Point of Sale Pharmacy Billing Basics Christina Brady POS User Support Specialist Office of Information Technology CNI Technology - Contractor Albuquerque, New Mexico

Objectives POS Billing Process RPMS packages used with POS billing POS Tips Current patches Emdeon POS Master Format List

RPMS Packages Used with POS Patient Registration – Eligibility Information Third Party Billing – Enter/Edit insurers and group numbers Accounts Receivable (A/R) – Posting of Remittance Advice/Explanation of Benefit Outpatient Pharmacy Package – Enter prescription to process electronically

Patient Registration Patient Registration allows users to add, edit, view, delete, or print information related to their facility’s patient. Page 1 - Allows the viewing of the patient’s demographic information which is required when calling the processor/insurer. For POS purposes you will need the ability to view this page. Page 4 - Allows you to add/edit insurers that have been created in table maintenance of TPB to patient’s profile. For POS purposes you will need the ability to view/edit this page.

Third Party Billing The Table Maintenance Menu in TPB allows you to add/edit the Insurer File Menu and the Group Insurance Plans Menu Adding an insurer in table maintenance ABM – TMTP – INTM – EDIN – 2 Add New Insurer Enter the name of your new insurer Enter the mailing address and phone number of insurer Insurer Status – “BILLABLE” Type of Insurer – “PRIVATE” for commercial plans and “MD” for Medicare Part D plans RX Billing Status – “P” to bill POS, “U” to make unbillable, and “O” for outpatient drugs only

Third Party Billing Cont. Add/Edit a group number in table maintenance ABM – TMTP – GRTM – EDGR Enter group name Do Group Numbers vary – Leave as default of “NO” Enter Group Number located on card (recommendation to have the group name and number the same) Example: Group Name: XYZ-RX Group Number: XYZ-RX (the group number is what crosses over on the claim not the group name)

Accounts Receivable (A/R) Payable POS claims and reversals will create a charge automatically in the A/R package through the POS interface to Third Party Billing. Charges are automatically posted to A/R when: An electronic claim transaction completes The insurer indicates that the claim is payable The insurer indicates that the claim has been “Captured” Charges that are not automatically posted to A/R are: Charges for patients without insurance Charges for patients with insurance, but the insurance can’t be billed electronically Charges for patients with insurance, but the drug is unbillable Unsuccessful electronic claims (rejected by the insurance)

Outpatient Pharmacy Package Enter prescription details under patient’s pharmacy profile Print prescription label to screen or to label printer to start the process of sending the claim to the insurer Maintain/Update the drug file on a monthly basis

Pharmacy Tips When entering a NEW prescription, a REFILL, or RENEWING a prescription, a “call to bill the claim” is made to the POS package when the label is printed. The reprinting of a label (REPRINT AN OUTPATIENT LABEL) does not affect the POS software. CANCELLING a prescription is used when a patient has a drug discontinued for some reason or if the prescription is replaced by another drug of a different dosage or strength. If a prescription is canceled NO call is made to the POS software because the patient received the prescription.

Pharmacy Tips To DELETE a prescription means the prescription is to be marked as not given to this patient. It is used when a prescription was given to a patient by mistake and caught before the patient got it. Using this option causes the POS software to automatically reverse the claim. RETURN MEDICATION TO STOCK option is to be used when a patient does not pick up a prescription. This process will automatically make a call to the POS to reverse the claim. You cannot dispense a 90 day supply for a 30. The dispensed amount is to equal the billed amount.

Tips for Contacting the Help Desk Research the claim first it will save time for you and the Help Desk if all the information required to solve the problem is available during the call Have the pharmacy’s NCPDP or NPI number available. This is normally the first question they ask The insurer recognizes claims by the internal rx number the one with the ` sign prior to the number displayed on the rejection report or at the end of the claim on the POS user screen

Design a Process for Working Rejections Review rejection report daily Run URM (POS / RPT / CLA / URM) to clear rejections from report before and after working rejections or running reports If time is limited, focus on high cost drugs To maximize collections, involve pharmacists. The business office and the pharmacy at each facility should decide on a plan of action to optimize the amount of collections received from the rejected claims. This is a joint effort and will take involvement from both departments as well as IT.

Current Patch Information Patient Registration – Version 7.1 patch 3 released nationally 4/17/2007 Third Party Billing – Version 2.5 patch 15 released nationally 9/25/2008 Accounts Receivable – Version 1.8 patch 7 released nationally 9/26/2008 Outpatient Pharmacy – Version 7.0 patch 6 released nationally 6/25/2008 Point of Sale – Version 1.0 patch 27 released nationally 9/8/2008

Master Format List Nationally used list for all POS Formats List updated with each patch and sent out on the POS Listserv Verify bin/pcn combination on master format list to determine the POS Format Name Sorting Excel sheet by bin, pcn, or format name makes it easier to locate correct plan Pay attention to comments when selecting a plan

Emdeon When to use Emdeon? After viewing the Master Format List and not able to find the bin/pcn combination that you need. Log into website and enter bin or pcn to identify plan needed Copy and paste plan into an email and send to support@ihs.gov requesting a new format be added to the Master Format Sheet Login: indianhealth Password: admin280

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