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Pharmacy Point of Sale Version D.0 Patch 42. Training Objectives Review Patch 42 changesReview Advance Setup of Insurer (ADV) optionNew security key for.

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Presentation on theme: "Pharmacy Point of Sale Version D.0 Patch 42. Training Objectives Review Patch 42 changesReview Advance Setup of Insurer (ADV) optionNew security key for."— Presentation transcript:

1 Pharmacy Point of Sale Version D.0 Patch 42

2 Training Objectives Review Patch 42 changesReview Advance Setup of Insurer (ADV) optionNew security key for ADV optionHow to add a new insurer using Quick Setup of Insurer (INS)Review Summary of Insurers (SUMI) ReportHow to change Insurers to D.0

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, 2012. 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 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. What is D.0?

5 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 Highlights of Patch 42

6 User input needed for the following fields: NCPDP VERSION: D.0// BIN NUMBER: 610100// PCN NUMBER: MEDDPRIME// RX - Dispensing Fee: GRACE PERIOD: 0// RX - Help Telephone #: (888)888-8888// 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// Advance Setup of Insurer - ADV

7 MEDICARE MEDICARE PARTD?: Y// Maximum RX's Per Claim: 1// RX PRIORITY: 650// NCPDP FIELD SPECIAL CODE: 304, 436, 455 MEDICAID MEDICARE PARTD?: N// Maximum RX's Per Claim: 4// RX PRIORITY: 5// NCPDP FIELD SPECIAL CODE: 304, 436, 455 PRIVATE MEDICARE PARTD?: N// Maximum RX's Per Claim: 4// RX PRIORITY: 20// NCPDP FIELD SPECIAL CODE: 436, 455 Default for type of insurer 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 Are you adding 'D-ARGUS' as a new ABSP INSURER (the 190TH)? No// Y (Yes) NCPDP VERSION: D.0 BIN NUMBER: 123456 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 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 Quick Setup of Insurer - INS

10 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)888-8881 REG - Patient registration TM - Table Maintenance Menu INS - Insurer File Menu EINS - Add/Edit an Insurer Adding A New Insurer

11 POS - Pharmacy Point of Sale MGR - Pharmacy POS Manager Menu SET - Pharmacy Point of Sale Setup Menu SUMI - POS Setup - Summary of Insurers Summary of Insurers – SUMI PHARMACY ELECTRONIC CLAIMS INSURERS NOV 17,2011 16:51 PAGE 1 Grace Ins. Disp Fee Per Sel. Insurer Pricing Formula Override Override Pts. -------------------------------------------------------------------------------- ----- Using NCPDP VERSION: 5.1 BIN: 123456 NPI FLAG: BOTH D-RX AMERICA STANDARD 4.50 0 650.00 BIN: 600428 NPI FLAG: BOTH GROUP HEALTH RX STANDARD 4.50 0 20.00 WESTERN RX STANDARD 4.50 0 20.00 LOVELACE SALUD RX STANDARD 4.50 0 5.00 NPI FLAG: EMPTY ----- Using NCPDP VERSION: D.0 BIN: 123221 NPI FLAG: BOTH CXX PRIVATE D.O STANDARD 20.00 BIN: 123321 NPI FLAG: BOTH XYZ MEDICAID D.0 STANDARD 5.00

12 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 D.0 checklist

13 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 List of Insurers that are associated with formats Fileman Report

14 File Man Report - Example ABSP INSURER LIST DEC 15,2011 11:13 PAGE 1 Processor Control Number ------------------------------------------------------------------------------------------------ RX NC SENIOR CARE PROGRAM ^ACS NC SENIOR CARE 5.1 ^610084 ^ RX D-SILVERSCRIPT ^ADV RX MGT MEDICARE PDP 5.1 ^004336 ^ADV HDN RX ADVANCE RX ^ADVANCE PRSCPT MGMT ADV 5.1 ^004336 ^ADV HDN D-SILVER SCRIPT ^ADVANCE PRSCPT MGMT ADV 5.1 ^004336 ^ADV HDN RX AETNA US PHARMACY ^AETNA 5.1 ^610502 ^670000 RX ANTHEM ^ALASKA NATIVE TRIBAL HLTH 5.1 ^004336 ^WISRX MAILHANDLERS ^ALTA RX 5.1 ^002286 ^6000002286 ALTA RX ^ALTA RX 5.1 ^002286 ^6000002286 PHARMANET RX ^ALTA RX 5.1 ^002286 ^6000002286 RX AMERICAN HEALTH CARE ^AMERICAN HEALTH CARE 5.1 ^610118 ^AHC TQC RX D-CMS DUAL ^ANTHEM 5.1 ^610575 ^ RX AMERIHEALTH MERCY ^ARGUS REGENCE BCBS WA 5.1 ^600428 ^ ARGUS RX ^ARGUS REGENCE BCBS WA 5.1 ^600428 ^ D-BC/BS OF NORTH DAKOTA ^BC/BS NORTH DAKOTA 5.1 ^610455 ^NDBCS RX BLUESCRIPT ^BLUESCRIPT BCBS ILLINOIS 5.1 ^011552 ^ILSC MEDICAID-TEST ^CALIFORNIA MED-CAL 5.1 ^610442 ^NONE RX CAREFIRST ^CAREFIRST BCBS 5.1 ^011834 ^03000000 CAREMARK D.0 447225 ^CAREMARK 5.1 ^610029 ^CRK RX D-ADVANTRA RX ^CAREMARK 5.1 ^610029 ^CRK HAMMERMILL HEALTH ^CAREMARK 5.1 ^610029 ^CRK

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

16 Argus Payer Tab

17 NCPDP FIELD NUMBER NCPDP FIELD NAME -------------------------------------------------------------------------------- 101 BIN NUMBER 102 VERSION/RELEASE NUMBER 103 TRANSACTION CODE 104 PROCESSOR CONTROL NUMBER 109 Transaction Count 110 Software Vendor/Cert ID 111 Segment Identification 112 Transaction Response Status 113 MEDICAID PAID AMOUNT 114 MEDICAID SUBROGATION ICN 115 MEDICAID ID NUMBER 116 MEDICAID AGENCY NUMBER 117 BILLING ENTITY TYPE IND 118 PAY TO QUALIFIER POS-Pharmacy Point of Sale RPT-Pharmacy electronic claims reports OTH-Other reports FLD-List NCPDP Fields List of NCPDP fields

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: 610029// PCN NUMBER: CRK// Select NCPDP FIELD SPECIAL CODE: 455// 110 Software Vendor/Cert ID SPECIAL CODE: S ABSP("X")=D012000084"

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: 600428// PCN NUMBER: 03020000 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: 003585// PCN NUMBER: 49110// Select NCPDP FIELD SPECIAL CODE: 455// 110 Software Vendor/Cert ID SPECIAL CODE: S ABSP("X")="INF"

21 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 Correcting the top 5 rejections Correcting Rejections

22 Example Rejection - - Prescription - - Authorization Number: 113145297006024999 Medication Order: 1 Prescription/Service Ref Num: 815214 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 Suppressed – The NCPDP field is not going across on the claimUnsuppressed – The NCPDP field will cross over on the claim Suppressed vs. Unsuppressed Definitions

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: 313// @ 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 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 Enter/Edit RPMS Insurance File Rx Settings Select INSURER NAME: D-ARGUS NEW YORK 12181 Yes...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 Help Desk Area IT Support Local Support Phone: 888-830-7280 E-mail: support@ihs.gov

27 Questions How do you do this… I dont Understand… Can you explain … Help!! Why this happening? What if…


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