RPMS POS – Working Rejections

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Presentation transcript:

RPMS POS – Working Rejections Christina Harris Pharmacy Biller Claremore Comprehensive Health Center April 2006

Topics to Cover RPMS POS Update POS and Medicare Part D NPI Update Understanding Rejections and how to correct them

Key Components to Using RPMS POS Coordinated effort: Business Office, IT, Pharmacy Best – “hire or assign pharmacy biller” Having the necessary menus/keys Network participating agreements Staying current with software patches Drug file clean-up Patient registration

POS Update Over 130 sites using RPMS POS POS v1 patch 16 POS v1 patch 16 works with Patient Registration v7.1 patch 1 Medicare Part D report that provides total $ and Rx count over a selected time period Includes BIN numbers on SUMI report (report that shows which insurers are sending claims electronically via POS) FTP site has resources for using POS (including this presentation) ftp://ftp.ihs.gov/rpms/POS/ NPI – facilities are responsible for obtaining NPI for providers (including pharmacists). NCPDP is only obtaining NPI for pharmacies.

ftp://ftp.ihs.gov/rpms/POS/

Medicare Part D - Order of what needs to be done: 1. Verify patches have been installed (Patient Reg v7.1, patch 1 and POS v1 patch 16) 2. Enter Insurers (use recommended naming convention) 3. Tie POS format to appropriate Insurer 4. Enter patient with Medicare Part D in Patient Registration Determine duel-eligible members Run E1 to determine plan name 4. Backbill 90+ days

Medicare Part D - KEY HANDOUTS ON FTP SITE General Instructions for Billing Medicare Part D Using RPMS POS Patient Registration Instructions (Addendum) for patch 1 – PDF file POS Formats SORT BY PLAN POS Medicare Part D Formats – SORTED BY BIN Setting up POS Format – Medicare Part D

Medicare Part D – Helpful Suggestions Use Plan Names as Insurer Names Eg. D-Silverscript versus Caremark Do NOT enter Person Code on page 4 of Patient Registration ALWAYS tie a Medicare Part D format to the insurer. Medicare Part D formats have been altered to send 1 claim for each transaction, as required. Commercial formats send 4 claims at a time. POS Medicare Part D report only works if the Medicare Part D formats are used.

Medicare Part D – Helpful Suggestions ALWAYS add Priority Points – recommend at least 605; 650 preferred. To verify Part D plans are set up correctly: Send a copy of SUMI report (POS / RPT / SET / SUMI) to OIT help desk at support@ihs.gov It will be reviewed and feedback will be provided. Use the E1 – a good tool verify what plan the patient is enrolled in. E1 is more accurate now than it was early on in the process.

Eligibility (E1) Transaction POS / RPT / ELIG On: FEB 07, 2006@15:19:40 Patient Name: Status: A Authorization #: Insurance Level: PRIMARY BIN: 007382 PCN: SHS GROUP: 0001 CARDHOLDER ID: 123456789 PERSON CODE: 1 PHONE NUMBER: 8001234567 The plan name can be determined by using one of the Excel spreadsheets on the ftp site.

National Provider Identifier (NPI) NCPDP will be providing enumeration for Pharmacy NPI. Taxonomy assigned to: Pharmacy – Indian Health Service/Tribal/Urban: 332800000X Plan to start testing in the fall of 2006

Rejection Codes Rejection codes are NCPDP standard codes used by processors. Complete list of rejection codes is located on the ftp site (NCPDP folder) M/I = Means Missing/Invalid All the rejection codes can by found on the ftp site Not all processors use rejections codes the same; Some may use M/I Group Number and others would use M/I Cardholder ID.

Common Rejections and how to Correct Them Review rejection report and what information it has on it. Recommend using RECEIPT for claim if planning to call pharmacy help desk.

Helpful Reports Reports to run on a daily basis include: REJ- which includes all of the rejections. It is good to run this report everyday to stay current with your rejections and prevent a rejection for claim too old. URM- Once you are finished working on your rejections it is imperative to run the urm to update the dollar figures in your day/ins reports. When working on these reports it is helpful to coordinate between the business office and the pharmacy.

POS Rejection Report (POS / RPT / CLA / REJ) ******************************************** * PHARMACY POINT OF SALE V1.0 * * * * Pharmacy electronic claims reports * CLA Claim results and status ... SET Setup (Configuration) reports ... SURV Surveys of RPMS database ... ELIG Eligibility Transaction OTH Other reports ...

REJ - Rejected claims report POS REJECTED claims for prescriptions RELEASED on FEB 9,2001 02/10@04:06 SAN FELIPE NCPDP (NABP) #3209219 Medicaid #B3713 MEDICAID EXEMPT Help Desk:(505)246-9988 opt 3 opt 1 Trans. Date/Time Claim ID Presc/Fill NDC Number Cardholder ID Group Number Qty $billed **** DUCK,RONALD FEB 9,2001 11:22 P01-610084-104611 `947794/0 51111048893 525340572 24 4.11 ACETAMINOPHEN 325 MG TAB 70:NDC NOT COVERED Page break by pharmacy division and insurer Help desk number is shown First thing help desk asks for is usually NABP # and/or Medicaid # And the next thing they ask for is Rx # (again, the INTERNAL number) And then they ask for the cardholder #

REJ - Rejected claims report POS REJECTED claims for prescriptions RELEASED on FEB 9,2001 02/10@04:06 SAN FELIPE NCPDP (NABP) #3209219 Medicaid #B3713 MEDICAID EXEMPT Help Desk:(505)246-9988 opt 3 opt 1 Trans. Date/Time Claim ID Presc/Fill NDC Number Cardholder ID Group Number Qty $billed **** DUCK,RONALD FEB 9,2001 11:22 P01-610084-104611 `947794/0 51111048893 525340572 24 4.11 ACETAMINOPHEN 325 MG TAB 70:NDC NOT COVERED Sorted by patient - and most expensive prescriptions are shown first within patient Shows basic information about the Rx (Help Desk has no concept of the “Claim ID”) Message & rejection reasons as sent by the insurer When a claim is resubmitted and paid, it no longer appears on the report AFTER the URM is run.

Rejection codes – Header Segment Ø1 M/I Bin Ø2 M/I Version Number Ø3 M/I Transaction Code Ø4 M/I Processor Control Number Problem: the wrong format is being used. To correct: contact the insurer to determine the correct BIN/PCN. Use the POS Format Master List on ftp site or Emdeon web site.

Rejection Code – Patient Segment Ø8 M/I Person Code Ø9 M/I Birth Date 1Ø M/I Patient Gender Code 11 M/I Patient Relationship Code 53 Non-Matched Person Code Problem: information in insurer’s system is different than what is on page 4 of Patient Registration. To correct: call processor pharmacy help desk to determine where discrepancy is.

Rejection codes – Insurance Segment Ø6 M/I Group Number Ø7 M/I Cardholder ID Number 51 Non-Matched Group ID 52 Non-Matched Cardholder ID Problem: there is information missing or there is an eligibility issue. To correct: check a current card or call the pharmacy help desk. The phone number is usually on the rejection report. Once correct in Patient Registration (page 4), the claim can be resubmitted in POS.

POS User Screen This is POS user screen – where claims that have been corrected in Patient Registration are resubmitted. In general, Corrections made to the prescription are done in the pharmacy package and this screen is not used. Use REC to pull up claim when calling Processor pharmacy help desk.

Rejection codes – Claim Segment 21 M/I Product/Service ID 22 M/I Dispense As Written (DAW)/Product Selection Code 28 M/I Date Prescription Written 54 Non-Matched Product/Service ID Number 55 Non-Matched Product Package Size 77 Discontinued Product/Service ID Number 78 Cost Exceeds Maximum Problem: Pharmacy issue To correct: have pharmacy verify the drug is entered correctly in drug file.

Rejection codes – Claim Segment 7Ø Product/Service Not Covered 81 Claim Too Old Usually uncorrectable

Rejection codes – Prescriber Segment 25 M/I Prescriber ID 56 Non-Matched Prescriber ID 71 Prescriber Is Not Covered Problem: Provider number needs to be verified or format is not submitting correct provider number. To solve: If provider number is correct; refer to RPMS Help desk to verify format is correct.

Over-rides/Prior Auth Prior Authorization Required 79 Refill Too Soon 76Plan Limitations Exceeded 8E M/I DUR/PPS Level Of Effort 8Ø Drug-Diagnosis Mismatch 88 DUR Reject Error You can share your process on how you do those. There are handouts on the ftp site that provide instructions on using DUR, Over-ride and Prior auth fields.

Rejection Codes - Processing 85 Claim Not Processed 87 Reversal Not Processed 91 Host Response Error Problem: claims were not processed To correct: try resubmitting claim. If still not working for several claims, notify RPMS Help Desk.

Design a Process for Working Rejections Review rejection report daily Run URM (POS / RPT / CLA / URM) to clear rejections from report If time is limited, focus on high cost drugs To maximize collections, involve pharmacists. Between the business office and the pharmacy each facility should decide on a plan of action to optimize the amount of collections received from the rejected claims.

Questions? You can tell them there will be more WebEx’s scheduled on medicare part D. The information will be distributed through Elmer Brewster.