1. Point of Sale (POS) Pharmacy Billing

2. Housekeeping Verify you can log into you facility
Verify that you have the POS menus (if you are using POS)
Verify you can print to the printer in the room

3. Objectives Describe the general principals of pharmacy billing.
Describe processes that need to be in place to be successful at pharmacy billing
List the reports are available in RPMS POS?
Describe how to correct different types of rejections using the POS software.

4. Training Plan Reference – FTP site: ftp://ftp.ihs.gov/rpms/POS/
Understand RPMS software – POS set-up
Learning business end of pharmacy billing to maximize collections
Network agreements (contracts), review insurers set-up
Audits, HIPAA, programming plans/projects

5. Point of Sale Pharmacy Billing
Outpatient Pharmacy package
Patient Registration package
RPMS system
Processor Response
Point of Sale
package
Switch
Transmission process (sending claim) versus response (from payer).
NCPDP sets standards for transmissions – payers, providers (pharmacies), vendors
Patient Care Component (PCC) - visit files
Third Party Billing &
Accounts receivable packages

6. 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
Outpatient Pharmacy 6.0, patch 5 or Outpatient Pharmacy 7.0, patch 3
POS version 1, patch 13
AWP (APSA) and Patient Education (APSE) updates
Drug file clean-up
Patient registration
Terminal ID# - provide info on how to process purchase order to WebMD.
To have a tribal facility added to Express Scripts contract – contact Pam Schweitzer
Load the software – site manager needs to be aware of minimum software requirements. See Configuration survey handout.
Pam Schweitzer can assist sites in set-up and training. Contact through outlook or ITSC Help Desk.

7. Pharmacy Benefit Management (PBM’s)
An organization that manages pharmaceutical benefits for employers, other providers or managed care organizations
Involved in: Benefit plan design, Claims processing, Formulary management, Manufacturer rebates, DUR review
Examples of PBM’s: Medco Health, Caremark, Express Scripts, First Health (Coventry), Rx America

8. PBM Web Site
See handout with links

9. Network Agreements Patient Insurance Card
Network enrollment application
Vendor Information
Software vendor: Indian Health Service
5300 Homestead Rd, Albuquerque, NM 87110
Software: RPMS POS, NCPDP V5.1
Addendum
Network participating agreements – first need to know main employers and primary insurance of patients seen at facility.
National IHS contracts in place – First Health, Express Scripts.

10. Status of Agreements - IHS
National
Express Scripts, First Health (Mail Handlers), Medicare Drug Card (PCA, Criterion)
Medco Health
Medicare Part D – January 1, 2006 (several)
In the works:
Tricare/Express Scripts – signing process
Caremark - review
Aetna – review
MedImpact – review
Argus – signing process
PCN – signing process
Pharmacare - review

11. Outpatient Pharmacy Package
SFUN / SITP / IHSP - location of POS “switch”
Drug file
AWP monthly updates
APSA
APSE – Patient Education - quarterly
Status of patches – Outpatient Pharmacy Supervisor Menu - Maintenance

12. Outpatient Pharmacy Package – Drug File, continued….
Mailman message – lists unmatched drugs
EAWP – Outpatient 6.0
AWP Manual Update
Outpatient Pharmacy v 6.0 patch 5
Outpatient Pharmacy v7.0 – new version (10/2004) – 46 sites using

13. AWP Manual Update
Subj: Outpatient Pharmacy AWP Automatic Update [#12914] 16 Nov 04 12:21
200 Lines
From: OUTPATIENT PHARMACY DEVELOPER in 'IN' basket. Page 1 **NEW**
An Average Wholesale Pricing update was performed on your system on
The total number of records updated = 924
Listed below are the active drugs that were not updated and the error codes.
Please review and correct all errors before attempting to run the manual
AWP update option.
Note: any 'missing 660 node' errors means that information like
Order Unit, Price Per Order Unit, Dispense Units Per
Order unit, Price Per Dispense Unit, etc) is missing!
ACETAZOLAMIDE 500MG INJ - DISP UNITS DON'T MATCH - Medi = 90 / Local = 1
ACYCLOVIR 200MG/5ML SUSP,ORAL - DISP UNITS DON'T MATCH - Medi = 473 / Local =480
AWP Manual update - Used by the pharmacists to clean up the drug file.
900+ records updated is “good.”

14. Drug AWP Edit - EAWP Select DRUG GENERIC NAME: GLYBURIDE 5MG TAB
ORDER UNIT: BT//
DISPENSE UNIT: TAB//
DISPENSE UNITS PER ORDER UNIT: 1000//
AWP PER ORDER UNIT: //
AWP PER DISP UNIT is
AWP EFFECTIVE DATE: JUN 5,2001//
NDC: //
DEA, SPECIAL HDLG: 6//
LAST PRICE UPDATE:
INACTIVE DATE:
PRICE PER ORDER UNIT: 17.31//
PRICE PER DISPENSE UNIT is 0.017
This is part of the pharmacy package – where the pharmacy updates the drug file. Critical fields for the NDC to “match,” (I.e. to the correct AWP) are:
Order unit, Dispense unit, dispense units per order unit, NDC.
It is highly recommended that DEA special handling be completed. “9” for OTC’s will enable you to not bill OTC’s, if so desired.
There is a handout – Drug Enter/Edit – that provides detail on how to clean up the drug file.

15. Formats NCPDP field names/numbers – POS / RPT / OTHR
Or see 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

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

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

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

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

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

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

22. Rejection Handout

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

24. 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

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

26. Prior authorization Can be input in either of these packages:
Show Rx Bill (Pharmacy package) or POS / U / N (POS package)
Example
Refill too soon due to dosage change:

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

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

29. Network Agreements Verify processor, patient name, employer Addendum
National contracts, Regional, Facility contracts
NCPDP Provider Number update

30. Universal Claim Form (UCF)
Part of 3PB package
Need to order forms:
Moore North America, Inc.
Moore National Customer Service Center: (800)
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

31. 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

32. 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

33. Wrap-Up
Action plan