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© Affiliated Computer Services, Inc. (ACS) 2007, 2008 DC PBM Compound Training June 24, 2009 and June 30, 2009
© Affiliated Computer Services, Inc. (ACS) 2008 Slide 2 Overview Introductions DC Compound Coverage DC DHCF Payer Specifications Multi-Line Compound Claim Guidelines IV and TPN Compound Submission Paper Claim Compound Submission Compound Reimbursement Questions?
© Affiliated Computer Services, Inc. (ACS) 2008 Slide 3 Introductions ACS Atlanta Staff Karen Crowley Louise Gustafson Daniel Shackelford, PharmD ACS DC Staff Wallene Bullard, PharmD Patricia Sims, PharmD
© Affiliated Computer Services, Inc. (ACS) 2008 Slide 4 DC Compound Coverage Provider Manual Section 5 - Compounds 5.1 Multi-Line Compound Claim Submission 5.2 IV Compound Submission and Dispensing Fee Section 6 - Paper Claim (Note: Pharmacies have 181 days from the first Date of Service (DOS) to submit an original claim. The timely filing rules apply to both POS and paper claims.) Universal Claim Form
© Affiliated Computer Services, Inc. (ACS) 2008 Slide 5 DC DHCF Payer Specifications NCPDP Version 5.1 Payer Sheet Claim Segment (Ø7) –Field 4Ø6-D6 - Compound Code »Ø = Not specified »1 = Not a compound »2 = Compound –42Ø-DK - Submission Clarification Code »Ø8 = Process compound for Approved Ingredients »This allows payment for covered ingredients and ignores non-covered ingredients
© Affiliated Computer Services, Inc. (ACS) 2008 Slide 6 DC DHCF Payer Specifications (cont.) NCPDP Version 5.1 Payer Sheet Compound Segment (1Ø) – Field 45Ø-EF - Compound Dosage Form Description Code * » Ø3 = Cream » Ø4 = Suppository » 11 = Solution » 12 = Suspension – 451-EG - Compound Dispensing Unit Form Indicator » 1 = Each » 2 = Grams » 3 = Milliliters * Some examples only - not inclusive of all valid values
© Affiliated Computer Services, Inc. (ACS) 2008 Slide 7 DC DHCF Payer Specifications (cont.) NCPDP Version 5.1 Payer Sheet Compound Segment (1Ø) – Field 452-EH - Compound Route of Administration * » 4 = Injection » 7 = Mouth/Throat » 11 = Oral » 17 = Topical – Field 447-EC - Compound Ingredient Component Count – Field 488-RE - Compound Product ID Qualifier Ø3 = National Drug Code (NDC) – Field 489-TE - Compound Product ID (NDC) – Field 448-ED - Compound Ingredient Quantity * Some examples only - not inclusive of all valid values
© Affiliated Computer Services, Inc. (ACS) 2008 Slide 8 Multi-Line Compound Claim Guidelines Compounds submitted with compound code = 2 must contain more than one ingredient Multi-line compounds are adjudicated line by line If one or more ingredients are denied, the entire compound will deny Submit “Submission Clarification Code” = “Ø8” to allow processing of covered ingredients To request PA of non-covered ingredients, contact Help Desk at (800) or fax PA form to (866) Compounds exceeding $ require UCF submission
© Affiliated Computer Services, Inc. (ACS) 2008 Slide 9 IV and TPN Compound Submission IV compound claims are determined by submitting a medication with an IV route of administration All IV compounds require prior authorization for submission (POS and Paper) Without PA claims will reject with NCPDP Reject Code 70 – Product/Service Not Covered Compounds containing an ingredient in Therapeutic Class C5B are classified as TPN claims
© Affiliated Computer Services, Inc. (ACS) 2008 Slide 10 Compound Reimbursement Compound Type Ingredient Cost (Each Line Item Calculated Separately) Dispensing Fee (For Entire Compound) ALL Compounds (excluding IV and TPN) Lesser of Submitted Ingredient Cost or District Allowed Amount or FMAC $4.50 IV Lesser of Submitted Ingredient Cost or District Allowed Amount or FMAC $7.25 TPN Lesser of Submitted Ingredient Cost or District Allowed Cost or FMAC $17.25
© Affiliated Computer Services, Inc. (ACS) 2008 Slide 11 Paper Claim Compound Submission When submitting paper claim forms, DC DHCF requires the use of the NCPDP Standard Universal Claim form. Paper claims are required for compound claims over $ Paper Claims should be sent to the ACS Call Center at the address below: ACS P.O. Box 967 Henderson, NC Attn: Paper Claims Processing
© Affiliated Computer Services, Inc. (ACS) 2008 Slide 12 Sample Compound Claims
© Affiliated Computer Services, Inc. (ACS) 2008 Slide 13 Sample Compound Claims
© Affiliated Computer Services, Inc. (ACS) 2008 Slide 14 Sample Compound Claims
© Affiliated Computer Services, Inc. (ACS) 2008 Slide 15
© Affiliated Computer Services, Inc. (ACS) 2008 Slide 16
© Affiliated Computer Services, Inc. (ACS) 2008 Slide 17
© Affiliated Computer Services, Inc. (ACS) 2008 Slide 18 Questions?
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