1. Point of Sale (POS) Pharmacy Billing

2. Training Plan Reference – FTP site: ftp://ftp.ihs.gov/pubs/POS/ ftp://ftp.ihs.gov/pubs/POS/ Understand RPMS software – POS set-up Learning business end of pharmacy billing to maximize collections – Focus on correcting rejections Participating agreements (contracts), review insurers set-up Audits, HIPAA, future programming plans

3. RPMS system Switch Third Party Billing & Accounts receivable packages Processor Response Outpatient Pharmacy package Point of Sale package Point of Sale Pharmacy Billing Patient Registration package Patient Care Component (PCC) - visit files

4. Pharmacy Benefit Management (PBM’s) Manufacturer rebates Process claims Manage/negotiate benefit with employer DUR responses

5. Outpatient Pharmacy Package SFUN / SITP / IHSP Drug file – AWP monthly updates http://www.ihs.gov/CIO/InfoTech_index.asp APSA – Mailman message – EAWP – AWP Manual Update – Find incorrect NDC’s report – Outpatient Pharmacy v 6.0 patch 5 Status of update – Outpatient Pharmacy v7.0 – new version (10/2004) barcoding

6. Formats NCPDP field names/numbers – POS / RPT / OTHR – handout WebMD: switch company –– GSA contract - $ 0.025/transaction Information needed when adding a new insurer/format: – Processor – BIN number – Plan name/number – Processor Control Number (PCN) or carrier ID – Help desk phone number Requesting a new format

7. Patient Registration Insurer Name Employer Group name/number – Table Maintenance Person code Ideas for collecting patient registration information

8. POS Set-up POS / MGR / Set-up BAS Pharm INS BILL PROV SUMI

9. POS Menu’s Reports – CLA / PAY, REJ, PAP, URM, DAY, INS – Survey

10. Setting up an Insurer – POS / MGR / SET / INS INS – RPMS insurer, POS Format (use Excel spreadsheet) ADV – assign priority points RPMS – set to P

11. Using POS User Menu Live Claims – Payable claim to RPMS A/R package

12. POS Rejections How often to run reports? – Ideally – rejection report daily Need process to address them. Coordinated between Business office and Pharmacy See Reject codes

13. Rejection Handout

14. POS Rejections Cardholder ID, Group number, eligibility Refill too soon, NDC, Day supply, drug not covered DUR, Prior Auth, Prescription Clarification code

15. Resources Web Links – handout Payer Help Desk – see POS rejection report for phone number. – Before calling, have claim pulled up: POS / U / EV / 3-Patient name / REC

16. POS Rejections DUR override: Show Rx Bill or POS / U / N – 439 REASON FOR SERVICE CODE – 440 PROFESSIONAL SERVICE CODE – 441 RESULT OF SERVICE CODE See handout for DUR codes

17. Prior authorization Can be input in either of these packages: – Show Rx Bill (Pharmacy package) or POS / U / N (POS package) – E.g. AdvancePCS Refill too soon due to dosage change: 98798798798

18. Backbilling Electronic limitations (# days to backbill) Prescription number POS / U / N

19. Troubleshooting RPMS support Network issues, changing internet providers, maintenance by payers. Taskmanager Cache conversion

20. Contracts Verify processor, patient name, employer Addendum National contracts, Regional, Facility contracts NCPDP Provider Number update

21. Universal Claim Form (UCF) – Part of 3PB package – Need to order forms: Moore North America, Inc. Moore National Customer Service Center: (800) 635-9500 For version 5.1, HIPAA compliant item # DAH2PT: 1500 forms per carton – 9 ½’’ x 11”, continuous pin feed; $56.21 per carton ($0.04 per form) + shipping

22. Audits Three to five years of records, payable claims – read contract to verify. Copy of Rx – Hard copy readily retrievable Copy of Prior Auth (PA) Signature log

23. HIPAA – Pharmacy Policy and Procedures addressing the following: – Privacy consultation area – Staff Training on HIPAA – Medication pick-up by proxy – Disposal or destruction of patient drug history information – Leaving information on patient’s home or work answering machines – Confidentiality Forms

24. Wrap-Up Action plan