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:
Pharmacy Point of Sale Version D.0 Patch 42
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
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.
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, What is D.0?
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
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// Advance Setup of Insurer - ADV
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
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.
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 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
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) REG - Patient registration TM - Table Maintenance Menu INS - Insurer File Menu EINS - Add/Edit an Insurer Adding A New Insurer
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, :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: NPI FLAG: BOTH GROUP HEALTH RX STANDARD WESTERN RX STANDARD LOVELACE SALUD RX STANDARD NPI FLAG: EMPTY Using NCPDP VERSION: D.0 BIN: NPI FLAG: BOTH CXX PRIVATE D.O STANDARD BIN: NPI FLAG: BOTH XYZ MEDICAID D.0 STANDARD 5.00
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
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
File Man Report - Example ABSP INSURER LIST DEC 15, :13 PAGE 1 Processor Control Number RX NC SENIOR CARE PROGRAM ^ACS NC SENIOR CARE 5.1 ^ ^ RX D-SILVERSCRIPT ^ADV RX MGT MEDICARE PDP 5.1 ^ ^ADV HDN RX ADVANCE RX ^ADVANCE PRSCPT MGMT ADV 5.1 ^ ^ADV HDN D-SILVER SCRIPT ^ADVANCE PRSCPT MGMT ADV 5.1 ^ ^ADV HDN RX AETNA US PHARMACY ^AETNA 5.1 ^ ^ RX ANTHEM ^ALASKA NATIVE TRIBAL HLTH 5.1 ^ ^WISRX MAILHANDLERS ^ALTA RX 5.1 ^ ^ ALTA RX ^ALTA RX 5.1 ^ ^ PHARMANET RX ^ALTA RX 5.1 ^ ^ RX AMERICAN HEALTH CARE ^AMERICAN HEALTH CARE 5.1 ^ ^AHC TQC RX D-CMS DUAL ^ANTHEM 5.1 ^ ^ RX AMERIHEALTH MERCY ^ARGUS REGENCE BCBS WA 5.1 ^ ^ ARGUS RX ^ARGUS REGENCE BCBS WA 5.1 ^ ^ D-BC/BS OF NORTH DAKOTA ^BC/BS NORTH DAKOTA 5.1 ^ ^NDBCS RX BLUESCRIPT ^BLUESCRIPT BCBS ILLINOIS 5.1 ^ ^ILSC MEDICAID-TEST ^CALIFORNIA MED-CAL 5.1 ^ ^NONE RX CAREFIRST ^CAREFIRST BCBS 5.1 ^ ^ CAREMARK D ^CAREMARK 5.1 ^ ^CRK RX D-ADVANTRA RX ^CAREMARK 5.1 ^ ^CRK HAMMERMILL HEALTH ^CAREMARK 5.1 ^ ^CRK
ftp://ftp.ihs.gov/rpms/POS/ D.0 Payer Implementation List
Argus Payer Tab
NCPDP FIELD NUMBER NCPDP FIELD NAME 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
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 "
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"
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"
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
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
Suppressed – The NCPDP field is not going across on the claimUnsuppressed – The NCPDP field will cross over on the claim Suppressed vs. Unsuppressed Definitions
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
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 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
Three Tiered Support Structure Help Desk Area IT Support Local Support Phone:
Questions How do you do this… I dont Understand… Can you explain … Help!! Why this happening? What if…