Pharmacy Point of Sale Version D.0 Patch 42

Training Objectives Review Patch 42 changes Review Advance Setup of Insurer (ADV) option New security key for ADV option How to add a new insurer using Quick Setup of Insurer (INS) Review Summary of Insurers (SUMI) Report How to change Insurers to D.0 The format file (ABSP NCPDP FORMAT)will no longer be used going forward. When Patch 42 is installed, a post-install program will move the site's format information into the Insurer file automatically. The end user should not have to do anything to continue with billing after the install, the same information will be sent to Emdeon after Patch 42 is installed. The benefit is the sites can now add Insurers any time they need to, without having to wait for a new patch with new formats. Users now have the ability to change versions from 5.1 to D.0 We have created new functionality when you add a new POS insurer. The user has the ability to enter (BIN, PCN, Version,..) and the system will default the rest of the fields depending on the Insurer type(MCARE,MCAID or Commercial). Most of the time you should not have to make any modifications to the default information. Even if you do, it's something that can be done at the site without needing a new release. Defaulted Fields include: MEDICARE PARTD?: N// Maximum RX's Per Claim: 4// Add Disp. Fee to Ingr. Cost: NO// Total exclusive of Patient Amt: N// Select NCPDP FIELD SPECIAL CODE: Select SUPPRESS NCPDP SEGMENT: INSURER NPI FLAG: BOTH RX - DIAL OUT TO: ENVOY DIRECT VIA T1 LINE RX - PRICING METHOD: STANDARD RX PRIORITY Points We have locked down the ADV INSURER menu option with a new security key so not anyone can change the data.  It is recommended that the key be allocated to a supervisor or super user for point of sale. Its recommended to use the Quick Setup of Insurer (INS) to set up a new insurer. The SUMI report was modified to now display the payers that are set up in 5.1 and D.0 The Medicare Part D Eligibility Check report was modified to now be sent in D.0 format

Introduction The major help desk request for Pharmacy Point of Sale was the need for a new format or a modification to the format.  Often times a delay in the release of a patch with these changes would takes months and this would result in loss in revenue for many sites.   In patch 42, we have done away with formats and have provided direct access to the user to make changes to BIN, PCN and NCPDP segments immediately.  Once patch 42 is installed, the format layout will be moved to the ABSP insurer file.  All insurers currently setup at each site will run a background conversion and user should not have to make any changes to the current layout. Also included in patch 42 is the NCPDP version D.0 which goes into effect January 1, 2012. We have tested many top insurers such as Argus, Medco and Caremark among others. Users will have to change the version to D.0 for insurers that are ready to accept claims and for those insurers D.0 testing has been completed.

What is D.0? Version D.0 is the new version of the National Council for Prescription Drug programs (NCPDP) standards for pharmacy transactions that replaces version 5.1. The mandatory compliance date for Version D.0 is January 1, 2012.

Highlights of Patch 42 NCPDP version D.0 No more formats to link to insurers Advance Insurer setup option allows edits by user Quick and Advance Insurer setup creates a default layout based on insurer type New security key for ADV option SUMI report sorts by 5.1 and D.0 version

Advance Setup of Insurer - ADV User input needed for the following fields: NCPDP VERSION: D.0// BIN NUMBER: 610100// PCN NUMBER: MEDDPRIME// RX - Dispensing Fee: GRACE PERIOD: 0// RX - Help Telephone #: (888)888-8888// Default set for the following fields: Add Disp. Fee to Ingr. Cost: NO// *Contract Required: NO// Total exclusive of Patient Amt: N// INSURER NPI FLAG: BOTH// RX - DIAL OUT TO: ENVOY DIRECT VIA T1 LINE// RX - PRICING METHOD: STANDARD//

Default for type of insurer MEDICARE MEDICAID PRIVATE MEDICARE PARTD?: Y// MEDICARE PARTD?: N// Maximum RX's Per Claim: 1// Maximum RX's Per Claim: 4// RX PRIORITY: 650// RX PRIORITY: 5// RX PRIORITY: 20// NCPDP FIELD SPECIAL CODE: 304, 436, 455 436, 455 SUPPRESS NCPDP FIELD: 115, 147, 334, 350, 354, 357, 359, 360, 361, 364, 365, 366, 367, 368, 384, 391, 420, 458, 459, 494, 495, 496, 497, 498, 499, 524, 995, 996, 997

ADV – Security Key ABSPZ INSURER NOTE: With more control, there is also concern for problems for unnecessary changes to insurer setup. A security key (ABSPZ INSURER) has been assigned to the ADV option. It is recommended the security key be allocated only to a supervisor or super user of Point of Sale. Please see your local IT person to have this key assigned to you.

Quick Setup of Insurer - INS POS - Pharmacy Point of Sale  MGR - Pharmacy POS Manager Menu  SET - Pharmacy Point of Sale Setup Menu  INS - Edit Pharmacy POS Insurance settings  INS - Quick setup of insurer Are you adding 'D-ARGUS' as a new ABSP INSURER (the 190TH)? No// Y (Yes) NCPDP VERSION: D.0 BIN NUMBER: 123456 PCN NUMBER: TEST123 MEDICARE PARTD?: Y// Maximum RX's Per Claim: 1// Select the PRICING METHOD RX - PRICING METHOD: STANDARD// NOTE: It is recommended to use this option when setting up a new insurer before any changes are made in the Advanced Insurer Setup Option

Adding A New Insurer REG - Patient registration  TM - Table Maintenance Menu INS - Insurer File Menu  EINS - Add/Edit an Insurer NAME: D-ARGUS// TYPE OF INSURER: PRIVATE// ?? Choose from: D MEDICAID FI P PRIVATE MD MCR PART D TYPE OF INSURER: PRIVATE// MD MCR PART D LONG NAME: D-ARGUS// STREET: P.O. BOX 298 CITY: TROY STATE: NEW YORK// ZIP: 12181// PHONE: (888)888-8881

Summary of Insurers – SUMI POS - Pharmacy Point of Sale  MGR - Pharmacy POS Manager Menu  SET - Pharmacy Point of Sale Setup Menu  SUMI - POS Setup - Summary of Insurers PHARMACY ELECTRONIC CLAIMS INSURERS NOV 17,2011 16:51 PAGE 1 Grace Ins. Disp Fee Per Sel. Insurer Pricing Formula Override Override Pts. -------------------------------------------------------------------------------- ----- Using NCPDP VERSION: 5.1 BIN: 123456 NPI FLAG: BOTH D-RX AMERICA STANDARD 4.50 0 650.00 BIN: 600428 GROUP HEALTH RX STANDARD 4.50 0 20.00 WESTERN RX STANDARD 4.50 0 20.00 LOVELACE SALUD RX STANDARD 4.50 0 5.00 NPI FLAG: EMPTY ----- Using NCPDP VERSION: D.0 BIN: 123221 CXX PRIVATE D.O STANDARD 20.00 BIN: 123321 XYZ MEDICAID D.0 STANDARD 5.00

D.0 checklist 1. Run Fileman Report of all insurers/BIN/PCN 2. Completed D.0 testing payer list 3. Print list of NCPDP fields 4. Caremark, Medco, Argus setup examples 5. Common rejections 6. Suppress/un-suppress NCPDP fields

Fileman Report List of Insurers that are associated with formats OUTPUT FROM WHAT FILE: ABSP INSURER// SORT BY: NUMBER// RX - NCPDP Record Format  START WITH RX - NCPDP Record Format: FIRST// WITHIN RX - NCPDP Record Format, SORT BY: FIRST PRINT FIELD: NAME;C1;L30;""  THEN PRINT FIELD: "^";C31;L1 THEN PRINT FIELD: RX - NCPDP Record Format;C32;L30;"" THEN PRINT FIELD: RX - NCPDP Record Format:    <- DO NOT FORGET TO USE A COLON TO WALK OVER TO FORMAT FILE THEN PRINT ABSP NCPDP FORMATS FIELD: "^";C62;L1   THEN PRINT ABSP NCPDP FORMATS FIELD: NDC BIN Number;C63;L15;""   THEN PRINT ABSP NCPDP FORMATS FIELD: "^";C78;L1   THEN PRINT ABSP NCPDP FORMATS FIELD: Processor Control Number;C79;L20;''     THEN PRINT ABSP NCPDP FORMATS FIELD: THEN PRINT FIELD:  Heading (S/C):// STORE PRINT LOGIC IN TEMPLATE: DEVICE: ;132;5000  

File Man Report - Example ABSP INSURER LIST DEC 15,2011 11:13 PAGE 1 Processor Control Number ------------------------------------------------------------------------------------------------ RX NC SENIOR CARE PROGRAM ^ACS NC SENIOR CARE 5.1 ^610084 ^ RX D-SILVERSCRIPT ^ADV RX MGT MEDICARE PDP 5.1 ^004336 ^ADV HDN RX ADVANCE RX ^ADVANCE PRSCPT MGMT ADV 5.1 ^004336 ^ADV HDN D-SILVER SCRIPT ^ADVANCE PRSCPT MGMT ADV 5.1 ^004336 ^ADV HDN RX AETNA US PHARMACY ^AETNA 5.1 ^610502 ^670000 RX ANTHEM ^ALASKA NATIVE TRIBAL HLTH 5.1 ^004336 ^WISRX MAILHANDLERS ^ALTA RX 5.1 ^002286 ^6000002286 ALTA RX ^ALTA RX 5.1 ^002286 ^6000002286 PHARMANET RX ^ALTA RX 5.1 ^002286 ^6000002286 RX AMERICAN HEALTH CARE ^AMERICAN HEALTH CARE 5.1 ^610118 ^AHC TQC RX D-CMS DUAL ^ANTHEM 5.1 ^610575 ^ RX AMERIHEALTH MERCY ^ARGUS REGENCE BCBS WA 5.1 ^600428 ^ ARGUS RX ^ARGUS REGENCE BCBS WA 5.1 ^600428 ^ D-BC/BS OF NORTH DAKOTA ^BC/BS NORTH DAKOTA 5.1 ^610455 ^NDBCS RX BLUESCRIPT ^BLUESCRIPT BCBS ILLINOIS 5.1 ^011552 ^ILSC MEDICAID-TEST ^CALIFORNIA MED-CAL 5.1 ^610442 ^NONE RX CAREFIRST ^CAREFIRST BCBS 5.1 ^011834 ^03000000 CAREMARK D.0 447225 ^CAREMARK 5.1 ^610029 ^CRK RX D-ADVANTRA RX ^CAREMARK 5.1 ^610029 ^CRK HAMMERMILL HEALTH ^CAREMARK 5.1 ^610029 ^CRK

D.0 Payer Implementation List ftp://ftp.ihs.gov/rpms/POS/

Argus Payer Tab

List of NCPDP fields NCPDP FIELD NUMBER NCPDP FIELD NAME POS-Pharmacy Point of Sale  RPT-Pharmacy electronic claims reports  OTH-Other reports FLD-List NCPDP Fields NCPDP FIELD NUMBER NCPDP FIELD NAME -------------------------------------------------------------------------------- 101 BIN NUMBER 102 VERSION/RELEASE NUMBER 103 TRANSACTION CODE 104 PROCESSOR CONTROL NUMBER 109 Transaction Count 110 Software Vendor/Cert ID 111 Segment Identification 112 Transaction Response Status 113 MEDICAID PAID AMOUNT 114 MEDICAID SUBROGATION ICN 115 MEDICAID ID NUMBER 116 MEDICAID AGENCY NUMBER 117 BILLING ENTITY TYPE IND 118 PAY TO QUALIFIER

Caremark D.0 setup Select Edit Pharmacy POS Insurance settings Option: ADV Advanced setup of insurer Select ABSP INSURER NAME: CAREMARK( CAREMARK ).... NAME: RX D-CAREMARK// NCPDP VERSION: 5.1// D.0 BIN NUMBER: 610029// PCN NUMBER: CRK// Select NCPDP FIELD SPECIAL CODE: 455// 110 Software Vendor/Cert ID SPECIAL CODE: S ABSP("X")=“D012000084"

Argus D.0 Setup Select Edit Pharmacy POS Insurance settings Option: ADV Advanced setup of insurer Select ABSP INSURER NAME: ARGUS( ARGUS )... NAME: ARGUS RX// NCPDP VERSION: 5.1// D.0 BIN NUMBER: 600428// PCN NUMBER: 03020000 Select NCPDP FIELD SPECIAL CODE: 455// 110 Software Vendor/Cert ID SPECIAL CODE: S ABSP("X")="601DN30Y"

Medco D.0 Setup Select Edit Pharmacy POS Insurance settings Option: adv Advanced setup of insurer Select ABSP INSURER NAME: medco( MEDCO/MEDCOST )...... NAME: MEDCO RX// NCPDP VERSION: 5.1// D.0 BIN NUMBER: 003585// PCN NUMBER: 49110// Select NCPDP FIELD SPECIAL CODE: 455// 110 Software Vendor/Cert ID SPECIAL CODE: S ABSP("X")="INF"

Correcting Rejections Correcting the top 5 rejections M/I Gross Amount Due Unsuppress Field 430 Value In Gross Amount Due Does Not Follow Pricing Formulary Unsuppress field 412 M/I Patient Last Name Unsuppress field 311                                          M/I Cardholder ID Unsuppress field 313 Express Scripts – Tricare Group Number change from TRRX to DODA

Example Rejection - - Prescription - - Authorization Number: 113145297006024999 Medication Order: 1 Prescription/Service Ref Num: 815214 Prescription/Srvc Ref Num Qual: 1 Prior Auth Processed Date: NOV 10,2011 Reject code: 20 M/I Cardholder Last Name Reject Count:1 Response Status (Prescription): R Transaction Response Status: REJECTED CLAIM

Definitions Suppressed vs. Unsuppressed Suppressed – The NCPDP field is not going across on the claim Unsuppressed – The NCPDP field will cross over on the claim

Unsuppress NCPDP Fields Select SUPPRESS NCPDP SEGMENT: Narrative// Select SUPPRESS NCPDP FIELD: 997// 313 CARDHOLDER LAST NAME ...OK? Yes// Y (Yes) SUPPRESS NCPDP FIELD: 313// @ SURE YOU WANT TO DELETE THE ENTIRE SUPPRESS NCPDP FIELD? Y (Yes) Select SUPPRESS NCPDP FIELD: Note: Anytime a field is unsuppressed use the option NEW to resubmit your claim

Enter/Edit RPMS Insurance File Rx Settings POS - Pharmacy Point of Sale  MGR - Pharmacy POS Manager Menu  SET - Pharmacy Point of Sale Setup Menu  INS - Edit Pharmacy POS Insurance settings  RPMS - Enter/edit RPMS Insurance file RX settings Select INSURER NAME: D-ARGUS NEW YORK 12181 ...OK? Yes// Yes RX BILLING STATUS: ?? These codes identify how to process pharmacy charges for a payer. Code "U" means drugs are not billable. Code "O" means only outpatient drugs are billable. Code "P" means the drugs are billable through Point Of Sale. Choose from: U UNBILLABLE O OUTPATIENT DRUGS ONLY P BILLED POINT OF SALE RX BILLING STATUS: BILLED POINT OF SALE

Three Tiered Support Structure Phone: 888-830-7280 Help Desk Area IT Support Local Support E-mail: support@ihs.gov “Currently there is a 3 tiered RPMS support structure. Local support. Usually the Site Manager. Area IT support. Usually area help desk. IHS RPMS Help desk. Which support should you be going to first? Answer: Local Support.

Questions What if… How do you do this… Can you explain … I don’t Understand… Why this happening? Help!!