2 Training Objectives Review Patch 42 changes Review 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.0The 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.0We 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: BOTHRX - DIAL OUT TO: ENVOY DIRECT VIA T1 LINERX - PRICING METHOD: STANDARDRX PRIORITY PointsWe 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.0The Medicare Part D Eligibility Check report was modified to now be sent in D.0 format
3 IntroductionThe 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 insurersAdvance Insurer setup option allows edits by userQuick and Advance Insurer setup creates a default layout based on insurer typeNew security key for ADV optionSUMI 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 MEDICAREMEDICAIDPRIVATEMEDICARE 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, 455436, 455SUPPRESS 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 insurerAre 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 InsurerREG - Patient registration TM - Table Maintenance Menu INS - Insurer File Menu EINS - Add/Edit an InsurerNAME: 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 InsurersPHARMACY 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 list3. Print list of NCPDP fields4. Caremark, Medco, Argus setup examples5. Common rejections6. 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;L1THEN 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 FILETHEN 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 1Processor Control NumberRX NC SENIOR CARE PROGRAM ^ACS NC SENIOR CARE ^ ^RX D-SILVERSCRIPT ^ADV RX MGT MEDICARE PDP ^ ^ADV HDNRX ADVANCE RX ^ADVANCE PRSCPT MGMT ADV ^ ^ADV HDND-SILVER SCRIPT ^ADVANCE PRSCPT MGMT ADV ^ ^ADV HDNRX AETNA US PHARMACY ^AETNA ^ ^670000RX ANTHEM ^ALASKA NATIVE TRIBAL HLTH 5.1 ^ ^WISRXMAILHANDLERS ^ALTA RX ^ ^ALTA RX ^ALTA RX ^ ^PHARMANET RX ^ALTA RX ^ ^RX AMERICAN HEALTH CARE ^AMERICAN HEALTH CARE ^ ^AHC TQCRX 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 ^ ^NDBCSRX BLUESCRIPT ^BLUESCRIPT BCBS ILLINOIS 5.1 ^ ^ILSCMEDICAID-TEST ^CALIFORNIA MED-CAL ^ ^NONERX CAREFIRST ^CAREFIRST BCBS ^ ^CAREMARK D ^CAREMARK ^ ^CRKRX D-ADVANTRA RX ^CAREMARK ^ ^CRKHAMMERMILL HEALTH ^CAREMARK ^ ^CRK
15 D.0 Payer Implementation List ftp://ftp.ihs.gov/rpms/POS/
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 FieldsNCPDPFIELDNUMBER NCPDP FIELD NAMEBIN NUMBERVERSION/RELEASE NUMBERTRANSACTION CODEPROCESSOR CONTROL NUMBERTransaction CountSoftware Vendor/Cert IDSegment IdentificationTransaction Response StatusMEDICAID PAID AMOUNTMEDICAID SUBROGATION ICNMEDICAID ID NUMBERMEDICAID AGENCY NUMBERBILLING ENTITY TYPE INDPAY TO QUALIFIER
18 Caremark D.0 setupSelect 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 SetupSelect 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 SetupSelect 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 rejectionsM/I Gross Amount DueUnsuppress Field 430Value In Gross Amount Due Does Not Follow Pricing FormularyUnsuppress field 412M/I Patient Last NameUnsuppress field 311 M/I Cardholder IDUnsuppress field 313Express Scripts – TricareGroup 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 claimUnsuppressed – 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 settingsSelect 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:HelpDeskArea IT SupportLocal 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!!