the Participating Provider Agreement. If you need additional information, please contact the applicable Provider Help Desk. American Health Care (Catamaran) PROVIDER HELP DESK For claims and online transaction response please call our Help Desk, representatives are available to assist onday through Friday from 5:00 A to 9:00 P PST and Saturday 8:30 A to 5:00 P PST: American Health Care ember Services It is important to always refer to the Provider Web Portal at Health Care.com/providers for the most up to date documents, manuals payer sheet and other important communications. General Questions can be referred to American Health Care, 3850 Atherton Road, Rocklin Ca, American Health Care (Catamaran) IDENTIFICATION CARDS/BANK IDENTIFICATION NUBERS (RxBINs):

4 Section 1 Claim Submission Provider Obligations All claims must be submitted online within 30 days of the date the prescription was filled. The following elements from the member identification card must be submitted for successful claims adjudication. ember identification number Person code (when printed on card) RxGRP (when printed on card) BIN/Processor Control Number Software All claims must be submitted using NCPDP Telecommunication Standard Version D.0, later version, or other standard as dictated by applicable governing or industry setting organizations as designated by American Health Care. Reversals Claims can be reversed up to 30 days after the submission date (or as specified by plan), but should be reversed within 14 days or as soon as reasonably practical or as specified by certain governing requirement to assure prescriptions with inaccurate information or those not dispensed to members are credited in a timely fashion. Compounds All American Health plans require multiple-ingredient compound claims submission. Please use the following guidelines when submitting compounds: One of the ingredients must be a legend drug product. Compound indicator field must indicate that the claim is for a compounded prescription.

5 Appropriate fields in the compound segment (see payer sheet for additional information) must be completed. In the event that a single product id is submitted please use the following guidelines when submitting compounds: One of the ingredients must be a legend drug product. Compound indicator field must indicate that the claim is for a compounded prescription. Product ID and total metric quantity of the most expensive legend prescription drug, and the total ingredient cost of all ingredients combined must be entered in the claim segment. Reimbursement is the lower of submitted cost, usual and customary price, or AWP. Other reimbursement pricing methods may be used. Submission of compounds with this method are subject to increased audit and may incur additional costs Note: Reconstituted preparations, such as powdered antibiotics that are mixed with water prior to dispensing are not considered compounded prescriptions. Tax Tax is calculated based on the applicable state or local law governing tax on prescription drugs. In order to be reimbursed for payment of tax, the Provider must enter the tax amount in the appropriate tax field. Claim System The electronic claim processing system is generally available 24 hours per day, 7 days per week, with the exception of regularly scheduled downtime, which generally occurs at non-peak hours in order to minimize the impact to our network providers. The transaction fee incurred by the Provider is up to twenty-five cents per on-line transaction. The transaction fee is assessed to support network Provider payment and reconciliation, help desk support, as well as but not limited to Provider network compliance, transactional, and billing education. However, excessive or disruptive process inquiries, including but not limited to non- contracted provider status, duplicate payment and

6 remittance requests, excessive member/provider grievances, third party biller intervention, incomplete or inaccurate credentialing submissions, contract compliance and/or failure of the Provider to submit claims through the American Health Care designated adjudication on-line adjudication process are subject to higher transaction fees, up to five dollars per transaction. Should a claim be submitted by a third party or other means separate from the provider itself, the claim may be subject to non-payment. American Health Care American reserves the right to make payment directly to Provider at its sole discretion.

7 Section 2 Audit I. Provider Audit American Health Care or its authorized agent or representatives reserves the right to audit a Provider s compliance with the agreements in effect. American Health Care has the right to inspect all records of the Provider relating to this agreement. The Provider shall maintain, adequate prescription records, and financial records relating to the provision of pharmaceutical services to our customers, including but not limited to: Provider books/databases, daily prescription logs, patient profiles, prescription hardcopy s, prescriber information, signature/delivery logs, refill information, wholesalermanufacturer- distributor and all other purchase invoices and documentation for all pharmaceutical services provided. This includes all policies and procedures related to maintenance of such records. Provider shall maintain and retain such records for a minimum of (10) ten years or as required by law. American Health Care Auditors shall have the right to audit any Provider submitting claims for payment during normal business hours and upon reasonable notice (usually 14 days) for any aspect of performance under their agreement by reviewing records and documents relating to such performance. Documents must be readily accessible. The Provider shall cooperate with American Health Care Auditors, and promptly provide access to all information or documents deemed necessary by the American Health Care Auditors. American Health Care at its sole expense may reproduce any record; however, no original copy may be removed from the Provider. A failure to cooperate with the aforementioned shall constitute a material breach of your American Health Care Agreement. In the event of a conflict between the Provider anual and the Agreement, the Provider anual prevails. American Health Care may report audit findings to its Clients, appropriate governmental entities, regulatory agencies, and professional review and audit organizations.

8 American Health Care does provide the opportunity to appeal the results of an audit based on state audit guidelines or mandates. However, be aware that the appeal process is not a vehicle for submission of new materials for inclusion in the audit review but is designed to provide a re-determination of previously submitted post audit documentation. II. Types of Audits American Health Care routinely monitors online claims data and conducts audits on a continuous basis. American Health Care Auditors conduct industry standard desktop audits and on-site audits, scheduled during normal business hours with prior written notice, and audits of an investigational nature. In order to conduct these audits, providers may be contacted by telephone, mail, fax, and or and are required to provide such records by the due date in a manner mutually agreeable by the parties, while at all times ensuring safe transmission of sensitive documentation. Onsite Auditors require a clutter free work area which is located away from the busiest area of the Pharmacy department with easy access to the required documents outlined in the audit notice; we attempt to minimize any disruption of the business processes while on-site. Please note; it is also helpful to have an assistant present to answer general questions, retrieve information required and facilitate an effective on-site audit. The Provider shall receive a post audit report, which allows for a 30 calendar day period to contest any findings identified. At the completion of the audit the Provider shall also receive a final audit report with the claims identified as discrepant and due for recovery. All documentation must be received no later than 30 calendar days from the date of the discrepancy report. Beyond that date, the audit shall be considered final. If an American Health Care Auditor is denied access to the Provider or is not provided access to the required requested audit documents, 100% of the amount paid for that claim(s) become due immediately.american Health Care may offset this said amount against any future payments due to the Provider and impose certain fines or penalties. III. Document Requirements All prescription documentation, regardless of the way it has been created, generated or transmitted shall contain the following:

9 Full name of the member for whom the prescription was written, and the address of the member along with a date of birth. Full name and address, telephone number and any other required identifiers of the prescriber. Name, strength and quantity of the medication prescribed. Specific dosing directions, if a prescription contains ambiguous directions the Provider must clarify these directions and notate the conversation to clarify. Substitution instructions where applicable, or substitution requested by member clearly notated. Refill instructions. iscellaneous or other informational notations as required by applicable laws or regulations. Compounded medications require a detailed compound worksheet; a valid prescription which also details the specific ingredients to be included in the compounded product. It is important to document the products, NDC s, quantity used, costs associated and procedures. Provider must utilize a signature/delivery log that contains all the information required by American Health Care. This should include; date of pick up, the prescription number, third party name, and the authorization to release information to a third party program. Provider must obtain a legible written signature that corresponds to a matched printed name or another authorized person to confirm receipt of the prescription product. If any state or federal laws require additional verification of the person picking up the medication, please include this notation on the signature log documents. Proper verification of the person picking up the prescription is essential to ensure the deterrence of potential fraud, waste and abuse. These prescription signature logs must be in date order and readily accessible for a minimum of three years or longer as required by law. Wholesaler, manufacturer and distributor invoices and other purchase invoices and documents must also be maintained for a minimum of three years or as required by law or regulation to substantiate that the drugs dispensed were purchased from an authorized source. The Provider must promptly comply with any requests to produce such documentation. If the Provider fails to promptly provide such requested documents,

10 American Health Care may offset 100% of the amount for any of the paid claims in question and impose additional fines or penalties. IV. Audit Processes In order to facilitate appropriate claim submission and to protect against fraud, waste, and abuse, American Health Care conducts Provider audits on a routine basis according to CS and American Health Care guidelines. American Health Care s Provider audit team works with our designated audit vendor to conduct desktop and on-site audits. Providers are identified for the desktop and on-site audit process based upon internal analysis. Please use the following information to help avoid problems and prepare for an audit. Day Supply Pharmacists are responsible for entering the correct day s supply of medication for all submissions. The results of an audit can include chargeable discrepancies for days supply error submission: The days supply for 25 doses of a medication, taken 25 per month, is 30 days. The days supply for 4 patches, 1 patch applied once weekly, is 28 days. If the prescribing provider indicates, "As directed," the Provider determines the dosing schedule in order to submit the correct days supply on the claim. Talk with the member/customer or call the prescriber to determine the appropriate amount to dispense. Claim reimbursement is based on quantity dispensed. It is important to remember that in order to provide appropriate pharmaceutical consultation, the Provider must be sure the member understands how much and how often the medication is to be taken. Insulin and Diabetic Supplies Use only the actual Product IDs (i.e. NDC numbers) of insulin and the supplies dispensed. Some patients require two types of insulin (i.e., long or short-acting). Often both medications appear on the same prescription. Since each drug has a unique NDC number, separate the prescription into two claims, submit the two products properly and

11 collect the appropriate copays. Diabetic supplies should be calculated properly and submitted according to the prescribers request and validated with the patient. Directions notated as needed or as directed require a documented interaction with the prescriber or patient on the prescription. Inhalers and Inhalation Products When submitting a claim, enter the quantity to be dispensed exactly as written by the prescriber on the prescription form. Dispensing limitations vary widely among plans. Depending on the patient s medical condition, it may be necessary to dispense more than one inhaler. If plan design allows and the prescriber writes accordingly, the patient may obtain more than one inhaler per prescription (Example: Proventil Inh -17g contains 200 puffs per canister; when used two puffs Q4H, one canister should last 17 days).

12 Section 3 Product Selection (aka Dispense as Written) American Health Care supports the NCPDP standard Product Selection Codes (PSC s). Accurate reimbursement is tied to proper PSC submission; the Provider must always specify the correct PSC when submitting a claim. American Health Care supports the NCPDP standard Product Selection Codes (PSC s). Accurate reimbursement is tied to proper PSC submission; the Provider must always specify the correct PSC when submitting a claim. Product Selection Codes (PSC): PSC 0 - NO DISPENSE AS WRITTEN (Substitution Allowed) (or no product selection indicated) Use the PSC 0 code when dispensing a generic drug; that is, when no party (i.e., neither prescriber, nor pharmacist, nor member) requests the branded version of a multi-source product. Use the PSC 0 code when dispensing a multi-source generic, even if the prescriber indicates the PSC code for the generic product and does not specify a manufacturer. PSC 1 PRESCRIBER writes DISPENSE AS WRITTEN Use when the Prescriber specifies the branded version of a drug on the hard copy prescription or in the orally communicated instructions. PSC 2 - EBER REQUESTED Valid Person Codes 001= Cardholder 002= Spouse 003, 004, etc. = Child (according to birth code)

13 PSC 3 - PHARACIST SELECTED BRAND PSC 4 - GENERIC NOT IN STOCK PSC 5 - BRAND DISPENSED, PRICED AS GENERIC Use when dispensing a brand as a generic. Claims submitted with PSC 5 are reimbursed at the generic price. PSC 6 OVERRIDE PSC 7 - SUBSTITUTION NOT ALLOWED; BRAND ANDATED BY LAW Do not use for NTI drugs, please use the correct codes 0, 1, or 2 and communicate with the prescriber. PSC 8 - GENERIC NOT AVAILABLE PSC 9 OTHER Some members have a choice between brand and generic drugs. However, in some programs, the member pays the difference between the cost of the brand and the available generic drug. Prescription Hard Copies A hard copy of each prescription must be readily retrievable upon request. Prescriptions for insulin and/or syringes must contain complete documentation of items and quantities dispensed along with directions for use. Prescription hard copies must be updated yearly unless state pharmacy law in which Provider is located specifically allows a prescription to be refilled after more than one year has passed. A prescription hard copy must be maintained for every prescription for ten years or longer as required by law. The hard copy (original and any updates) of the prescription, including telephone prescriptions, must contain data elements required by state pharmacy laws in which Provider is located and all of the prescriber instructions including Product Selection Code instructions that support the Provider s claim transmission.

14 Prescriptions in which the dosage/quantity is changed require either written documentation on the prescription or a new hard copy prescription to be issued. In cases of the prescriber writing As Directed, documentation as to the exact directions or, at a minimum, the maximum ( up to ) dose of medication taken per day must be documented on the hard copy or electronically and be viewable upon request. If undocumented at the time of the audit, the entire claim is marked as discrepant until proper documentation is provided. Only prescriptions generated by the prescriber are accepted as post audit documentation for as directed prescriptions. If less or more medication (if permitted) is given than ordered by the prescriber, the reason for this must be documented. Any increase in the amount of medication over the original prescribing order must be documented for prescriber authorization. Signature Log Provider shall require the signature of the member or the member s representative on a permanent record before dispensing any prescription. At each Provider location, Provider shall maintain a hard copy or (pre-approved by American Health Care) electronic signature log which contains the following: the prescription number; the date the medication is received by the member; and the signature of each member who receives a medication or the signature of his/her designee. A log in date order must be maintained for all claims submitted on-line to American Health Care. Signature logs must be maintained for ten years or longer corresponding to the state. Pharmacy laws in which Provider is located for retaining prescription hard copies. The logs must be available for inspection and audit by a representative of American Health Care and/or its designated agent.

15 Section 4 Dispensing Limitations Enter the quantity to be dispensed exactly as written on the prescription form. A 30-day supply is no longer standard; some programs permit extended days supplies. Always transmit the accurate days supply and allow the on-line system to communicate the allowable days supply. Note subsequent changes or refill authorizations approved by the prescriber on the hard copy, or in a readily retrievable electronic format, acceptable by the State Board of Pharmacy in which Provider is located. U&C Usual and Customary Charge means the usual and customary price charged by the Provider to the general public at the time of dispensing, including any advertised or sale prices, discounts, coupons or other deductions. PSC Submissions Incorrect PSC codes are the most common cause of Provider charge backs and may lead to removal from the network. When an auditor cites a prescription for a missing or incorrect PSC code, follow-up documentation is not permitted. A transmitted PSC 1 code must be supported on the prescription hard copy (original and update). No PSC 1 code defaults should be set; this leads to removal from the network. A PSC 2 code should be transmitted when the member requests that the prescriber be contacted to obtain approval for a brand drug when the prescriber did not initially mandate dispense as written. Avoid use of PSC 7 for NTI drugs, please use the correct codes 0, 1, or 2 and communicate with the prescriber.

16 iscellaneous Claims are adjudicated based on data provided to American Health Care. If a claim is adjudicated based on incorrectly submitted data, an adjustment may be necessary. To prevent audit charge backs on compounded or other prescriptions, the Provider must ensure its systems are not programmed to place an amount in the ingredient cost field that is equal to the AWP of the most expensive NDC multiplied by the final product quantity. Transmit the data as listed on the prescription and as ordered by the prescriber. Proper submission of days supply, quantity (obtain and document "as directed" instructions), NDC number, eligibility information, etc. Transmit PSC 1 code only when initially authorized by the prescriber; the prescription hard copy (including hard copies documenting phoned-in prescriptions) must support a PSC 1 code. Obtain a signature on the signature log. Pharmacists should monitor the will-call bin and process unclaimed prescriptions on a timely basis but no less than twice monthly. Reversals of prescriptions affect the member s deductible and copayment. Transmit proper member information, including relationship code, sex and proper prescriber identification number. Provider must charge the member the patient pay amount indicated in the on-line response. Remember to change the compound indicator if the Provider is filling a compounded drug product. Provider should follow all audit guidelines as notated on the communications to the Provider via telephone, letter or electronic requests. American Health Care may deny payment for unsupported claims or missing signatures. American Health Care may satisfy an unpaid audit liability by any of the following methods which may include but are not limited to: request for a check, offset against future claims payment and use of a collection agency. American Health Care has the right to assess reasonable fines, penalties and fees to cover unexpected costs. These actions may include the imposition of fines or penalties due to repeated audits, termination from the network, corrective action plans.

17 Summary of Audit Discrepancies Discrepancy Type Recovery Amount Documentation Allowed Y/N) issing Prescription Full Recovery Yes Unauthorized Refill Full Recovery No Quantity/Day Supply Discrepancy Partial Recovery No issing Signature from Signature Log Full Recovery Yes iss Fill Discrepancy Up to Full Recovery No Invalid Prescription Full Recovery No PSC Discrepancy Partial Recovery No Other/iscellaneous Up to Full Recovery Situational Fraud, Waste and Abuse American Health Care does not knowingly allow fraudulent activity of any kind by any of its contracted providers, associates, members, vendors, contractors and/or other business entities, and investigates and reports any such known activity to the appropriate regulatory, federal and state agencies for further action and investigation. The Provider can always report any suspected fraud, waste or abuse by calling the American Health Care Ethics and Compliance Hotline, toll-free number at available any time, 24 hours a day 7 days a week. Filling less than the prescribed quantity of a drug Billing for brand-name drugs when generic drugs are dispensed Billing multiple payers for the same prescriptions Dispensing expired or adulterated prescription drugs

18 Forging or altering prescriptions Refilling prescriptions erroneously Compliance/Fraud, Waste and Abuse (FWA) training is an important component of Provider operations and is required to be completed annually and upon intimal hire for all local, state and federally funded pharmacy benefit programs. To assist Providers with this training American Health Care has posted various materials on our website or Health Care.com Preferred Drug List AHC has established a list of pharmaceutical products which may be dispensed by the precipitating pharmacies to enrollees in accordance with the instructions found in this manual. This list is subject to periodic review and modification by AHC. Change Notification ember Pharmacy must immediately notify AHC in writing of any change in the information provided in the provider agreement, the pharmacy network participation acceptance form, or any information or documentation provided to AHC in connection with any credentialing or quality assurance initiatives. Any Changes in such documentation must be reported to: American Health Care 3850 Atherton Road Rocklin, CA 95675

19 aterials Reproduced With the Consent of National Council for Prescription Drug Programs, Inc. 2Ø1Ø NCPDP IPLEENTATION GUIDE FOR VERSION D.Ø 1. GENERAL INFORATION FOR A PAYER ABOUT THE TEPLATES COPYRIGHT INFORATION EXTERNAL CODE LIST GENERAL INSTRUCTIONS TO PAYERS HOW TO USE THIS DOCUENT TRANSISSIONS PLAN DIFFERENTIATION SEGENTS andatory Segments Situational Segments Optional Segments FIELDS OR VALUES Situations on Fields Counts and Counters Zero (0) and an O SPECIFIC TOPIC DISCUSSION Partial Fill Transaction Processing Coordination of benefits (COB) Processing Compounds Vaccine Administration 32

20 2.7 FIELD LEGEND ANDATORY FILED SITUATIONAL FIELDS - REQUIRED SITUATIONAL FEILEDS QUALIFIED REQUIREENT INFORATIONAL ONLY FIELDS OPTIONAL FIELDS NOT USED FIELDS NCPDP VERSION D CLAI BILLING/CLAI REBILL INSTRUCTIONS GENERAL INFORATION REQUEST TEPLATE INFORATION RESPONSE TEPLATE INFORATION CERTIFICATION AND/OR TEST DATA NCPDP VERSION D CLAI BILLING/CLAI REBILL TEPLATE REQUEST CLAI BILLING/CLAI REBILL PAYER SHEET TEPLATE RESPONSE CLAI BILLING/CLAI REBILL PAYER SHEET TEPLATE Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Response Claim Billing/Claim Rebill Accepted/Rejected Response Claim Billing/Claim Rebill Rejected /Rejected Response NCPDP VERSION D CLAI REVERSAL INSTRUCTIONS GENERAL INFORATION REQUEST TEPLATE INFORATION RESPONSE TEPLATE INFORATION NCPDP VERSION D CLAI REVERSAL TEPLATE REQUEST CLAI REVERSAL PAYER SHEET TEPLATE 184

21 6.2 RESPONSE CLAI REVERSAL PAYER SHEET TEPLATE Claim Reversal Accepted/Approved Response Claim Reversal Accepted/Rejected Response Claim Reversal Rejected/Rejected Response EXAPLES OF PAYER TEPLATES EXAPLE 1 HEALTH PLAN OF AERICA PAYER SHEET Claim Billing/Claim Rebill CLAI BILLING/CLAI REBILL REQUEST CLAI BILLING/CLAI REBILL ACCEPTED/PAID (OR DUPLICATE OF PAID) RESPONSE CLAI BILLING/CLAI REBILL ACCEPTED/REJECTED RESPONSE CLAI BILLING/CLAI REBILL REJECTED/REJECTED RESPONSE Claim Reversal CLAI REVERSAL REQUESTED CLAI REVERSAL ACCEPTED/APPROVED RESPONSE CLAI REVERSAL ACCEPTED/REJECTED RESPONSE CLAI REVERSAL REJECTED/REJECTED RESPONSE EXAPLE 2 HEALTH SERVICE OF AERICA PAYER SHEET - SERVICE Service Billing/Service Rebill SERVICE BILLING/SERVICE REBILL REQUEST SERVICE BILLING/SERVICE REBILL ACCEPTED/PAID (OR DUPLICATE OF PAID) RESPONSE SERVICE BILLING/SERVICE REBILL ACCEPTED/REJECTED RESPONSE SERVICE BILLING/SERVICE REBILL REJECTED/REJECTED RESPONSE EXAPLE 3 ABC, INC. PAYER SHEET TWO PLANS 215

22 Workers Compensation Claim Billing WORKERS COPENSATION CLAI BILLING ACCEPTED/PAID (OR DUPLICATE OF PAID) RESPONSE 215 WORKERS COPENSATION CLAI BILLING ACCEPTED/REJECTED RESPONSE 215 WORKERS COPENSATION CALI BILLING REJECTED/REJECTED RESPONSE Workers Compensation Claim Reversal WORKERS COPENSATION CLAI REVERSAL REQUEST WORKERS COPENSATION CLAI REVERSAL ACCEPTED/APPROVED RESPONSE 216 WORKERS COPENSATION CLAI REVERSAL ACCEPTED/REJECTED RESPONSE 216 WORKERS COPENSATION CLAI REVERSAL REJECTED/REJECTED RESPONSE Non-Workers Compensation Claim NON-WORKERS COPENSATION CLAI REQUEST NON-WORKERS COPENSATION CLAI BILLING ACCEPTED/PAID (OR DUPLICATE OF PAID) RESPONSE 234 NON-WORKERS COPENSATION CLAI BILLING ACCEPTED/REJECTED RESPONSE 254 NON-WORKERS COPENSATION CLAI BILLING REJECTED/REJECTED RESPONSE Non-Workers Compensation Claim Reversal NON-WORKERS COPENSATION CLAI REVERSAL REQUEST NON-WORKERS COPENSATION CLAI REVERSAL ACCEPTED/APPROVED RESPONSE 280 NON-WORKERS COPENSATION CLAI REVERSAL ACCEPTED/REJECTED RESPONSE 286

23 NON-WORKERS COPENSATION CLAI REVERSAL REJECTED/REJECTED RESPONSE 291 EXAPLE 4 AERICAN PROCESSOR INC PAYER SHEET ULTIPLE PLANS Claim Billing/Claim Rebill CLAI BILLING/CLAI REBILL REQUEST FREQUENTLY ASKED QUESTIONS USE OF RED FONT FONT SIZE APPENDIX A. HISTORY OF IPLETENTATION GUIDE CHANGES EDITORIAL CORRECTIONS VERSION 1.1 CORRECTIONS VERSION VERSION

24 GENERAL INFORATION FOR A PAYER ABOUT THE TEPLATES This document is to be used as a reference in filling out and creating a Payer Sheet based on NCPDP Telecommunication Standard Implementation Guide Version D.Ø and above. The Payer Sheet must contain request and response information. Payers must read the instructional sections before filling out the templates. Payers may take the request template section and response template section, fill out the template per their usage, and send to their trading partners. Payer Sheets may be used in addition to provider manuals, or included in provider manuals. Payers must indicate any fields (if applicable) to be used in transaction processing, in accordance with the rules established in the NCPDP documents. Refer to the NCPDP Telecommunication Version D documents Telecommunication Standard Implementation Guide Version D.Ø, Data Dictionary, External Code List, and Telecommunication Version D Questions, Answers and Editorial Updates) for more detailed information on field values and segments. For initial development considerations, refer also to the NCPDP SNIP Liaison Special Committee recommendations regarding suggestions for initial implementation and testing ( In this document, the following templates have been created: Claim Billing/Claim Rebill o Request o Responses (Paid and Rejected) Claim Reversal o Request o Responses (Approved and Rejected) Payers should fill out a template for each request and response transaction supported. If other transactions are supported (Service Billing request, responses, Service Reversal request, responses, Prior Authorization Inquiry request, responses, etc) payer templates should be created following the guidelines in this document. Payers are reminded to fill out template for each response type supported, including the Rejected transmission, Rejected transaction response.

25 If the payer does not support the Claim Rebill (B3) transaction, the Claim Rebill verbiage should be removed from the payer s template. The Examples sections show how segments and fields on payer sheets might be filled out. Transmissions Refer to the NCPDP Telecommunication Standard Implementation Guide Version D.Ø for the structure and syntax of the transaction(s) within the transmission. In the template, the (112-A) fields are not shown. Segment, Group, and Field Separators are not shown as they are part of the syntax. These fields are not shown because they are part of the underlying structure of the transaction and are covered in the guide. This template is to show the business and plan requirements. Plan Differentiation If the payer does not have different plans, this section can be skipped. If the payer supports multiple plans or has different BINs and/or PCNs that cause different segments to be used multiple payer templates must be created for each unique combination. For example ixing plans that are Primary only (i.e., Coordination Of Benefits/Other Payments Segment not used) with plans that are supplemental (i.e., COB Segment used) ixing plans where one or more use the Workers Compensation Segment while others do not ixing plans where one or more use the Coupon Segment while others do not Because a payer sheet may be created that represents the superset of requirements for multiple plans, the pharmacy will submit based on this superset. An individual plan(s) benefit under this superset may not require all of the fields in the superset In this

26 instance the plan will ignore the fields that do not apply to the particular transaction being submitted. For example One plan or more uses Patient Gender Code while others covered in the same template do not Scenario Examples BIN PCN Different Payer Templates Required? Comment The payer supports one BIN with multiple PCNs where some plans are Primary only and others are supplemental PCN = XYZ (Primary only) PCN = BBC (Supplemental) PCN = GAR (Supplemental) Yes Since one of the plans is Primary only, it needs a separate payer sheet. The payer supports one BIN with multiple PCNs. Each PCN supports the same method of coordination of benefit processing PCN = XYZ PCN = BBC PCN = GAR No Since all plans under this BIN have the same segments the same Payer Template can be used. (See section Specific Topic Discussion) The payer supports Workers Compensation claims and non- Workers Compensation claims under the same BIN. 61ØØ41 PCN = WRK for Workers Compensation claims PCN = ABC for non-workers Compensation claims. Yes Two Payer Templates must be used because different segments are used (Workers Compensation claims will use the Workers Compensation Segment; non-workers Compensation claims do not use the Workers Compensation Segment)

27 Scenario Examples BIN PCN Different Payer Templates Required? Comment The payer supports coupons claims and non-coupon claims under the same BIN. The payer supports claim and service billings under the same BIN. The payer supports a plan that may be primary or supplemental Has no impact Yes Two Payer Templates must be used because different segments are used (Coupon transactions will use the Coupon Segment non-coupon transactions do not use the Coupon Segment) Has no impact Yes Two Payer Templates must be used to avoid confusion in segments used for claim billing versus service billing Has no impact No One Payer Template should be used since all segments usage are the same, with the exception of the Coordination of Benefits/Other Payments Segment which will designate the usage of the supplemental rules. The processor supports plans that require their own BINs Has no impact No Since all plans for this processor have the same segments the same Payer Template can be used. (See section Specific Topic Discussion) Segments Each segment is listed as mandatory, situational, or optional for a given transaction in the NCPDP Telecommunication Standard Implementation Guide. If the segment is mandatory for a given transaction, that segment must be sent. If the segment is situational, the situations outlined

28 in the guide must be followed for use. If the segment is optional, please refer to the NCPDP Telecommunication Standard Implementation Guide Version D.Ø for more information on optional usage andatory Segments Segments which are designed mandatory in the NCPDP Telecommunication Standard Implementation Guide must be included on the Payer Sheet. In the mandatory segments, the Payer must fill in the values to be used in the mandatory or situational fields as defined in the NCPDP Telecommunication Standard Implementation Guide. On the template, each mandatory segment contains an initial question about the use of the segment (This Segment is always sent), with an X in the Check column. The Check X is in black and must not be modified by the Payer. An example: Situational Segments On the template, each situational segment contains two initial questions about the use of the segment (This Segment is always sent) and (This Segment is situational). The Payer must answer either of the initial questions with a check. If the Segment is situational, a situation for when the Segment is used must be described. An example The payer must: 1. If this situational segment is Not Used by the Payer, the segment and charts must not be shown (the initial question chart and the segment with fields chart should be deleted). 2. If this situational segment is used by the Payer, a. Either the question This Segment is always sent or This Segment is situation must contain a Check X on the template for each situational segment. This tells the reader how the segment is supported in this transaction. i. If This Segment is always sent is checked 1. The segment is used in every transaction associated with this template. 2. In the field charts, the Payer must list the fields supported and all situations applicable. 3. In the field charts, the Payer must exclude Not Used fields. ii. If This Segment is always situational is checked 1. The segment is used in some of the business cases of this transaction. 2. The Payer should provide guidance when this segment is used in the If Situational, column.

29 3. In the field charts, the Payer must list the fields supported and all situations applicable. If column is not applicable, it will be shaded (for example, If Situational, cell above for the question This Segment is always sent ). Optional Segments The NCPDP Telecommunication Standard Implementation Guide Version D.Ø allows segments defined as optional in the Controlled Substance Reporting transactions only. Use the methodology shown below for optional segments. On the template, the optional segment contains two initial questions about the use of the segment (This Segment is always sent) and (This Segment is optional). The Payer must answer either of the initial questions with a check. If the Segment is optional, a situation for when the Segment is used must be described. An example: Situations on Fields The Payer template has been pre-filled in the column with the field-level situations from the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. These pre-filled situations begin with the tag Imp Guide: If the payer wishes to further define the situation and explain their usage, situations can be added to the tag Payer Requirement: If the NCPDP Telecommunication Standard Implementation Guide Version D.Ø situation satisfies the payer s instructions, the statement can be entered Payer Requirement. Field # NCPDP Field Name Value Payer 414- DE DATE PRESCRIPTION TTEN R 354- NX SUBISSION CLARIFICATION CODE COUNT aximum count of 3. RW Imp Guide: Required if Submission Clarification Code (42Ø-DK) is used. Payer Requirement: Same as Imp Guide.

30 It is very important that the NCPDP Telecommunication Standard Implementation Guide Version D.Ø and above be consulted for full information on field usage. The following is an example of a pre-filled situation for a field. The tag Imp Guide: contains the field-level situation from the Imp Guide (Imp Guide: Required when the patient has a first name.). The tag Payer Requirement: contains further guidance of the situation(s) from the payer (Payer Requirement: Required as all patients are enrolled with a first name. If newborn, use BABY BOY or BABY GIRL. If person has only one name, put one name in this field.). Field # NCPDP Field Name Value Payer 31Ø- PATIEN RST E RW Imp Guide: Required when the patient has a first name. Payer Requirement: Required as all patients are enrolled with a first name. If newborn, use BABY BOY or BABY GIRL. If person has only one name, put one name in this field. Counts and Counters Each count and counter field has a maximum number of occurrences allowed in the NCPDP Telecommunication Standard Implementation Guide. If the payer supports less than the maximum number of occurrences, this must be explained for the appropriate field in the Payer Situation column of the template. 458-SE PROCEDURE ODIFIER CODE COUNT aximum count of 1Ø. Imp Guide: Required if Procedure odifier Code (459-ER) is used.

31 Payer Requirement: Zero (Ø) and an O When denoting a field or a value, the slashed zero (Ø) should be used to clearly differentiate between a zero (Ø) and an O. This is not a requirement, but is highly recommended for clarity. Specific Topic Discussion Partial Fill Transaction Processing If Partial Fill logic is supported electronically, Payer supports partial fills should be checked. If not supported, Payer does not support partial fills should be checked. (See Claim Segment in section Request Claim Billing/Claim Rebill Payer Sheet Template) If Partial Fill logic is not supported electronically, please explain the providers procedure for handling partial fill claims. Refer to section Specific Segment Discussion, Request Segments, Claim Segment, Partial Fill of the NCPDP Telecommunication Implementation Guide Version D.Ø. Coordination of Benefits (COB) Processing If the Coordination of Benefits Segment is used, indicate if you will be requiring providers to report: 1. Scenario 1 - Other Payer Amount Paid Repetitions Only or 2. Scenario 2 - Other Payer-Patient Responsibility Amount Repetitions and Benefit Stage Repetitions Only or 3. Scenario 3 - Other Payer Amount Paid, Other Payer-Patient Responsibility Amount, and Benefit Stage Repetitions Present (Government Programs). (Note: For additional information on the scenarios, see Coordination Of Benefits/Other Payments Segment, in section Request Claim Billing/Claim Rebill Payer Sheet Template) Only one scenario method may be supported per template. The template shows the Coordination of Benefits/Other Payments Segment that must be used for each scenario method. The Payer must choose the appropriate scenario method with the segment chart, and delete the other scenario methods with their segment charts.

32 For Coordination of Benefits (COB) the following considerations and information should be provided in the payer sheets: 1. This Segment is always sent must be checked if the payer is always a secondary or supplemental plan. This Segment is situational must be checked if the payer is sometimes a secondary or supplemental plan. 2. The Billing/Reversal windows should be stated since COB billing occurs among different payers. 3. If there is a different Help Desk phone number related to COB inquiries, it should be given. If additional information is needed, see section Specific Segment Discussion, Request Segments, Coordination of Benefits/Other Payments Segment and section Standard Conventions, Repetition and ultiple Occurrences, Repeating Data Elements, Request Segments, Coordination of Benefits/Other Payments Segment of the NCPDP Telecommunication Standard Implementation Guide Version D.Ø for information important to processing coordination of benefits. Compounds In the NCPDP Telecommunication Standard Implementation Guide Version D.Ø there is only one way for the pharmacy to submit and the processor to adjudicate compound claims. Use the Compound Segment for multi-ingredient prescriptions The other options allowed in previous implementation guides which are no longer supported by the Standard Determine and submit the most expensive legend drug s NDC with the quantity of the dispensed product The use of billing codes or dummy NDC values Vaccine Administration For vaccine administration, edicare Part D should be handled the same way in version 5.1 and D.0. For all other payers - If the vaccine administration fee is part of the drug benefit cost, the edicare Part D-based Claim Billing method can be used. Information is found in the

33 Telecommunication Version 5 Questions, Answers and Editorial Updates document ( If the vaccine administration fee is not part of the drug benefit cost, the Claim Billing is used for the drug benefit cost, and the Service Billing is to be used to bill the administration fee. The payer sheet should designate which way supported if the vaccine administration is part of the drug benefit cost, the appropriate fields should be designated on the Claim Billing. If vaccine administration is not part of the drug benefit cost, the Service Billing payer sheet is to be provided. Field Legend This legend is used by the Payer to determine how to complete the Payer Template for the field designations. Telecommunication Implementation Guide Designation Implementation Guide Value Explanation Payer Sheet Value Payer Situation Defined ANDATORY The Field is mandatory for the Segment in the Transaction. andatory elements have structural requirements. SITUATIONAL The Field has been further designated as R or Q, as shown below. Required R The Field has been designated with the situation of "Required" for the Segment in the designated Transaction. R Qualified Requirement Q The situations designated have qualifications for usage ("Required if x", "Not RW (Required When). Yes for RW

34 Telecommunication Implementation Guide Designation Implementation Guide Value required if y"). Explanation Payer Sheet Value Payer Situation Defined If NA (Not Applicable by the Payer), do not list field. INFORATIONAL ONLY I The Field is for informational purposes only in the designated Transaction. RW (Required When). Yes for RW For response fields, if the payer supports the business usage, the informational field should be returned. If NA (Not Applicable by the Payer), do not list field. OPTIONAL O The Field has been designated as optional usage (situations were intentionally not defined). Limited usage. See requirements in NCPDP Telecommunication Standard Implementation Guide. RW (Required When). If NA (Not Applicable by the Payer), do not list field. Yes for RW NOT USED N The Field is not used for the Segment in the designated Transaction. If NA (Not Applicable by the Payer), do not list field. Not used are shaded for clarity.

35 Further explanation of this legend follows. andatory Fields Field Legend above: If a field is designated as (andatory) in the NCPDP Telecommunication Implementation Guide Version D.Ø, the only Payer Sheet Value is (andatory). The payer may not define a situation (column Defined = No). On the Payer Template: The Payer column is and the column is not filled out. The Value column of the template may contain instructional material. The template indicates the mandatory fields for each segment, as defined by the NCPDP Telecommunication Standard Implementation Guide Version D.Ø. These are the only fields that have the andatory designation on the template. Situational Fields - Required Field Legend above: If a field is designated as R (Required) in the NCPDP Telecommunication Implementation Guide Version D.Ø for this transaction, the only Payer Sheet Value is R (Required). The payer may not define a situation (column Defined = No), as the situation is Required. On the Payer Template: The Payer column is R and the column is not filled out. The Value column of the template may contain instructional material. Situational Fields Qualified Requirement Field Legend above: If a field is designated as Q (Qualified Requirement) in the NCPDP Telecommunication Implementation Guide Version D.Ø for this transaction, the field may be used according to the situations defined in the implementation guide, or not used. On the Payer Template: The only Payer Sheet Values is RW (Required When). If RW, then Defined = Yes and the column must contain guidance for the implementer based on the situation(s) allowed by the NCPDP Telecommunication Implementation Guide Version D.Ø for this transaction. The Value column of the template will contain instructional material.

36 If the field is not used, Payers must not include the field in the segment (the row in the table should be deleted). Payers are not allowed to list the field with an NA (Not Applicable by the Payer) designation. Informational Only Fields Field Legend above: Fields that are defined with situations of I (Informational Only) for this transaction in the NCPDP Telecommunication Standard Implementation Guide Version D.Ø, provide additional data related to the transaction. If the field is designated as I (Informational Only) for this transaction, the field may be used according to the situations defined in the implementation guide, or not used. On the Payer Template: The only Payer Sheet Values is RW (Required When). If RW, then Defined = Yes and the column must contain guidance for the implementer based on the situation(s) allowed by the NCPDP Telecommunication Implementation Guide Version D.Ø for this transaction. If the field is not used, Payers must not include the field in the segment (the row in the table should be deleted). Payers are not allowed to list the field with an NA (Not Applicable by the Payer) designation. For response fields, if the payer supports the business usage, the informational field should be returned. Optional Fields Field Legend above: Fields that are defined with situations of O (Optional) for this transaction in the NCPDP Telecommunication Standard Implementation Guide Version D.Ø are fields in limited environments. Please refer to the guide for more information on optional field usage. The field may be not used. On the Payer Template: The only Payer Sheet Values is RW (Required When). When the Payer column is RW (Required When), the column must contain guidance for the implementer. Optional fields are limited and usage between trading partners must be well defined. See the requirements in the NCPDP Telecommunication Standard Implementation Guide.