1. Pharmacy Point of Sale
Version D.0 Patch 42

2. Training Objectives Review Patch 42 changes
Review Advance Setup of Insurer (ADV) option
New security key for ADV option
How to add a new insurer using Quick Setup of Insurer (INS)
Review Summary of Insurers (SUMI) Report
How to change Insurers to D.0
The format file (ABSP NCPDP FORMAT)will no longer be used going forward. When Patch 42 is installed, a post-install program will move the site's format information into the Insurer file automatically. The end user should not have to do anything to continue with billing after the install, the same information will be sent to Emdeon after Patch 42 is installed.
The benefit is the sites can now add Insurers any time they need to, without having to wait for a new patch with new formats.
Users now have the ability to change versions from 5.1 to D.0
We have created new functionality when you add a new POS insurer. The user has the ability to enter (BIN, PCN, Version,..) and the system will default the rest of the fields depending on the Insurer type(MCARE,MCAID or Commercial). Most of the time you should not have to make any modifications to the default information. Even if you do, it's something that can be done at the site without needing a new release.
Defaulted Fields include:
MEDICARE PARTD?: N//
Maximum RX's Per Claim: 4//
Add Disp. Fee to Ingr. Cost: NO//
Total exclusive of Patient Amt: N//
Select NCPDP FIELD SPECIAL CODE:
Select SUPPRESS NCPDP SEGMENT:
INSURER NPI FLAG: BOTH
RX - DIAL OUT TO: ENVOY DIRECT VIA T1 LINE
RX - PRICING METHOD: STANDARD
RX PRIORITY Points
We have locked down the ADV INSURER menu option with a new security key so not anyone can change the data.  It is recommended that the key be allocated to a supervisor or super user for point of sale.
Its recommended to use the Quick Setup of Insurer (INS) to set up a new insurer.
The SUMI report was modified to now display the payers that are set up in 5.1 and D.0
The Medicare Part D Eligibility Check report was modified to now be sent in D.0 format

3. Introduction
The major help desk request for Pharmacy Point of Sale was the need for a new format or a modification to the format.  Often times a delay in the release of a patch with these changes would takes months and this would result in loss in revenue for many sites. 
 In patch 42, we have done away with formats and have provided direct access to the user to make changes to BIN, PCN and NCPDP segments immediately.  Once patch 42 is installed, the format layout will be moved to the ABSP insurer file.  All insurers currently setup at each site will run a background conversion and user should not have to make any changes to the current layout.
Also included in patch 42 is the NCPDP version D.0 which goes into effect January 1, We have tested many top insurers such as Argus, Medco and Caremark among others. Users will have to change the version to D.0 for insurers that are ready to accept claims and for those insurers D.0 testing has been completed.

4. What is D.0?
Version D.0 is the new version of the National Council for Prescription Drug programs (NCPDP) standards for pharmacy transactions that replaces version 5.1.
The mandatory compliance date for Version D.0 is January 1, 2012.

5. Highlights of Patch 42 NCPDP version D.0
No more formats to link to insurers
Advance Insurer setup option allows edits by user
Quick and Advance Insurer setup creates a default layout based on insurer type
New security key for ADV option
SUMI report sorts by 5.1 and D.0 version

6. Advance Setup of Insurer - ADV
User input needed for the following fields:
NCPDP VERSION: D.0//
BIN NUMBER: //
PCN NUMBER: MEDDPRIME//
RX - Dispensing Fee:
GRACE PERIOD: 0//
RX - Help Telephone #: (888) //
Default set for the following fields:
Add Disp. Fee to Ingr. Cost: NO//
*Contract Required: NO//
Total exclusive of Patient Amt: N//
INSURER NPI FLAG: BOTH//
RX - DIAL OUT TO: ENVOY DIRECT VIA T1 LINE//
RX - PRICING METHOD: STANDARD//

7. Default for type of insurer
MEDICARE
MEDICAID
PRIVATE
MEDICARE PARTD?: Y//
MEDICARE PARTD?: N//
Maximum RX's Per Claim: 1//
Maximum RX's Per Claim: 4//
RX PRIORITY: 650//
RX PRIORITY: 5//
RX PRIORITY: 20//
NCPDP FIELD SPECIAL CODE:
304, 436, 455
436, 455
SUPPRESS NCPDP FIELD:
115, 147, 334, 350, 354, 357, 359, 360, 361, 364, 365, 366, 367, 368, 384, 391, 420, 458, 459, 494, 495, 496, 497, 498, 499, 524, 995, 996, 997

8. ADV – Security Key ABSPZ INSURER
NOTE: With more control, there is also concern for problems for unnecessary changes to insurer setup. A security key (ABSPZ INSURER) has been assigned to the ADV option. It is recommended the security key be allocated only to a supervisor or super user of Point of Sale. Please see your local IT person to have this key assigned to you.

9. Quick Setup of Insurer - INS
POS - Pharmacy Point of Sale  MGR - Pharmacy POS Manager Menu  SET - Pharmacy Point of Sale Setup Menu  INS - Edit Pharmacy POS Insurance settings  INS - Quick setup of insurer
Are you adding 'D-ARGUS' as a new ABSP INSURER (the 190TH)? No// Y (Yes) NCPDP VERSION: D.0 BIN NUMBER: PCN NUMBER: TEST123 MEDICARE PARTD?: Y// Maximum RX's Per Claim: 1// Select the PRICING METHOD RX - PRICING METHOD: STANDARD// NOTE: It is recommended to use this option when setting up a new insurer before any changes are made in the Advanced Insurer Setup Option

10. Adding A New Insurer
REG - Patient registration  TM - Table Maintenance Menu INS - Insurer File Menu  EINS - Add/Edit an Insurer
NAME: D-ARGUS// TYPE OF INSURER: PRIVATE// ?? Choose from: D MEDICAID FI P PRIVATE MD MCR PART D TYPE OF INSURER: PRIVATE// MD MCR PART D LONG NAME: D-ARGUS// STREET: P.O. BOX 298 CITY: TROY STATE: NEW YORK// ZIP: 12181// PHONE: (888)

11. Summary of Insurers – SUMI
POS - Pharmacy Point of Sale  MGR - Pharmacy POS Manager Menu  SET - Pharmacy Point of Sale Setup Menu  SUMI - POS Setup - Summary of Insurers
PHARMACY ELECTRONIC CLAIMS INSURERS NOV 17, :51 PAGE 1 Grace Ins. Disp Fee Per Sel. Insurer Pricing Formula Override Override Pts Using NCPDP VERSION: 5.1 BIN: NPI FLAG: BOTH D-RX AMERICA STANDARD BIN: GROUP HEALTH RX STANDARD WESTERN RX STANDARD LOVELACE SALUD RX STANDARD NPI FLAG: EMPTY Using NCPDP VERSION: D.0 BIN: CXX PRIVATE D.O STANDARD BIN: XYZ MEDICAID D.0 STANDARD 5.00

12. D.0 checklist 1. Run Fileman Report of all insurers/BIN/PCN
2. Completed D.0 testing payer list
3. Print list of NCPDP fields
4. Caremark, Medco, Argus setup examples
5. Common rejections
6. Suppress/un-suppress NCPDP fields

13. Fileman Report List of Insurers that are associated with formats
OUTPUT FROM WHAT FILE: ABSP INSURER//
SORT BY: NUMBER// RX - NCPDP Record Format 
START WITH RX - NCPDP Record Format: FIRST//
WITHIN RX - NCPDP Record Format, SORT BY:
FIRST PRINT FIELD: NAME;C1;L30;"" 
THEN PRINT FIELD: "^";C31;L1
THEN PRINT FIELD: RX - NCPDP Record Format;C32;L30;""
THEN PRINT FIELD: RX - NCPDP Record Format:    <- DO NOT FORGET TO USE A COLON TO WALK OVER TO FORMAT FILE
THEN PRINT ABSP NCPDP FORMATS FIELD: "^";C62;L1
  THEN PRINT ABSP NCPDP FORMATS FIELD: NDC BIN Number;C63;L15;""
  THEN PRINT ABSP NCPDP FORMATS FIELD: "^";C78;L1
  THEN PRINT ABSP NCPDP FORMATS FIELD: Processor Control Number;C79;L20;''
    THEN PRINT ABSP NCPDP FORMATS FIELD:
THEN PRINT FIELD:
 Heading (S/C)://
STORE PRINT LOGIC IN TEMPLATE:
DEVICE: ;132;5000

14. File Man Report - Example
ABSP INSURER LIST DEC 15, :13 PAGE 1
Processor Control Number
RX NC SENIOR CARE PROGRAM ^ACS NC SENIOR CARE ^ ^
RX D-SILVERSCRIPT ^ADV RX MGT MEDICARE PDP ^ ^ADV HDN
RX ADVANCE RX ^ADVANCE PRSCPT MGMT ADV ^ ^ADV HDN
D-SILVER SCRIPT ^ADVANCE PRSCPT MGMT ADV ^ ^ADV HDN
RX AETNA US PHARMACY ^AETNA ^ ^670000
RX ANTHEM ^ALASKA NATIVE TRIBAL HLTH 5.1 ^ ^WISRX
MAILHANDLERS ^ALTA RX ^ ^
ALTA RX ^ALTA RX ^ ^
PHARMANET RX ^ALTA RX ^ ^
RX AMERICAN HEALTH CARE ^AMERICAN HEALTH CARE ^ ^AHC TQC
RX D-CMS DUAL ^ANTHEM ^ ^
RX AMERIHEALTH MERCY ^ARGUS REGENCE BCBS WA ^ ^
ARGUS RX ^ARGUS REGENCE BCBS WA ^ ^
D-BC/BS OF NORTH DAKOTA ^BC/BS NORTH DAKOTA ^ ^NDBCS
RX BLUESCRIPT ^BLUESCRIPT BCBS ILLINOIS 5.1 ^ ^ILSC
MEDICAID-TEST ^CALIFORNIA MED-CAL ^ ^NONE
RX CAREFIRST ^CAREFIRST BCBS ^ ^
CAREMARK D ^CAREMARK ^ ^CRK
RX D-ADVANTRA RX ^CAREMARK ^ ^CRK
HAMMERMILL HEALTH ^CAREMARK ^ ^CRK

15. D.0 Payer Implementation List
ftp://ftp.ihs.gov/rpms/POS/

16. Argus Payer Tab

17. List of NCPDP fields NCPDP FIELD NUMBER NCPDP FIELD NAME
POS-Pharmacy Point of Sale  RPT-Pharmacy electronic claims reports  OTH-Other reports FLD-List NCPDP Fields
NCPDP
FIELD
NUMBER NCPDP FIELD NAME
BIN NUMBER
VERSION/RELEASE NUMBER
TRANSACTION CODE
PROCESSOR CONTROL NUMBER
Transaction Count
Software Vendor/Cert ID
Segment Identification
Transaction Response Status
MEDICAID PAID AMOUNT
MEDICAID SUBROGATION ICN
MEDICAID ID NUMBER
MEDICAID AGENCY NUMBER
BILLING ENTITY TYPE IND
PAY TO QUALIFIER

18. Caremark D.0 setup
Select Edit Pharmacy POS Insurance settings Option: ADV Advanced setup of insurer Select ABSP INSURER NAME: CAREMARK( CAREMARK ).... NAME: RX D-CAREMARK// NCPDP VERSION: 5.1// D.0 BIN NUMBER: // PCN NUMBER: CRK// Select NCPDP FIELD SPECIAL CODE: 455// 110 Software Vendor/Cert ID SPECIAL CODE: S ABSP("X")=“D "

19. Argus D.0 Setup
Select Edit Pharmacy POS Insurance settings Option: ADV Advanced setup of insurer Select ABSP INSURER NAME: ARGUS( ARGUS )... NAME: ARGUS RX// NCPDP VERSION: 5.1// D.0 BIN NUMBER: // PCN NUMBER: Select NCPDP FIELD SPECIAL CODE: 455// 110 Software Vendor/Cert ID SPECIAL CODE: S ABSP("X")="601DN30Y"

20. Medco D.0 Setup
Select Edit Pharmacy POS Insurance settings Option: adv Advanced setup of insurer Select ABSP INSURER NAME: medco( MEDCO/MEDCOST ) NAME: MEDCO RX// NCPDP VERSION: 5.1// D.0 BIN NUMBER: // PCN NUMBER: 49110// Select NCPDP FIELD SPECIAL CODE: 455// 110 Software Vendor/Cert ID SPECIAL CODE: S ABSP("X")="INF"

21. Correcting Rejections
Correcting the top 5 rejections
M/I Gross Amount Due
Unsuppress Field 430
Value In Gross Amount Due Does Not Follow Pricing Formulary
Unsuppress field 412
M/I Patient Last Name
Unsuppress field 311                                         
M/I Cardholder ID
Unsuppress field 313
Express Scripts – Tricare
Group Number change from TRRX to DODA

22. Example Rejection
- - Prescription - - Authorization Number: Medication Order: 1 Prescription/Service Ref Num: Prescription/Srvc Ref Num Qual: 1 Prior Auth Processed Date: NOV 10,2011 Reject code: 20 M/I Cardholder Last Name Reject Count:1 Response Status (Prescription): R Transaction Response Status: REJECTED CLAIM

23. Definitions Suppressed vs. Unsuppressed
Suppressed – The NCPDP field is not going across on the claim
Unsuppressed – The NCPDP field will cross over on the claim

24. Unsuppress NCPDP Fields
Select SUPPRESS NCPDP SEGMENT: Narrative// Select SUPPRESS NCPDP FIELD: 997// 313 CARDHOLDER LAST NAME ...OK? Yes// Y (Yes) SUPPRESS NCPDP FIELD: SURE YOU WANT TO DELETE THE ENTIRE SUPPRESS NCPDP FIELD? Y (Yes) Select SUPPRESS NCPDP FIELD:
Note: Anytime a field is unsuppressed use the option NEW to resubmit your claim

25. Enter/Edit RPMS Insurance File Rx Settings
POS - Pharmacy Point of Sale  MGR - Pharmacy POS Manager Menu  SET - Pharmacy Point of Sale Setup Menu  INS - Edit Pharmacy POS Insurance settings  RPMS - Enter/edit RPMS Insurance file RX settings
Select INSURER NAME: D-ARGUS NEW YORK OK? Yes// Yes RX BILLING STATUS: ?? These codes identify how to process pharmacy charges for a payer. Code "U" means drugs are not billable. Code "O" means only outpatient drugs are billable. Code "P" means the drugs are billable through Point Of Sale. Choose from: U UNBILLABLE O OUTPATIENT DRUGS ONLY P BILLED POINT OF SALE RX BILLING STATUS: BILLED POINT OF SALE

26. Three Tiered Support Structure
Phone:
Help
Desk
Area IT Support
Local Support
“Currently there is a 3 tiered RPMS support structure.
Local support. Usually the Site Manager.
Area IT support. Usually area help desk.
IHS RPMS Help desk.
Which support should you be going to first?
Answer: Local Support.

27. Questions What if… How do you do this… Can you explain …
I don’t Understand…
Why this happening?
Help!!