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Veterans Health AdministrationChief Business Office

Business DevelopmentePharmacy Team

ePharmacy Update for Pharmacy Informatics

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Agenda

• ePharmacy Project Overview

• ePharmacy team and project information

• ePharmacy Statistics

• ePharmacy Enhancements

• Billing Methodology Change - Potential Impact

• Pharmacy actions to maximize revenue

• ePharmacy Training

• TRICARE Processing differences & Business Rules

• Questions

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ePharmacy Project Overview

• ePharmacy is the e-business initiative enabling real-time electronic prescription claims to the PBM/payer.

– All pharmacies have been submitting claims to 3rd party PBM/payers since September 2008

– ePharmacy is not involved with billing for the provision of Pharmacy services, for example medication management programs

– ePharmacy is not the same as ePrescribing, which is the electronic transfer of prescription information from prescriber to pharmacy

– ePharmacy is sometimes mistakenly referred to as eBilling, a term that can refer to other types of electronic billing

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ePharmacy Project Overview cont.

• The ePharmacy Implementation team is responsible for ensuring the project is functional and meets goals etc.

– Connie Meeker is Project Manager

– Ellen Giglia is an ePharmacy Implementation manager for revenue related issues

– Deb Wistuba is an ePharmacy Implementation manager for revenue related issues

– Gwyn Smith is CBO Liaison

– Greg Laird is an ePharmacy Implementation manager for Pharmacy related issues

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2010 Total Fills

6,043,357

ePharmacy Fill Volume Calendar Year 2010

2010 Average Fills per Month

503,613

A fill is an instance of a single prescription prepared for a patient and electronically submitted to a Pharmacy Benefit Manager (PBM)/payer.

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ePharmacy by the Numbers

• There were a total of 136,695,024 prescriptions filled by VA facilities in CY 2010

• ePharmacy fills accounted for 6,043,357 of those 136,695,024 prescriptions or 4.4% of total fills

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ePharmacy Rejections OverviewCalendar Year 2010

2010 Total Claims

8,709,5752010 Rejected Claims

3,034,2042010 Overall Rejection Rate

34.84%

This pie chart compares the percent of claims initially rejected in 2010 by rejection category. The percent values represent the rejection rate as a percent of total claims. A claim is used to submit a prescription fill

to a PBM/payer for reimbursement.

When rejected, claims are returned to VHA with one or more rejection codes that indicate why a claim was rejected. Similar rejection codes are grouped together into rejection categories. A claim can be rejected for multiple reasons and counted under multiple categories. Therefore, the sum of the rejection rates by category may overstate the overall rejection rate.

2010 Claim Rejection Categories

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NDC Rejects

• About 2.4% of overall rejects are for product related (NDC) reasons

• The overwhelming majority of our NDC rejects have to do with some sort of repackaged drug

• About 64% of our NDC rejects are for Aphena Pharma Solutions (PrePak Systems) products

• Repackaged drug products need to be registered with the major drug information databases First DataBank and Medispan, to be recognized by the third parties

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NDC Rejects

• Most of our Aphena Pharma Solutions product rejects are due to the product being re-packaged, then sent back to the CMOP and used before the registration is complete

• Some third party plans do not reimburse for re-packaged products

• One of our ePharmacy business rules is to transmit the NDC used to fill the prescription

• Facilities should not change the NDC to some other NDC just to get reimbursed.

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90 Day Fill Rejects

• There has been recent interest from some VAs with the system to capture revenue lost as a result of 90 day fill rejects

• Some of the methods proposed have been:

• Designate VA CMOPs as mail-order pharmacies

• Pursue legislation to mandate reimbursement for 90 day fills

• Change 90 day fill prescriptions to 30 day fills to be reimbursed

• The CBO and PBM have extensively researched and evaluated the issue

• For various reasons, none of the methods listed above are recommended at this time

• The CBO will continue to pursue methods to reduce the number of 90 day fill rejects

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ePharmacy Future

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Phase 5/D.0

• Phase 5 will be the next release - sometime this summer

• Will bring us into compliance with D.0, which is the NCPDP communication standard that replaces 5.1

• Very involved process

• Testing has to be done with external partners, e.g. Emdeon and insurance companies

• Some payers require our software be certified

• Need to maintain backwards compatibility - capability to transmit claim in both 5.1 and D.0 during transition period

• Mostly changes that affect the revenue side of ePharmacy

• No major Pharmacy changes

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Phase 5/D.0 cont.

• ECME numbers (prescription number that is transmitted to the third party) expanded from 7 to 12 characters

• All screens that display ECME number are being changed.

• Pharmacy screens:

• Rx View screen from View Prescription [PSO VIEW]

• The Reject Information screen from the Third Party Payer Rejects – Worklist [PSO REJECTS WORKLIST] 

• Third Party Payer Rejects – View/Process [PSO REJECTS VIEW/PROCESS] 

• Additional information will be available from the Reject Information screen to assist with reject resolution

• Submit Clarification Code (CLA) action modified so up to three submission clarification codes may be entered

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Reject Status : OPEN/UNRESOLVED Payer Message : 1-ABOVE GERIATRIC MAX QTY/DAY,MAX DAILY QTY 2.0,DUR REJECT ERRO R Reason : HD (HIGH DOSE ALERT ) +DUR Text : 1-ABOVE GERIATRIC MAX QTY/DAY INSURANCE Information Insurance : MEDCO HEALTH DIRECT CLAIMS Contact : (800) 555-1557 Group Name : ECME TEST INS Group Number : GROUP Cardholder ID : ############# Enter ?? for more actions VW View Rx IGN Ignore Reject OVR Submit Override CodesMP Medication Profile RES Resubmit Claim CSD Change Suspense DateSelect: Quit// ??

The following actions are also available:COM Add Comments DN Down a Line PS Print ScreenCLA Submit Clarif. Code UP Up a Line PT Print ListED Edit Rx FS First Screen SL Search ListPA Submit Prior Auth. LS Last Screen ADPL Auto Display(On/Off)+ Next Screen GO Go to Page QU Quit- Previous Screen RD Re Display Screen ARI View Addtnl Rej Info

Phase 5/D.0 – Additional Reject Information

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Reason : ID (INGREDIENT DUPLICATION) +DUR Text : 1-ABOVE GERIATRIC MAX QTY/DAY INSURANCE Information Insurance : MEDCO HEALTH DIRECT CLAIMS Contact : (800) 555-1557 Group Name : ECME TEST INS Group Number : GROUP Cardholder ID : ############# Enter ?? for more actions VW View Rx IGN Ignore Reject OVR Submit Override CodesMP Medication Profile RES Resubmit Claim CSD Change Suspense DateSelect: Quit//ARI

DUR Response: 1 Reason Code: TD (THERAPEUTIC ) Clinical Significance Code: MINOR Other Pharmacy Indicator: OTHER PHARMACY Previous Date of Fill: MAR 30, 2011 Quantity of Previous Fill: 0000090000 Database Indicator: OTHER Other Prescriber Indicator: OTHER PRESCRIBER DUR Text: DUR Add Text: ALPRAZOLAM TAB 0.5MG

Phase 5/D.0 – Additional Reject Information Cont.

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Reject Status : OPEN/UNRESOLVED Payer Message : 1-ABOVE GERIATRIC MAX QTY/DAY,MAX DAILY QTY 2.0,DUR REJECT ERRO R Reason : HD (HIGH DOSE ALERT ) DUR Text : 1-ABOVE GERIATRIC MAX QTY/DAY INSURANCE Information Insurance : MEDCO HEALTH DIRECT CLAIMS Contact : (800) 555-1557 Group Name : ECME TEST INS Group Number : GROUP Cardholder ID : ############# Enter ?? for more actions VW View Rx IGN Ignore Reject OVR Submit Override CodesMP Medication Profile RES Resubmit Claim CSD Change Suspense DateSelect: Quit// ??

The following actions are also available:COM Add Comments DN Down a Line PS Print ScreenCLA Submit Clarif. Code UP Up a Line PT Print ListED Edit Rx FS First Screen SL Search ListPA Submit Prior Auth. LS Last Screen ADPL Auto Display(On/Off)+ Next Screen GO Go to Page QU Quit- Previous Screen RD Re Display Screen ARI View Addtnl Rej Info

Phase 5/D.0 – Multiple Clarification Codes

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Reject Status : OPEN/UNRESOLVED Payer Message : 1-ABOVE GERIATRIC MAX QTY/DAY,MAX DAILY QTY 2.0,DUR REJECT ERRO R Reason : HD (HIGH DOSE ALERT ) DUR Text : 1-ABOVE GERIATRIC MAX QTY/DAY INSURANCE Information Insurance : MEDCO HEALTH DIRECT CLAIMS Contact : (800) 555-1557 Group Name : ECME TEST INS Group Number : GROUP Cardholder ID : ############# Enter ?? for more actions VW View Rx IGN Ignore Reject OVR Submit Override CodesMP Medication Profile RES Resubmit Claim CSD Change Suspense DateSelect: Quit// CLA CLA Submission Clarification Code 1: 2 OTHER OVERRIDESubmission Clarification Code 2: 3 VACATION SUPPLYSubmission Clarification Code 3: 5 THERAPY CHANGE

When you confirm, a new claim will be submitted for the prescription and this REJECT will be marked resolved.

Confirm? YES//

Phase 5/D.0 – Multiple Clarification Codes cont.

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D.0 v2

• Development and testing for D.0 V2 will be combined with our Phase 6 enhancements

• Testing is expected to start in September and Phase 6/D.0 V2 software expected to be released in February 2012

• Expand electronic transmissions to include CHAMPVA pharmacy claims.

• Submit all mandatory NCPDP fields, required NCPDP fields, and situational required NCPDP fields to PBMs/Payers regardless of payer sheet specifications.

• Accurately utilize NCPDP fields for pricing of VHA outpatient pharmacy claims. Include capability to allow for this pricing on paper claims as well.

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Phase 6

• Field names that display on both the Third Party Payer Rejects - Worklist Pharmacy Worklist) and ECME User screen (OPECC Worklist) will be standardized

• Information that shows on the Pharmacy Reject Information screen will also show on the ECME User screen log

• The BIN number will be added to the Pharmacy Worklist Reject Information and View/Process Information screens

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Phase 6 cont

• The ‘Reason For Service’ field of the Submit Override Codes action of the Reject Information screen will be editable

• Users will be able to enter multiple Reject Action codes from the Reject Information screen if needed.

• A new action will be added to the Reject Information screen that will calculate the next date of fill based on the last ePharmacy date of service and days supply.

• ePharmacy screens using ‘Fill Date’ labels will be changed to ‘Date of Service’ when appropriate.

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Reject Information(UNRESOLVED)Apr 06, 2011@08:30:37 Page: 1 of 1 Division : ECMETEST DIV NPI#: 130689XXXXPatient : PATIENT, TESTONE(###-##-####) Sex: M DOB: MMM, ##, ####(##)Rx# : #####713I/3 ECME#: ####202 Fill Date: MMM ##, ####CMOP Drug: DIAZEPAM 10MG TAB NDC Code: 67544-0020-30 REJECT Information Reject Type : 88 - DUR Reject Error- received on APR 06, 2011@00:44:26 Reject Status : OPEN/UNRESOLVED Payer Addl Msg : 1-ABOVE GERIATRIC MAX QTY/DAY,MAX DAILY QTY 2.0,DUR REJECT ERROR Reason Code : HD (HIGH DOSE ALERT ) + DUR Text : 1-ABOVE GERIATRIC MAX QTY/DAY INSURANCE Information Insurance : MEDCO HEALTH DIRECT CLAIMS Contact : (800) 555-1557 BIN Number 610014 Group Number : GROUP Cardholder ID : ############ Enter ?? for more actions VW View Rx IGN Ignore Reject OVR Submit Override CodesMP Medication Profile RES Resubmit Claim CSD Change Suspense DateSelect: Quit// Select: Quit// Select: Quit// OVR Submit Override Codes

Reason for Service Code : DD DRUG-DRUG INTERACTIONProfessional Service Code:

Reject Information Screen Changes

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INSURANCE Information Insurance : MEDCO HEALTH DIRECT CLAIMS Contact : (800) 555-1557 Group Name : ECME TEST INS Group Number : GROUP Cardholder ID : ############# Enter ?? for more actions VW View Rx IGN Ignore Reject OVR Submit Override CodesMP Medication Profile RES Resubmit Claim CSD Change Suspense DateSelect Item(s): Quit// SDC Suspense Date Calculation

LAST DATE OF SERVICE: Jan 01, 2011//

LAST DAYS SUPPLY: 60//

NEW SUSPENSE DATE: Feb 15, 2011//T+4 (FEB 11, 2011)

When you confirm, this REJECT will be marked resolved. A new claim will be re-submitted to the 3rd party payer when the prescription label for this fill is printed from suspense on Feb 11, 2011.

Note: THE LABEL FOR THIS PRESCRIPTION FILL WILL NOT BE PRINTED LOCAL FROM SUSPENSE BEFORE Feb 19, 2011.

Confirm? ? YES// [Closing...OK] Please wait...

Reject Information Screen Changes cont

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Phase 6 cont

• The ¾ days supply hold calculation will round up for any partial day

• Fill Date will no longer be used to determine the date of service – only Current Date and Release Date will be used

• A screen reminder to obtain a signature when prescriptions are picked-up will be provided when ePharmacy window prescriptions are released

• A reminder to obtain signature will also be provided when removing a patient’s name from the Bingo Board

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Phase 6 cont

• An indicator for ePharmacy prescriptions will be provided via OPAI

• A new option ‘View ECME Rx’ will be available that will provide a user all the information regarding an ePharmacy prescription

• The Issue Date transmitted on claims for ePharmacy prescriptions entered with a future ‘Issue Date’ will be changed to the current date

• Claims submitted by the OPECC using the Process Secondary/TRICARE Rx to ECME option, will reflect that in the Prescription activity log

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Reject Information(UNRESOLVED)Apr 06, 2011@08:30:37 Page: 1 of 1 Division : ECMETEST DIV NPI#: 130689XXXXPatient : PATIENT, TESTONE(###-##-####) Sex: M DOB: MMM, ##, ####(##)Rx# : #####713I/3 ECME#: ####202 Fill Date: MMM ##, ####CMOP Drug: DIAZEPAM 10MG TAB NDC Code: 67544-0020-30 REJECT Information Reject Type : 88 - DUR Reject Error- received on APR 06, 2011@00:44:26 Reject Status : OPEN/UNRESOLVED Payer Message : 1-ABOVE GERIATRIC MAX QTY/DAY,MAX DAILY QTY 2.0,DUR REJECT ERRO R Reason : HD (HIGH DOSE ALERT ) DUR Text : 1-ABOVE GERIATRIC MAX QTY/DAY INSURANCE Information Insurance : MEDCO HEALTH DIRECT CLAIMS Contact : (800) 555-1557 Group Name : ECME TEST INS Group Number : GROUP Cardholder ID : ############ Enter ?? for more actions VW View Rx IGN Ignore Reject OVR Submit Override CodesMP Medication Profile RES Resubmit Claim CSD Change Suspense DateSelect: Quit// Select: Quit//

Pop Quiz – DUR Reject

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VW View Rx IGN Ignore Reject OVR Submit Override CodesMP Medication Profile RES Resubmit Claim CSD Change Suspense DateSelect: Quit// CLA CLA

Clarification Code: 2 OTHER OVERRIDE

When you confirm, a new claim will be submitted for the prescription and this REJECT will be marked resolved. Confirm? YES//

Pop Quiz – DUR Reject - answer

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Billing Methodology Change

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Why the Change?

VA published a rule in the Federal Register to implement a new billing methodology to provide VA with a more accurate billing methodology in relationship to the actual cost of prescription drugs.

The new billing methodology is more in line with the way the private sector bills.

Key points to remember are:

•The new billing methodology requires VA to bill the actual cost of the drug plus an administrative fee

•The new billing methodology was implemented with prescriptions filled beginning March 18, 2011

The rule was published in the Federal Register on October 6, 2010 and is available at: http://edocket.access.gpo.gov/2010/pdf/2010-25043.pdf

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Administrative Fee Calculation

The administrative fee will be calculated annually based on experience from a prior fiscal year (October through September)

Drug Indirect Costs + Dispensing CostsTotal RX Fills

Updates to the administrative fee will be implemented and updated via a patch in January of each year with the exception of this year

For example:

•The administrative fee of $11.40 (calculated for FY09) will apply to prescriptions filled beginning March 18, 2011 through December 2011

•The administrative fee calculated for FY10 will apply to prescriptions filled for the calendar year January to December 2012

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Drug File Cost Methodology

• Here is how the prescription cost will be determined:

• For original fills, the UNIT PRICE OF DRUG field (#17) of Prescription File (#52) will be used for the drug cost 

• For refills, the CURRENT UNIT PRICE OF DRUG field (#1.2) of the Prescription File REFILL multiple (#52.1) will be used for the drug cost

• The administrative charge (currently $11.40) will be added to these costs and used for the ePharmacy claim

• The Prescription file fields mentioned above will obtain their costs from the Drug File entry for the item

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Drug File Cost Methodology Cont.

• The drug cost that will be transmitted to the third party will be the drug file cost for the NDC chosen for the prescription when the claim is submitted 

• In most cases the NDC chosen by the software will be the Last Local NDC, or Last CMOP NDC 

• For local fills, if the NDC chosen for the prescription is the default NDC (Drug file field #31 NDC):

• The drug cost used will be the value of the PRICE PER DISPENSE UNIT field (#16) of DRUG file (#50)

• If the NDC selected is a synonym:

• The PRICE PER DISPENSE UNIT field (#404) of the SYNONYM multiple (#9) of the DRUG file (#50) will be used

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Drug File Cost Methodology Cont.

• In the case of CMOP fills, the default NDC price will be used, which is taken from PRICE PER DISPENSE UNIT field (#16) of DRUG file (#50)

• Functionality currently doesn’t exist to allow CMOP drug costs to be shared between VistA and CMOP. 

• Drug cost values are stored at the same time as drug file updates to the NDC occur, for example through the Drug Accountability process 

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Reimbursement by PBMs and TPPs

• Impact of PBM Agreements

• PBMs will continue to pay under the terms and conditions of their current agreements with VA

• Some agreements are written with “lesser of” logic using reimbursement methodologies such as:

• Average Wholesale Price (AWP) less a discount

• Maximum Allowable Cost (MAC) pricing

• Usual and Customary (U&C) pricing

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Reimbursement by PBMs and TPPs cont.

Example of PBM reimbursement to facilities:

The PBMs agreement is written that they will pay the lower of:

(a) the pharmacy Usual & Customary (U&C) charge which combines the drug cost and administrative fee; or

(b) the AWP less a discount

For this example, the AWP less a discount is lower than the U&C. The payment returned to VHA will be the lower amount, which in this example is the AWP less the discount and not the U&C billed by VHA.

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Potential for Additional Revenue

• A high level analysis completed prior to the publication of the billing methodology rule indicated that it would result in approximately a 3% increase in revenue

• The new methodology of billing the actual cost of the prescription plus an administrative fee will provide potential for increased revenue with regard to high cost medications

• Instead of a maximum of $51 per prescription, VA has the potential of receiving a much larger payment amount on some high-end prescriptions

• Facilities who are the most successful at ensuring prescriptions are billed and claims are approved will benefit the most

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Need for Prior Authorizations

• Many high cost medications require prior authorizations

• Most third party prior authorization rejects are returned with reject code 75 : Prior Authorization, and are followed up by the OPECC

• Some rejects for prior authorization are returned as 88: DUR and are seen on the Third Party Payer Rejects – Worklist

• These are usually Ignored by the pharmacists with an appropriate comment back to the OPECC

• Proper follow-up on prior authorizations rejects is a must to maximize revenue for prescriptions

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Prior Authorization Process

• Prior Authorization processes are determined at the facility level and vary from facility to facility

• Most sites currently have a method to follow-up on claims that need Prior Authorization

• Prior Authorization process at many facilities pre-dates ePharmacy, as a process was needed when the VA billed prescription claims on paper as well

• At some facilities Revenue is in charge of following up on Prior Authorizations

• Some facilities have Utilization Review nurses handle the process

• Still other processes involve Pharmacy

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ECME returned status: Cannot find price for Item

• Facilities started reporting this problem shortly after the Billing methodology change went into effect.

• Claims are not generated when the above error is returned

• Reported for prescriptions for drug with very low prices, e.g. HCTZ 25/TRIAMTERENE 37.5MG TAB, GLYBURIDE 2.5MG TAB

• It appears the Price Per Dispense unit calculated field value for some of these is less than $0.00, and the Integrated Billing software needs a price of at least $0.01 to bill the prescription

• At this time the issue is still being investigated, but a fix will be implemented

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Pharmacy Actions to Maximize Revenue

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Pharmacy Actions to Maximize Revenue

• Ensure all prescriptions are billed

• Make sure pharmacy and medical staff understand that service designation is not only important for VA copay determination but also determines whether we bill for prescription or not.

• any prescription that is not service connected can be billed

• Encourage prescribers to accurately mark prescriptions as SC or NSC

• Ensure prescriptions are properly marked as SC or NSC when finishing prescription

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Pharmacy Actions to Maximize Revenue

• Take an active role in Reject Resolution

• Remember that Rx reimbursement is important to the veteran as well because of VA copay reduction

• Work closely with your OPECC

• Even the best OPECCs do not have the overall knowledge of products and medication therapy required to evaluate some prescription rejects they receive

• Consider setting up additional rejects to transfer to your Pharmacy Worklist

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Pharmacy Actions to Maximize Revenue cont.

• Ensure you have your parameters set-up to generate the ePharmacy - OPEN/UNRESOLVED REJECTS LIST messages

• Ensure appropriate staff are enrolled in theG.PSO REJECTS BACKGROUND MESSAGE so the messages will be received

• Periodically evaluate the ‘Ignored Rejects Report’ too ensure staff are only ‘Ignoring’ appropriate rejects

• Ensure that the quantity dispensed for ePharmacy prescriptions is appropriate for the days supply

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Pharmacy Actions to Maximize Revenue cont.

• Billing for AIDS medications is more lucrative now because of their high cost

• Ensure drugs used exclusively for the sensitive conditions are properly marked in your drug file

• Work with your OPECC to ensure patients on these drugs have ROI’s entered into VistA

• Some pharmacies are interested in billing for medications administered in the clinic• If the patient picks up the prescription from the Pharmacy and

brings it to clinic it can be billed through ePharmacy

• If Pharmacy delivers the medication to the clinic the prescription is billed as part of the clinic visit

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IR Ignored Rejects Report MP ePharmacy Medication Profile (View Only) NV NDC Validation PF ePharmacy Medication Profile Division Preferences SP ePharmacy Site Parameters VP Third Party Payer Rejects - View/Process WL Third Party Payer Rejects - Worklist TC TRICARE Bypass/Override Report

Select ePharmacy Menu Option: sp ePharmacy Site Parameters

Regardless of any parameters defined, Refill-Too-Soon, Drug UtilizationReview(DUR) and Tricare rejects will always be placed on the Third Party Payer Rejects - Worklist, also known as Pharmacy Reject Worklist. Theseparameters are uneditable and are the default parameters.

Division: ECMETEST DIV ...OK? Yes//

ePharmacy Menu Screen

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Division: ECMETEST DIV ...OK? Yes// (Yes)

ALLOW ALL REJECTS: NO// REJECT WORKLIST DAYS: 7//

Previously defined override reject codes:

Code Description Auto Send----- ---------------------------------- ------- 22 M/I Dispense As Written (DAW)/Product Selection Co YES M5 Requires Manual Claim YES 99 Host Processing Error YES Select REJECT CODE: 75 Prior Authorization RequiredCODE: 75// AUTO SEND: ?? Enter Yes for auto update or No for requires OPECC intervention. Choose from: 0 NO 1 YESAUTO SEND: 0 NO

ePharmacy Site Parameter Screen

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Code Description Auto Send----- ---------------------------------- ------- 22 M/I Dispense As Written (DAW)/Product Selection Co YES M5 Requires Manual Claim YES 77 Discontinued Product/Service ID Number NO 50 Non-Matched Pharmacy Number NO 19 M/I Days Supply NO EU M/I Prior Authorization Type Code YES 21 M/I Product/Service ID NO EV M/I Prior Authorization Number Submitted YES 75 Prior Authorization Required NO 54 Non-Matched Product/Service ID Number NO E7 M/I Quantity Dispensed YES 55 Non-Matched Product Package Size YES 25 M/I Prescriber ID NO E4 M/I Reason For Service Code YES E5 M/I Professional Service Code YES E6 M/I Result Of Service Code YES

Reject Transfer Screen

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Reject Information(UNRESOLVED)Mar 28, 2011@08:58:27 Page: 1 of 2 Division : ECMETEST DIV NPI#: 130689XXXXPatient : PATIENT,ECME ONE(###-##-####) Sex: M DOB: MMM 24,####(##)Rx# : ####1594A/1 ECME#: ###0914 Fill Date: Mar 25, 2011CMOP Drug: ALBUTEROL 90MCG (CFC-F) 200D ORAL INHL NDC Code: 59310-0579-20 REJECT Information Reject Type : E4 - M/I Reason For Service - received on MAR 25, 2011@19:45:35Reject Status : OPEN/UNRESOLVED Payer Message : USE VENTOLIN HFA OR OV 5555/08,M/I REASON FOR SERVICE CODE, REQ UIRED ON DUR/PPS BILLING Reason : PP (PLAN PROTOCOL ) DUR Text : FOR LOWER COPAY OPTION COMMENTS - MAR 25, 2011@19:45:35 - Automatically transferred due to override for reject code. (RPH,ONE) INSURANCE Information Insurance : MEDCO HEALTH DIRECT CLAIMS + Enter ?? for more actions VW View Rx IGN Ignore Reject OVR Submit Override CodesMP Medication Profile RES Resubmit Claim CSD Change Suspense DateSelect: Next Screen//

Reject Information Screen – E4 Reject

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DUR Reject for Valtrex cont

• Prescription rejected because we were using brand name Valtrex when a generic is available

• Changing the DAW from 0 NO PRODUCT SELECTION INDICATED, to 5 SUBSTITUTION ALLOWED-BRAND DRUG DISPENSED AS A GENERIC, produced a payable claim

• We billed the default cost of $3.1897 X 180 = $574.15 + $11.40 = $585.55

• The insurance reimbursed the following way:

• Ingredient cost pd $548.05

• Patient copay $25.00

• Dispensing fee $1.25

• Total amt pd $524.30

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Reject Information(UNRESOLVED)Mar 28, 2011@08:58:27 Page: 1 of 2 Division : ECMETEST DIV NPI#: 130689XXXXPatient : PATIENT,ECME ONE(###-##-####) Sex: M DOB: MMM 24,####(##)Rx# : ####8819B/3 ECME#: 6662743 Fill Date: Mar 30, 2011CMOP Drug: VALACYCLOVIR HCL 500MG TAB NDC Code: 00173-0933-08

REJECT Information Reject Type : 88 - DUR Reject Error- received on MAR 21, 2011@10:41:14 Reject Status : CLOSED/RESOLVED Payer Message : TRY VALACYCLOVIR FIRST.DRUG IS NON-COMPLIANT WITH STEP THERAPY. TO DISPUTE CLAIM, CALL 800-238-6279 FOR FORMS/INSTRUCTIONS Reason : DUR Text : INSURANCE Information Insurance : AETNA PHARMACY MANAGEMENTContact : (800)238-6279Group Name : ECME TEST INS Group Number : GROUP Cardholder ID : ############

VW View Rx IGN Ignore Reject OVR Submit Override CodesMP Medication Profile RES Resubmit Claim CSD Change Suspense DateSelect: Next Screen//

Reject Information Screen – Valtrex

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ePHARMACY TRAINING

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ePharmacy Training

• ePharmacy for Pharmacists 101 training were presented in June 2011

• ePharmacy for Pharmacists 201 and 301 sessions are being planned

• Similar training is being provided to the OPECCs

• TRICARE training will be provided to new facilities prior to implementation

• ePharmacy Support Calls are held the second Monday of each Month

• Please visit our ePharmacy Training Page

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Pharmacy Section of ePharmacy Training Site

• List of ePharmacy VISN Points of Contact (POCs) (April 2011)

• ePharmacy Helpful Hints (updated January 2011)

• ePharmacy Issue Reporting Form (updated July 2009)

• ePharmacy Issue Reporting Form Instructions (June 2009)

• ePharmacy Checklist for New ePharmacy Site Managers (02/10)

• Advanced Pharmacy Reject Resolution Training (February 2010)

• Advanced Training – ePharmacy Options & Bulletins (February 2010)

• DEA Special Handling Field Instructions (August 2010)

• NCPDP Dispense Unit and Quantity Multiplier Instructions (updated May 2010)

• Pharmacy Benefits Management Services Clinical INFORMatics Share Point Site

• Click on NCPDP Document folder to access the NCPDP Disp Unit & Qty Mult Exceptions List spreadsheet.

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Pharmacy Section of ePharmacy Training Site cont

• e-Pharmacy NDC Validation (06/13/06)

• ePharmacy Quick Reference Card for finishing & releasing staff (01/08)

• ePharmacy Quick Reference Card for ePharmacy Site Manager

• e-Pharmacy Rejects & Resolutions Guide v6 (revised Nov 2010 )

• Pharmacy Roles & Responsibilities (03/08)

• List of Drugs Used for Sensitive Diagnoses (08/09/09)

• Third Party Audits (01/10)

• VeHU 2007 - e-Pharmacy - Basic Training (08/07)

• VeHU 2007 - e-Pharmacy - Advanced Training (08/07)

• The National Council for Prescription Drug Programs (NCPDP) web site NCPDP Provider ID application form

• Dispensing Pharmacy Information Spreadsheet (06/14/06 ) (To be completed only when a pharmacy is obtaining a new NCPDP number. )

• How to Identify and Resolve Stranded ePharmacy Claims (Sep 2009)

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TRICARE

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TRICARE Implementation

• The only pharmacies currently authorized to process TRICARE prescriptions are Dallas, Louisville, Loma Linda, Long Beach, Palo Alto and Topeka.

• Other facilities will need to be approved for processing.

• Facilities must follow the national VA Memorandum of Understanding (MOU) with the Department of Defense (DoD) in order to process TRICARE prescription claims.

• Express Scripts, the PBM for TRICARE, has system checks in place that will reject TRICARE claims submitted by any VA pharmacy that has not been authorized through the ePharmacy Implementation Team.

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ePharmacy TRICARE Processing Rules

• TRICARE claims are submitted electronically in real-time when …

• The patient’s only eligibility is TRICARE, Sharing Agreement, or Active Duty.

• The patient has separate active TRICARE insurance plan entry with pharmacy coverage set to yes (no other Rx plans)

• TRICARE claims are submitted manually by the TRICARE OPECC when …• The patient has dual eligibility (e.g., Veteran and TRICARE

or TRICARE and Employee, etc.) -- or --

• The TRICARE beneficiary has Other Health Insurance (OHI) primary to TRICARE.

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Processing differences

Veteran 3rd Party Claims TRICARE ClaimsSubmitted charge equals drug cost plus admin fee ($11.40 for 2011)

Submitted charge equals drug cost plus dispensing fee (currently $8)

Only time Prescription label will not print is if claim rejects for DUR/RTS

Prescription label will NOT print if claim rejects for any reason

Prescription processed and dispensed to veteran even if claim rejects

Any reject must be resolved to a payable status or Ignored before prescription can be filled

Pharmacy staff are not notified of non-DUR/RTS rejects

Pharmacy staff given choice to Discontinue, Quit or Ignore processing for non-DUR/RTS rejects

DUR/RTS & site-defined rejects are only rejects on Pharmacy Worklist

ALL TRICARE rejects appear on Pharmacy Worklist (Non-DUR/RTS rejects appear in a separate section)

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TRICARE Rules for Pharmacy Processing OTC & Supplies

• Certain medications (most OTC and supply items) are not covered under the TRICARE contract (will not reimburse).

• Facilities lose money by filling TRICARE prescriptions for these products.

• Pharmacy should notify patient and/or provider if a prescription can not be filled due to limitations of TRICARE contract (i.e., OTC and supplies).

• Per the patient’s TRICARE policy, the patient is responsible for buying these items at a retail pharmacy.

• Pharmacy finishing & releasing staff will see new “TRICARE - NON-BILLABLE” message.

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Non-Billable TRICARE products

• The DEA, Special HDLG field of the Drug file is used to determine which products can be dispensed to TRICARE patients.• Drug file entries at facilities should already be marked for

ePharmacy claims processing and therefore no additional updating is required.

• Prescriptions for non-billable OTC and supply items will not be allowed to be processed by Outpatient Pharmacy software.• Pharmacy staff holding the PSO TRICARE security key can

Override a TRICARE reject if there is an immediate medical need to dispense the medication.

• TRICARE Bypass/Override Report tracks TRICARE Ignore actions

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TRICARE Non-Billable Rejects – Non TRICARE Sites

• Sites should have at least one or more staff with the PSO TRICARE key

• For example:

• Cannot print a label to fill a prescription for a non-billable product, e.g. a vaccine marked with M or 0

• Check with local revenue staff - patient Insurance may not be entered correctly

• If insurance is correct and you still want to fill the prescription, the reject can be Ignored and the Rx filled

• Need the PSO TRICARE to Ignore a TRICARE claim and fill Rx

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ePharmacy TRICARE Processing Rules – Dual Eligibility

• TRICARE sites have reported challenges surrounding Dual Eligibility

• Pharmacy does not know veteran is using TRICARE eligibility until Rx rejects

• Patient could receive prescription if using veteran eligibility, but Rx not covered by TRICARE

• Guidance at this time is to process under TRICARE billing rules

• If the prescription reject cannot be resolved to payable, TRICARE will not pay, and the site needs to make a decision to provide the prescription or not.

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Outpatient Rx for TRICARE Inpatients

• Outpatient medications for TRICARE inpatients:

• The software will not create an ePharmacy claim for a Outpatient Rx filled for a TRICARE eligible who is an inpatient. (e.g. patient is on a self-medication, a “pass” med or the provider has written a discharge medication order)

• These prescriptions are not billable per the VA/DoD TRICARE MOU, and are billed as part of the inpatient stay

• Since no claim is sent, no rejects will be received and prescriptions are always allowed to be filled.

• TRICARE Bypass/Override Report tracks these TRICARE Inpatient “bypassed” prescriptions. This report is locked with the PSO TRICARE MGR security key.

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Pop Quiz – TRICARE

True or False?

• Any facility that wants to process TRICARE prescriptions can do so right now.

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Pop Quiz Question – TRICARE - answer

Answer: _________

The answer is false. Only 6 facilities are currently approved for TRICARE prescription processing. Others will need to be approved.

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Educational Resources

•ePharmacy TRICARE Support Calls – VANTS 82429• 3rd Wednesday of each month @ 2 pm Eastern

•VistA University – ePharmacy Training Page• http://vaww.vistau.med.va.gov/VistaU/e-bp/e-pharmacy.

htm

• Live Meeting Sessions• e-Pharmacy Checklists• Show-Me videos• Reject & Resolution Guide

•ePharmacy Simulation Training located on VA LMS• How to access ePharmacy web courses on VA LMS • Link to VA LMS

• The TRICARE Eligibility instructions are in  Procedure Guide 1601D.01: TRICARE, Chapter 2:

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Questions?Send your questions to the

VHA ePharmacy Implementation Team

mail group in Outlook