2217
Plaza
Drive,
Rocklin,
CA
95765
Office 1‐800‐872‐8276 • Fax 1‐877‐579‐4701 • [email protected]
2013
Pharmacy
Manual
www.americanhealthcare.com
memberservices@americanhealthcare.com Office: 1-800-872-8276
3850
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Road,
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Table of Contents
Section 1
Claim Submission
Section
2 Audit
Section
3
Product
Selection
Section
4
Dispensing
Limitations
Section
5
Miscellaneous
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Pharmacy Manual
This American Health Care Provider Manual is designed to answer your questions
regarding online claim submission for American Health Care. The Provider Manual 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
1-877-633-4701
For claims and online transaction response please call our Help Desk, representatives are
available to assist Monday through Friday from 5:00 AM to 9:00 PM PST and Saturday
8:30 AM to 5:00 PM PST:
American Health Care Member Services
1-800-872-8276
It is important to always refer to the Provider Web Portal at
www.American 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, 95675
American Health Care (Catamaran) IDENTIFICATION CARDS/BANK
IDENTIFICATION NUMBERS (RxBINs):
610118
014872
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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.
•
Member 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.
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•
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
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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.
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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, wholesaler-
manufacturer- 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 Manual and the Agreement,
the Provider Manual prevails.
American Health Care may report audit findings to its Clients, appropriate governmental
entities, regulatory agencies, and professional review and audit organizations.
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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 email 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:
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•
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.
•
Miscellaneous 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,
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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
CMS 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
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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).
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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 - MEMBER REQUESTED
Valid Person Codes
001= Cardholder
002= Spouse
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PSC 3 - PHARMACIST 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 MANDATED 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.
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•
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.
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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.
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Miscellaneous
•
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.
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Summary of Audit Discrepancies
Discrepancy Type
Recovery Amount
Documentation
Allowed Y/N)
Missing Prescription
Full Recovery
Yes
Unauthorized
Refill
Full
Recovery
No
Quantity/Day Supply Discrepancy
Partial Recovery
No
Missing Signature from Signature Log Full Recovery
Yes
Miss Fill Discrepancy
Up to Full Recovery
No
Invalid
Prescription
Full
Recovery
No
PSC
Discrepancy
Partial
Recovery
No
Other/Miscellaneous
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
1-866-532-0657 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
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•
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
www.catamaranrx.com
or
www.American 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
Member 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
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Materials Reproduced With the Consent of ©National Council for Prescription Drug Programs, Inc.
2Ø1Ø NCPDP”
I
MPLEMENTATIONG
UIDE FORV
ERSIOND.Ø
1.
GENERAL INFORMATION FOR A PAYER ABOUT THE TEMPLATES
23
1.1
COPYRIGHT INFORMATION
23
1.2
EXTERNAL CODE LIST
23
2.
GENERAL INSTRUCTIONS TO PAYERS
24
2.1
HOW TO USE THIS DOCUMENT
24
2.2 TRANSMISSIONS
24
2.3 PLAN
DIFFERENTIATION
24
2.4 SEGMENTS
27
2.4.1
Mandatory Segments
27
2.4.2
Situational Segments
27
2.4.3
Optional Segments
28
2.5
FIELDS OR VALUES
28
2.5.1
Situations on Fields
28
2.5.2
Counts and Counters
30
2.5.3
Zero (0) and an “O”
30
2.6
SPECIFIC TOPIC DISCUSSION
31
2.6.1
Partial Fill Transaction Processing
31
2.6.2
Coordination of benefits (COB) Processing
31
2.6.3
Compounds
32
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2.7 FIELD
LEGEND
33
2.8 MANDATORY
FILED
35
2.9
SITUATIONAL FIELDS - REQUIRED
35
2.10
SITUATIONAL FEILEDS – QUALIFIED REQUIREMENT
35
2.11 INFORMATIONAL
ONLY
FIELDS
36
2.12 OPTIONAL
FIELDS
36
2.13
NOT USED FIELDS
36
3.
NCPDP VERSION D CLAIM BILLING/CLAIM REBILL
INSTRUCTIONS
37
3.1 GENERAL
INFORMATION
37
3.2 REQUEST
TEMPLATE
INFORMATION
37
3.3
RESPONSE TEMPLATE INFORMATION
37
3.4
CERTIFICATION AND/OR TEST DATA
38
4.
NCPDP VERSION D CLAIM BILLING/CLAIM REBILL TEMPLATE
38
4.1 REQUEST
CLAIM
BILLING/CLAIM REBILL PAYER SHEET TEMPLATE
40
4.2
RESPONSE CLAIM BILLING/CLAIM REBILL PAYER SHEET TEMPLATE
114
4.2.1
Claim Billing/Claim Rebill Accepted/Paid (or Duplicate of Paid) Response
115
4.2.2
Claim Billing/Claim Rebill Accepted/Rejected Response
155
4.2.3
Claim Billing/Claim Rebill Rejected /Rejected Response
177
5.
NCPDP VERSION D CLAIM REVERSAL INSTRUCTIONS
183
5.1
GENERAL INFORMATION
183
5.2 REQUEST
TEMPLATE
INFORMATION
183
5.3
RESPONSE TEMPLATE INFORMATION
183
6.
NCPDP VERSION D CLAIM REVERSAL TEMPLATE
184
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6.2
RESPONSE CLAIM REVERSAL PAYER SHEET TEMPLATE
186
6.2.1
Claim Reversal Accepted/Approved Response
192
6.2.2
Claim Reversal Accepted/Rejected Response
198
6.2.3
Claim Reversal Rejected/Rejected Response
206
7.
EXAMPLES OF PAYER TEMPLATES
211
8.
EXAMPLE 1 – HEALTH PLAN OF AMERICA PAYER SHEET
211
8.1.1
Claim Billing/Claim Rebill
212
8.1.1.1 CLAIM BILLING/CLAIM REBILL REQUEST
212
8.1.1.2
CLAIM BILLING/CLAIM REBILL ACCEPTED/PAID (OR DUPLICATE OF
PAID) RESPONSE
212
8.1.1.3 CLAIM BILLING/CLAIM REBILL ACCEPTED/REJECTED RESPONSE
212
8.1.1.4 CLAIM BILLING/CLAIM REBILL REJECTED/REJECTED RESPONSE
213
8.1.2
Claim Reversal
213
8.1.2.1 CLAIM REVERSAL REQUESTED
213
8.1.2.2 CLAIM REVERSAL ACCEPTED/APPROVED RESPONSE
213
8.1.2.3 CLAIM REVERSAL ACCEPTED/REJECTED RESPONSE
213
8.1.2.4 CLAIM REVERSAL REJECTED/REJECTED RESPONSE
213
9.
EXAMPLE 2 – HEALTH SERVICE OF AMERICA PAYER SHEET -
SERVICE
214
9.1.1
Service Billing/Service Rebill
214
9.1.1.1 SERVICE BILLING/SERVICE REBILL REQUEST
214
9.1.1.2
SERVICE BILLING/SERVICE REBILL ACCEPTED/PAID (OR DUPLICATE
OF PAID) RESPONSE
214
9.1.1.3 SERVICE
BILLING/SERVICE
REBILL
ACCEPTED/REJECTED RESPONSE
214
9.1.1.4 SERVICE
BILLING/SERVICE
REBILL
REJECTED/REJECTED RESPONSE
214
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10.1.1
Workers’ Compensation Claim Billing
215
10.1.1.2
WORKERS’ COMPENSATION CLAIM BILLING ACCEPTED/PAID (OR
DUPLICATE OF PAID) RESPONSE
215
10.1.1.3
WORKERS’ COMPENSATION CLAIM BILLING ACCEPTED/REJECTED
RESPONSE 215
10.1.1.4
WORKERS’ COMPENSATION CALIM BILLING REJECTED/REJECTED
RESPONSE 215
10.1.2
Workers’ Compensation Claim Reversal
216
10.1.2.1 WORKERS’
COMPENSATION
CLAIM REVERSAL REQUEST
216
10.1.2.2
WORKERS’ COMPENSATION CLAIM REVERSAL
ACCEPTED/APPROVED RESPONSE
216
10.1.2.3
WORKERS’ COMPENSATION CLAIM REVERSAL
ACCEPTED/REJECTED RESPONSE
216
10.1.2.4
WORKERS’ COMPENSATION CLAIM REVERSAL
REJECTED/REJECTED RESPONSE
216
10.1.3
Non-Workers’ Compensation Claim
217
10.1.3.1 NON-WORKERS’ COMPENSATION CLAIM REQUEST
217
10.1.3.2
NON-WORKERS’ COMPENSATION CLAIM BILLING ACCEPTED/PAID
(OR DUPLICATE OF PAID) RESPONSE
234
10.1.3.3
NON-WORKERS’ COMPENSATION CLAIM BILLING
ACCEPTED/REJECTED RESPONSE
254
10.1.3.4
NON-WORKERS’ COMPENSATION CLAIM BILLING
REJECTED/REJECTED RESPONSE
269
10.1.4
Non-Workers’ Compensation Claim Reversal
274
10.1.4.1 NON-WORKERS’ COMPENSATION CLAIM REVERSAL REQUEST
274
10.1.4.2
NON-WORKERS’ COMPENSATION CLAIM REVERSAL
ACCEPTED/APPROVED RESPONSE
280
10.1.4.3
NON-WORKERS’ COMPENSATION CLAIM REVERSAL
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10.1.4.4
NON-WORKERS’ COMPENSATION CLAIM REVERSAL
REJECTED/REJECTED RESPONSE
291
11.
EXAMPLE 4 – AMERICAN PROCESSOR INC PAYER SHEET –
MULTIPLE PLANS
294
11.1.1
Claim Billing/Claim Rebill
294
11.1.1.1 CLAIM BILLING/CLAIM REBILL REQUEST
294
12. FREQUENTLY
ASKED
QUESTIONS
297
12.1
USE OF RED FONT
297
12.2 FONT
SIZE
297
13.
APPENDIX A. HISTORY OF IMPLETMENTATION GUIDE CHANGES
298
13.1 EDITORIAL
CORRECTIONS
298
13.2
VERSION 1.1 CORRECTIONS
298
13.3 VERSION
1.2
298
13.4 VERSION
1.3
298
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GENERAL INFORMATION FOR A PAYER ABOUT THE TEMPLATES
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 (
www.ncpdp.org
).
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.
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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 Segment Identification (112-AM) 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
•
Mixing 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)
•
Mixing plans where one or more use the Workers’ Compensation Segment while others
do not
•
Mixing 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
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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
223346 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.
223346 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)
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Scenario
Examples
BIN PCN Different
Payer Templates Required?
Comment
The payer supports coupons claims and non-coupon claims under the same BIN.
44356 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)
The payer supports claim and service billings under the same BIN.
112234 Has no impact Yes Two Payer Templates must be used to avoid confusion in segments used for claim billing versus service billing. The payer supports
a plan that may be primary or
supplemental
662211 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
445511 887766
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
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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
Mandatory 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, Payer Situation” column.
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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, Payer Situation” 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 Payer Situation 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
Usage
Payer Situation
414-DE
DATE PRESCRIPTION TTEN
R
354-NX
SUBMISSION
CLARIFICATION CODE COUNT
Maximum count of 3.
RW Imp Guide: Required if Submission
Clarification Code (42Ø-DK) is used.
Payer Requirement: Same as Imp
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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
Usage
Payer Situation
31Ø-
PATIEN
RST
ME
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.
Field # NCPDP Field Name
Value
Payer
Usage
Payer Situation
458-SE PROCEDURE
MODIFIER CODE
COUNT
Maximum count of
1Ø.
Imp Guide: Required if
Procedure Modifier Code
(459-ER) is used.
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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.
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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 Multiple 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, Medicare 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
Medicare Part D-based Claim Billing method can be used. Information is found in the
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Telecommunication Version 5 Questions, Answers and Editorial Updates document
(
http://www.ncpdp.org/public_documents.aspx#v5ed
).
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
MANDATORY M The Field is mandatory for
the Segment in the Transaction.
Mandatory elements have structural requirements.
M
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).
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Telecommunication Implementation Guide Designation Implementation Guide Value
Explanation Payer Sheet Value Payer
Situation Defined required if y").
If NA (Not Applicable by the Payer), do not list field.
INFORMATIONAL ONLY
I The Field is for
informational purposes only in the designated
Transaction.
For response fields, if the payer supports the business usage, the informational field should be returned.
RW (Required When).
If NA (Not Applicable by the Payer), do not list field.
Yes for RW
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.
Not used are shaded for clarity.
If NA (Not Applicable by the Payer), do not list field.
