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

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

3. 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

4. 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.

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

6. 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

7. 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

8. 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.

9. 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
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.

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

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

12. 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.

13. 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.

14. 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.

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

16. REJ - Rejected claims report
POS REJECTED claims for prescriptions RELEASED on FEB 9,2001
SAN FELIPE NCPDP (NABP) # Medicaid #B3713
MEDICAID EXEMPT Help Desk:(505) opt 3 opt 1
Trans. Date/Time Claim ID Presc/Fill NDC Number
Cardholder ID Group Number Qty $billed
**** DUCK,RONALD
FEB 9, :22 P `947794/
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 #

17. REJ - Rejected claims report
POS REJECTED claims for prescriptions RELEASED on FEB 9,2001
SAN FELIPE NCPDP (NABP) # Medicaid #B3713
MEDICAID EXEMPT Help Desk:(505) opt 3 opt 1
Trans. Date/Time Claim ID Presc/Fill NDC Number
Cardholder ID Group Number Qty $billed
**** DUCK,RONALD
FEB 9, :22 P `947794/
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.

18. 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.

19. 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.

20. 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.

21. 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.

22. 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.

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

24. 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.

25. 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.

26. 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.

27. 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.

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