RPMS POS Pharmacy Billing May 17, 2006. 2 Agenda POS Basics POS Basics Patient Registration, the Eligibility Transaction (E1) & Medicare Part D Patient.

RPMS POS Pharmacy Billing May 17, 2006

2 Agenda POS Basics POS Basics Patient Registration, the Eligibility Transaction (E1) & Medicare Part D Patient Registration, the Eligibility Transaction (E1) & Medicare Part D Reports Reports Correcting Common Rejections Correcting Common Rejections Upcoming sessions Upcoming sessions

3 POS Basics References: ftp://ftp.ihs.gov/rpms/POS/ References: ftp://ftp.ihs.gov/rpms/POS/ ftp://ftp.ihs.gov/rpms/POS/ Current patches: Current patches: –POS v1 patch 16 –APSA (AWP monthly patch) –Patient Reg v7.1 patch 1 RPMS Support Desk: rpmshelp@ihs.gov RPMS Support Desk: rpmshelp@ihs.gov rpmshelp@ihs.gov

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

5 ftp://ftp.ihs.gov/rpms/POS /POS%20User%20Informat ion/ ftp://ftp.ihs.gov/rpms/POS /POS%20User%20Informat ion/

6 http://home.ihs.gov/ITSC- CIO/CSMT/SRCB/patchtbl.p df http://home.ihs.gov/ITSC- CIO/CSMT/SRCB/patchtbl.p df

7 APS AWP/PMI UPDATE STATUS Select IHS-Specific Pharmacy Options Option: APS AWP/PMI UPDATE STATUS Select IHS-Specific Pharmacy Options Option: APS AWP/PMI UPDATE STATUS AVERAGE WHOLESALE PRICE (AWP) AVERAGE WHOLESALE PRICE (AWP) >>> UPDATE STATUS >> UPDATE STATUS <<< Last AWP monthly update occurred on..................MAY 3,2006 Last AWP monthly update occurred on..................MAY 3,2006 Most recent 'manual' AWP update was ran on...........MAY 15,2006@13:40:07 Most recent 'manual' AWP update was ran on...........MAY 15,2006@13:40:07 Total number of DRUGS updated with AWP...............547 Total number of DRUGS updated with AWP...............547 >>> ACTIVE DRUGS STATUS >> ACTIVE DRUGS STATUS <<< The Total Number of Active Drugs.....................571 The Total Number of Active Drugs.....................571 PATIENT DRUG EDUCATION DATABASE (PDED) PATIENT DRUG EDUCATION DATABASE (PDED) >>> UPDATE STATUS >> UPDATE STATUS <<< The last quarterly PDED update occurred on...........APR 3,2006 The last quarterly PDED update occurred on...........APR 3,2006 PATIENT DRUG EDUCATION DATABASE WILL EXPIRE ON.......JUL 5,2006 PATIENT DRUG EDUCATION DATABASE WILL EXPIRE ON.......JUL 5,2006

9 POS Basics Maintenance Maintenance –Check for stranded claims POS / RPT / CLA / STR POS / RPT / CLA / STR START WITH START TIME: FIRST// START WITH START TIME: FIRST// If there are stranded claims; resubmit via POS Claims Data Entry Screen (User Screen) If there are stranded claims; resubmit via POS Claims Data Entry Screen (User Screen) Know the RPMS Insurers that are set to transmit via POS Know the RPMS Insurers that are set to transmit via POS POS / RPT / SET / SUMI POS / RPT / SET / SUMI Review Rx Priority Points Review Rx Priority Points

10 ******************************************** ******************************************** * PHARMACY POINT OF SALE V1.0 * * PHARMACY POINT OF SALE V1.0 * * Pharmacy electronic claims reports * ******************************************** ******************************************** CLA Claim results and status... CLA Claim results and status... SET Setup (Configuration) reports... SET Setup (Configuration) reports... SURV Surveys of RPMS database... SURV Surveys of RPMS database... ELIG Medicare Part D Eligibility Check ELIG Medicare Part D Eligibility Check OTH Other reports... OTH Other reports...

11 SUMI Report PHARMACY ELECTRONIC CLAIMS INSURERS MAY 17,2006 01:17 PAGE 1 Grace Ins. Grace Ins. Disp Fee Per Sel. Disp Fee Per Sel. Insurer Pricing Formula Override Override Pts. -------------------------------------------------------------------------------- ===== DIAL OUT to: ENVOY DIRECT VIA T1 LINE ===== DIAL OUT to: ENVOY DIRECT VIA T1 LINE ----- Using electronic FORMAT: ADVANCE RX MGT SILVERSCRPT 5.1 ----- Using electronic FORMAT: ADVANCE RX MGT SILVERSCRPT 5.1 BIN: 004336 BIN: 004336 D-SILVERSCRIPT STANDARD 650.00 ----- Using electronic FORMAT: EXPRESS SCRIPTS 5.1 ----- Using electronic FORMAT: EXPRESS SCRIPTS 5.1 BIN: 003858 BIN: 003858 BENEFIT PLANNERS, INC. STANDARD 5.00 EXPRESS SCRIPTS,INC. STANDARD 20.00 EXPRESS SCRIPTS STANDARD 20.00 ----- Using electronic FORMAT: GEHA 5.1 ----- Using electronic FORMAT: GEHA 5.1 BIN: 610014 BIN: 610014 GEHA/RX STANDARD 20.00 ----- Using electronic FORMAT: PAID 5.1 ----- Using electronic FORMAT: PAID 5.1 BIN: 610014 BIN: 610014 PAID PRESCRIPTIONS, L.L.C. STANDARD 20.00 PAID PRESCRIPTIONS, INC. STANDARD 20.00

13 EXAMPLE OF SURVEY BY INSURER Count Name Now sending format 10909 SOUTH DAKOTA MEDICAID(`442) 10909 SOUTH DAKOTA MEDICAID(`442) 1315 FIRST HEALTH(`1012) MAILHANDLERS 5.1 1315 FIRST HEALTH(`1012) MAILHANDLERS 5.1 901 BC/BS FEDERAL EMPLOYEE PROG(`953) 901 BC/BS FEDERAL EMPLOYEE PROG(`953) 519 D-HUMANA STANDARD(`1121) CAREPLUS HP HUMANA PDP 5.1 519 D-HUMANA STANDARD(`1121) CAREPLUS HP HUMANA PDP 5.1 381 PAID PRESCRIPTION DRUG PROGRAM(`951) PAID 5.1 381 PAID PRESCRIPTION DRUG PROGRAM(`951) PAID 5.1 319 D-SILVERSCRIPT(`1133) ADVANCE RX MGT SILVERSCRPT 5.1 319 D-SILVERSCRIPT(`1133) ADVANCE RX MGT SILVERSCRPT 5.1 301 D-ADVANTAGE FREEDOM(`1124) MEDICARE PARTD RXAMERI PDP 5.1 301 D-ADVANTAGE FREEDOM(`1124) MEDICARE PARTD RXAMERI PDP 5.1 284 D-YOURX PLAN(`1138) MEDCO MEDICARE PDP 5.1 284 D-YOURX PLAN(`1138) MEDCO MEDICARE PDP 5.1 259 D-PACIFICARE SAVER(`1130) MEDICARE PARTD RXSOLUTIONS 5.1 259 D-PACIFICARE SAVER(`1130) MEDICARE PARTD RXSOLUTIONS 5.1 259 D-WELLCARE SIGNATURE(`1137) WELLCARE MEDICARERX 5.1 259 D-WELLCARE SIGNATURE(`1137) WELLCARE MEDICARERX 5.1 216 D-COMMUNITY CARE RX(`1128) MEMBER HEALTH BASIC PDP 5.1 216 D-COMMUNITY CARE RX(`1128) MEMBER HEALTH BASIC PDP 5.1 190 D-UNITED HEALTHRX(`1135) PRIMARY MEDICARE PARTD WHI 5. 190 D-UNITED HEALTHRX(`1135) PRIMARY MEDICARE PARTD WHI 5.

14 Medicare Part D – Getting Started 1. Verify patches have been installed (Patient Reg v7.1, patch 1 and POS v1 patch 16) 2. Enter Insurers (use recommended naming convention, i.e. D-PLAN NAME) in 3PB Table Maintenance Insurer File. 3. Tie Medicare Part D POS format to appropriate Insurer 4. Enter patient with Medicare Part D in Patient Registration Determine duel-eligible members Can Run E1 to determine BIN, PCN & Group number which correlates to a Plan Name. 4. Backbill 180 days

16 Using the Eligibility Check (E1) ******************************************** ******************************************** * PHARMACY POINT OF SALE V1.0 * * PHARMACY POINT OF SALE V1.0 * * Pharmacy electronic claims reports * ******************************************** ******************************************** CLA Claim results and status... CLA Claim results and status... SET Setup (Configuration) reports... SET Setup (Configuration) reports... SURV Surveys of RPMS database... SURV Surveys of RPMS database... ELIG Medicare Part D Eligibility Check ELIG Medicare Part D Eligibility Check OTH Other reports... OTH Other reports...

17 Eligibility Check (E1) Generate eligibility chk (Med Part D) for which patient? DEMO PATIENT Generate eligibility chk (Med Part D) for which patient? DEMO PATIENT M 04-20-1940 154459999 WE 59999 M 04-20-1940 154459999 WE 59999 On: On: Patient Name: DEMO PATIENT Patient Name: DEMO PATIENT Status: A Status: A Authorization #: Authorization #: Insurance Level: PRIMARY Insurance Level: PRIMARY BIN: 012304 BIN: 012304 PCN: MPD PCN: MPD GROUP: PDA23 GROUP: PDA23 CARDHOLDER ID: 123456789 CARDHOLDER ID: 123456789 PERSON CODE: 1 PERSON CODE: 1 PHONE NUMBER: 8005551212 PHONE NUMBER: 8005551212

18 POS Medicare Part D formats – sorted by BIN

19 Medicare Part D formats sorted by Plan

20 Linking Insurer to POS format ******************************************** ******************************************** * PHARMACY POINT OF SALE V1.0 * * PHARMACY POINT OF SALE V1.0 * * * * * * Edit Pharmacy POS Insurance settings * * Edit Pharmacy POS Insurance settings * ******************************************** ******************************************** SYS Insurance selection parameters (system-wide) SYS Insurance selection parameters (system-wide) INS Quick setup of insurer INS Quick setup of insurer ADV Advanced setup of insurer ADV Advanced setup of insurer RPMS Enter/edit RPMS Insurance file RX settings RPMS Enter/edit RPMS Insurance file RX settings SUMI POS Setup - Summary of Insurers SUMI POS Setup - Summary of Insurers

21 SUMI Report PHARMACY ELECTRONIC CLAIMS INSURERS MAY 17,2006 01:17 PAGE 1 Grace Ins. Grace Ins. Disp Fee Per Sel. Disp Fee Per Sel. Insurer Pricing Formula Override Override Pts. -------------------------------------------------------------------------------- ===== DIAL OUT to: ENVOY DIRECT VIA T1 LINE ===== DIAL OUT to: ENVOY DIRECT VIA T1 LINE ----- Using electronic FORMAT: ADVANCE RX MGT SILVERSCRPT 5.1 ----- Using electronic FORMAT: ADVANCE RX MGT SILVERSCRPT 5.1 BIN: 004336 BIN: 004336 D-SILVERSCRIPT STANDARD 650.00 ----- Using electronic FORMAT: EXPRESS SCRIPTS 5.1 ----- Using electronic FORMAT: EXPRESS SCRIPTS 5.1 BIN: 003858 BIN: 003858 BENEFIT PLANNERS, INC. STANDARD 5.00 EXPRESS SCRIPTS,INC. STANDARD 20.00 EXPRESS SCRIPTS STANDARD 20.00 ----- Using electronic FORMAT: GEHA 5.1 ----- Using electronic FORMAT: GEHA 5.1 BIN: 610014 BIN: 610014 GEHA/RX STANDARD 20.00 ----- Using electronic FORMAT: PAID 5.1 ----- Using electronic FORMAT: PAID 5.1 BIN: 610014 BIN: 610014 PAID PRESCRIPTIONS, L.L.C. STANDARD 20.00 PAID PRESCRIPTIONS, INC. STANDARD 20.00

22 Medicare Part D insurers set up to POS format POS / RPT / CLA / MPD POS / RPT / CLA / MPD –MPD TOTALS – MEDICARE PART D INSURERS Any insurers/plans listed on this report are tied to a format that is “tagged” as Medicare Part D. Any insurers/plans listed on this report are tied to a format that is “tagged” as Medicare Part D. PAYABLE ADJUSTED PAPER REJECTED RX CNT PAYABLE ADJUSTED PAPER REJECTED RX CNT-------------------------------------------------------------------------------------------------------------------------------------------------------------- D-PACIFICARE SAVER 283.10 77.87 0.00 0.00 6 283.10 77.87 0.00 0.00 6------------------------------------------------------------------------------- D-PRESCRIPTION PATHWAY 15.54 5.01 0.00 10.75 2 15.54 5.01 0.00 10.75 2

23 Entering Information on Page 4 of Patient Registration

24 Adding Medicare Part D Plan on page 4

25 Completed Patient Reg page 4

27 Reports: Claims Results and Status ******************************************** ******************************************** * PHARMACY POINT OF SALE V1.0 * * PHARMACY POINT OF SALE V1.0 * * Claim results and status * * Claim results and status * ******************************************** ******************************************** PAY Payable claims report PAY Payable claims report REJ Rejected claims report REJ Rejected claims report CAP Captured claims report CAP Captured claims report PAP Paper claims report PAP Paper claims report UN Uninsured claims report UN Uninsured claims report DUP Duplicate claims report (should be none) DUP Duplicate claims report (should be none) MISS Find prescriptions missed by POS MISS Find prescriptions missed by POS NRV Reversals needed NRV Reversals needed URM Update Report Master File for a date range URM Update Report Master File for a date range REC Recent transactions REC Recent transactions STR List possibly stranded claims STR List possibly stranded claims DAY TOTALS - by RELEASED DATE DAY TOTALS - by RELEASED DATE INS TOTALS - by INSURER INS TOTALS - by INSURER MPD TOTALS - MEDICARE PART D INSURERS MPD TOTALS - MEDICARE PART D INSURERS

28 REPORTS Before running any reports, run the Update Report Master File (URM). Before running any reports, run the Update Report Master File (URM). If backbilling, run report at least as far back as claims were being re-submitted. If backbilling, run report at least as far back as claims were being re-submitted. Corrected claims will display on the Release date (equivalent to fill date) Corrected claims will display on the Release date (equivalent to fill date) Recommended schedule of running reports: Recommended schedule of running reports: –Rejection – daily –Payable – daily – to review how much plans are paying. –URM – after correcting rejections; before running rejection report. –Stranded Claim – weekly or if POS “not working” –Management reports – monthly DAY – totals by release date DAY – totals by release date MCD – totals by medicare Part D insurer; MCD – totals by medicare Part D insurer;

29 Rejection Codes Complete list of rejection codes is located on the ftp site (NCPDP folder) Complete list of rejection codes is located on the ftp site (NCPDP folder) M/I = Means Missing/Invalid M/I = Means Missing/Invalid Rejection codes are NCPDP standard codes used by processors. Rejection codes are NCPDP standard codes used by processors. Not all processors use the codes the same way. Not all processors use the codes the same way.

30 Rejection codes

31 Rejection – M/I BIN PCN Group REJECTION: MAR 28,2006 10:20 P06-610468-100173 `1050039/0 12345123412 123456789 150 185.80 CARBAMAZEPINE 04:M/I Processor Control Number 04:M/I Processor Control Number 06:M/I Group Number 06:M/I Group Number 01:M/I Bin 01:M/I Bin To Correct: If commercial plan – contact processor help desk to verify BIN/PCN and group number. For Medicare part D plan – try E1

32 Rejection – M/I BIN PCN Group Patient Name: DEMO PATIENT Patient Name: DEMO PATIENT Status: A Status: A Authorization #: Authorization #: Insurance Level: PRIMARY Insurance Level: PRIMARY BIN: 610468 BIN: 610468 PCN: UAFC PCN: UAFC GROUP: 8310000 GROUP: 8310000 CARDHOLDER ID: 123456789 CARDHOLDER ID: 123456789 PERSON CODE: 1 PERSON CODE: 1 PHONE NUMBER: 8006988394 PHONE NUMBER: 8006988394

33 Rejection – M/I BIN PCN Group

34 Rejection – M/I Transaction Code Ø3: M/I Transaction Code Ø3: M/I Transaction Code If this is a Medicare Part D insurer, this usually means that a non- Medicare Part D format is being used. Refer to Part D plans by BIN to find a different POS format. If this is a Medicare Part D insurer, this usually means that a non- Medicare Part D format is being used. Refer to Part D plans by BIN to find a different POS format.

35 Rejection – M/I Birth Date 09:M/I Birth Date 09:M/I Birth Date –Contact processor to determine which birthdate they have in their system. –For Medicare Part D patients – enter birthdate information on page 4 of Medicare Part D page. –To over-ride birth date field: POS / N / Override / Field 304 POS / N / Override / Field 304 Enter birthdate as: YYYYMMDD Enter birthdate as: YYYYMMDD

36 Rejection – 85: Claim not processed MAR 23,2006 10:00 P06-610459-108961 `104700/1 00093067005 0123456 60 75.74 GEMFIBROZIL 600MG TAB 0123456 60 75.74 GEMFIBROZIL 600MG TAB 85:Claim Not Processed 85:Claim Not Processed NN:Transaction Rejected At Switch Or Intermediary NN:Transaction Rejected At Switch Or Intermediary 98:Connection To Payer Is Down 98:Connection To Payer Is Down These type of rejections are more common with some of the processors with the implementation of Medicare Part D. Try Resubmitting the claim – POS / U / EV / 3 – Single Patient / RES

37 Upcoming WebEx Sessions Registration required – up to 30 in each class Registration required – up to 30 in each class https://ihs-training.webex.com/ https://ihs-training.webex.com/ https://ihs-training.webex.com/ –May 25 – Set up Insurers to POS format –May 26 th – Rx Priority Points –June 14 th – Using the Claim Data Entry Screen –June 28 – Establishing a Pharmacy Billing Program –Welcome additional topics Train-the-Trainer – Area experts actively using POS – refer to Elmer Train-the-Trainer – Area experts actively using POS – refer to Elmer

RPMS POS Pharmacy Billing May 17, 2006. 2 Agenda POS Basics POS Basics Patient Registration, the Eligibility Transaction (E1) & Medicare Part D Patient.

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RPMS POS Pharmacy Billing May 17, 2006. 2 Agenda POS Basics POS Basics Patient Registration, the Eligibility Transaction (E1) & Medicare Part D Patient.

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