1. ePharmacy Update for Pharmacy Informatics
Veterans Health Administration Chief Business Office Business Development ePharmacy Team
ePharmacy Update for Pharmacy Informatics

2. Agenda ePharmacy Project Overview
ePharmacy team and project information
ePharmacy Statistics
ePharmacy Enhancements
Billing Methodology Change - Potential Impact
Pharmacy actions to maximize revenue
ePharmacy Training
TRICARE Processing differences & Business Rules
Questions
First I want to thank Rosemary and Daphene and Phill and whoever else was responsible for allowing ePharmacy to have a presence at this meeting.
I would also like to recognize the ePharmacy POC’s and ePharmacy Site managers
As far as our agenda:
I will be providing a brief Overview of our ePharmacy project that will include some
ePharmacy team and project information
I have a few slides on ePharmacy Statistics that may interest some of you.
I will provide an overview of the ePharmacy Enhancements we are currently working on.
I have some slides on the Billing Methodology Change and it’s potential Impact
I have included some Pharmacy actions you may consider to help maximize revenue
I will go over some ePharmacy training we have recently given and review some other training we have planned.
If there is time I want to review some differences with regard to processing TRICARE prescriptions and some business rules involved
At the end of the session I will try to answer any questions you may have.

3. ePharmacy Project Overview
ePharmacy is the e-business initiative enabling real-time electronic prescription claims to the PBM/payer.
All pharmacies have been submitting claims to 3rd party PBM/payers since September 2008
ePharmacy is not involved with billing for the provision of Pharmacy services, for example medication management programs
ePharmacy is not the same as ePrescribing, which is the electronic transfer of prescription information from prescriber to pharmacy
ePharmacy is sometimes mistakenly referred to as eBilling, a term that can refer to other types of electronic billing
As you probably know, with ePharmacy the VA bills prescriptions electronically and this can be done in real time, as well as through back-billing.
All VA Pharmacies are submitting prescription claims via ePharmacy and the majority of claims are submitted this way.
So far we have not been involved with billing for medication management, which if done is billed in a separate way.
Just to make sure you know, don’t confuse us with some of the other programs and initiatives that start with an ‘e’ like ePrescribing and eBilling

4. ePharmacy Project Overview cont.
The ePharmacy Implementation team is responsible for ensuring the project is functional and meets goals etc.
Connie Meeker is Project Manager
Ellen Giglia is an ePharmacy Implementation manager for revenue related issues
Deb Wistuba is an ePharmacy Implementation manager for revenue related issues
Gwyn Smith is CBO Liaison
Greg Laird is an ePharmacy Implementation manager for Pharmacy related issues
These are the ladies I get to work with on the ePharmacy team
Connie Meeker is our Project Manager. Connie has a background as a revenue analyst and coordinator
Ellen Giglia has a background in education, but she has also worked in VA facility computer departments throughout the VA system.
Deb Wistuba has a VA revenue background including billing and account receivable, and is also our payer relations laision.
Gwyn Smith coordinates several VA ePharmacy projects and is our go-between with CBO top level management.

5. ePharmacy Fill Volume Calendar Year 2010
A fill is an instance of a single prescription prepared for a patient and electronically submitted to a Pharmacy Benefit Manager (PBM)/payer.
2010 Total Fills
6,043,357
2010 Average Fills per Month
503,613
Here is the first of just a few statistics slides I will show. This shows the number of ePharmacy prescriptions generated in FCY10.
Claim numbers have increased this year because of the electronic conversion of the BCBS FEP claims.
Our total claims volume, which counts the claims generated for prescription fills that have multiple transmissions, has just recently went over the million claims per month mark.
Anyone interested in the dollar volumes can ask your revenue office (OPECC) to run the Payable Claims report. Reimbursement is expected to increase because of FEP and the Billing Methodology changes.

6. ePharmacy by the Numbers
There were a total of 136,695,024 prescriptions filled by VA facilities in CY 2010
ePharmacy fills accounted for 6,043,357 of those 136,695,024 prescriptions or 4.4% of total fills
Another way to look at the relative impact of ePharmacy is to show the percentage of claims to total fills. You can see that ePharmacy prescriptions account for less than 5% of total Rx fills.
The prescription fills were obtained from the ProClarity PBM Outpatient cube data. Our data people obtained the claims numbers from AAC data.
The facilities with the highest percentages are only about 10%.

7. ePharmacy Rejections Overview Calendar Year 2010
2010 Claim Rejection Categories
This pie chart compares the percent of claims initially rejected in 2010 by rejection category. The percent values represent the rejection rate as a percent of total claims. A claim is used to submit a prescription fill to a PBM/payer for reimbursement.
When rejected, claims are returned to VHA with one or more rejection codes that indicate why a claim was rejected. Similar rejection codes are grouped together into rejection categories. A claim can be rejected for multiple reasons and counted under multiple categories. Therefore, the sum of the rejection rates by category may overstate the overall rejection rate.
This slide shows the CY 2010 percentages of rejects that pharmacy helps resolve and/or are interested in.
You can see that Refill Too Soon and DUR rejects together account for about 5% of all rejects. The other rejects Pharmacy needs to help resolve make up another percent.
If an NDC reject does need to be resolved, Pharmacy usually needs to do that. Even though NDC rejects account for a about 2.4% of total claims they get lot’s of attention so we will review those in a little more detail.
The 90 day fill rejects is an issue the ePharmacy team has been spending quite a bit of time on recently.
2010 Total Claims 8,709,575
2010 Rejected Claims 3,034,204
2010 Overall Rejection Rate 34.84%

8. NDC Rejects
About 2.4% of overall rejects are for product related (NDC) reasons
The overwhelming majority of our NDC rejects have to do with some sort of repackaged drug
About 64% of our NDC rejects are for Aphena Pharma Solutions (PrePak Systems) products
Repackaged drug products need to be registered with the major drug information databases First DataBank and Medispan, to be recognized by the third parties
Only about 2.4% of overall rejects are for product related (NDC) reasons, and the overwhelming majority of our NDC rejects have to do with some sort of repackaged drug.
We use one major re-packager, and about 64% of our NDC rejects are for Aphena Pharma Solutions – formerly PrePak Systems products
These repackaged drug products need to be registered with the major drug information databases First DataBank and Medispan, to be recognized by the third parties, and there-in lies the problem.

9. NDC Rejects
Most of our Aphena Pharma Solutions product rejects are due to the product being re-packaged, then sent back to the CMOP and used before the registration is complete
Some third party plans do not reimburse for re-packaged products
One of our ePharmacy business rules is to transmit the NDC used to fill the prescription
Facilities should not change the NDC to some other NDC just to get reimbursed.
Most of our Aphena Pharma Solutions product rejects are due to the product being re-packaged, then sent back to the CMOP and used before the registration is complete
The other major reason we see rejects for re-packaged drugs is because some third party plans do not reimburse for re-packaged products
Just a reminder that one of our ePharmacy business rules is to transmit the NDC used to fill the prescription
Facilities should not change the NDC to some other NDC just to get reimbursed.

10. 90 Day Fill Rejects
There has been recent interest from some VAs with the system to capture revenue lost as a result of 90 day fill rejects
Some of the methods proposed have been:
Designate VA CMOPs as mail-order pharmacies
Pursue legislation to mandate reimbursement for 90 day fills
Change 90 day fill prescriptions to 30 day fills to be reimbursed
The CBO and PBM have extensively researched and evaluated the issue
For various reasons, none of the methods listed above are recommended at this time
The CBO will continue to pursue methods to reduce the number of 90 day fill rejects
There has been recent interest from some VAs with the system to capture revenue lost as a result of 90 day fill rejects.
Some of the methods proposed have been:
Designate VA CMOPs as mail-order pharmacies
Pursue legislation to mandate reimbursement for 90 day fills
Change 90 day fill prescriptions to 30 day fills to be reimbursed
The CBO and PBM have extensively researched and evaluated the issue
For various reasons, none of the methods listed above are recommended at this time
The CBO will continue to pursue methods to reduce the number of 90 day fill rejects

11. ePharmacy Future
Now I would like to share some current development for ePharmacy

12. Phase 5/D.0 Phase 5 will be the next release - sometime this summer
Will bring us into compliance with D.0, which is the NCPDP communication standard that replaces 5.1
Very involved process
Testing has to be done with external partners, e.g. Emdeon and insurance companies
Some payers require our software be certified
Need to maintain backwards compatibility - capability to transmit claim in both 5.1 and D.0 during transition period
Mostly changes that affect the revenue side of ePharmacy
No major Pharmacy changes
We have our next Phase, Phase 5 that will be the next release - sometime this summer. I want to thank the test sites that tested this enhancement, Birmingham, Loma Linda, LouisvillePhoenix, Richmond and St Louis and the eastern half of VISN 15.
This release will bring us into compliance with D.0, which is the NCPDP communication standard that replaces 5.1
It is a very involved process however, for example testing has to be done with external partners, e.g. Emdeon our switch, as well as some of our insurance companies
Some of the major payers also require our software be certified, which means we prove to them before going live that we can meet the standards and their particular requirements.
As such we need to maintain backwards compatibility - capability to transmit claim in both 5.1 and D.0 during transition period
Most of the D.0 changes affect the revenue side of ePharmacy and there are no major Pharmacy changes

13. Phase 5/D.0 cont.
ECME numbers (prescription number that is transmitted to the third party) expanded from 7 to 12 characters
All screens that display ECME number are being changed.
Pharmacy screens:
Rx View screen from View Prescription [PSO VIEW]
The Reject Information screen from the Third Party Payer Rejects – Worklist [PSO REJECTS WORKLIST] 
Third Party Payer Rejects – View/Process [PSO REJECTS VIEW/PROCESS] 
Additional information will be available from the Reject Information screen to assist with reject resolution
Submit Clarification Code (CLA) action modified so up to three submission clarification codes may be entered
Some of the changes Pharmacy will see are the ECME numbers (prescription number that is transmitted to the third party) will be expanded from 7 to 12 characters
So all screens that display ECME number are being changed.
Pharmacy screens:
Rx View screen from View Prescription [PSO VIEW]
The Reject Information screen from the Third Party Payer Rejects – Worklist [PSO REJECTS WORKLIST] 
Third Party Payer Rejects – View/Process [PSO REJECTS VIEW/PROCESS] 
Additional information will be available from the Reject Information screen to assist with reject resolution
Submit Clarification Code (CLA) action modified so up to three submission clarification codes may be entered

14. Phase 5/D.0 – Additional Reject Information
Reject Status : OPEN/UNRESOLVED
Payer Message : 1-ABOVE GERIATRIC MAX QTY/DAY,MAX DAILY QTY 2.0,DUR REJECT ERRO R
Reason : HD (HIGH DOSE ALERT )
+DUR Text : 1-ABOVE GERIATRIC MAX QTY/DAY
INSURANCE Information
Insurance : MEDCO HEALTH DIRECT CLAIMS
Contact : (800)
Group Name : ECME TEST INS
Group Number : GROUP
Cardholder ID : #############
Enter ?? for more actions
VW View Rx IGN Ignore Reject OVR Submit Override Codes
MP Medication Profile RES Resubmit Claim CSD Change Suspense Date
Select: Quit// ??
The following actions are also available:
COM Add Comments DN Down a Line PS Print Screen
CLA Submit Clarif. Code UP Up a Line PT Print List
ED Edit Rx FS First Screen SL Search List
PA Submit Prior Auth. LS Last Screen ADPL Auto Display(On/Off)
+ Next Screen GO Go to Page QU Quit
- Previous Screen RD Re Display Screen ARI View Addtnl Rej Info
This is a screen shot of a Reject Information screen, showing where the View Additional Rejects action will be located. Additional information that may be helpful in resolving rejects will be displayed here. Information will be available if returned by the payer. If information is available, a +sign will appear in front of the DUR Text field. You use the hidden action – ARI to display the additional information.

15. Phase 5/D.0 – Additional Reject Information Cont.
Reason : ID (INGREDIENT DUPLICATION)
+DUR Text : 1-ABOVE GERIATRIC MAX QTY/DAY
INSURANCE Information
Insurance : MEDCO HEALTH DIRECT CLAIMS
Contact : (800)
Group Name : ECME TEST INS
Group Number : GROUP
Cardholder ID : #############
Enter ?? for more actions
VW View Rx IGN Ignore Reject OVR Submit Override Codes
MP Medication Profile RES Resubmit Claim CSD Change Suspense Date
Select: Quit//ARI
DUR Response: 1
Reason Code: TD (THERAPEUTIC )
Clinical Significance Code: MINOR
Other Pharmacy Indicator: OTHER PHARMACY
Previous Date of Fill: MAR 30, 2011
Quantity of Previous Fill:
Database Indicator: OTHER
Other Prescriber Indicator: OTHER PRESCRIBER
DUR Text:
DUR Add Text: ALPRAZOLAM TAB 0.5MG
This is a screen shot of the Reject Information screen, showing part of the information that will be returned with the View Additional Rejects action. This DUR response information can be especially helpful when resolving DUR rejects that are actually because of an early fill issue, and the third party does not return the last date of fill, or date of next allowed fill.

16. Phase 5/D.0 – Multiple Clarification Codes
Reject Status : OPEN/UNRESOLVED
Payer Message : 1-ABOVE GERIATRIC MAX QTY/DAY,MAX DAILY QTY 2.0,DUR REJECT ERRO R
Reason : HD (HIGH DOSE ALERT )
DUR Text : 1-ABOVE GERIATRIC MAX QTY/DAY
INSURANCE Information
Insurance : MEDCO HEALTH DIRECT CLAIMS
Contact : (800)
Group Name : ECME TEST INS
Group Number : GROUP
Cardholder ID : #############
Enter ?? for more actions
VW View Rx IGN Ignore Reject OVR Submit Override Codes
MP Medication Profile RES Resubmit Claim CSD Change Suspense Date
Select: Quit// ??
The following actions are also available:
COM Add Comments DN Down a Line PS Print Screen
CLA Submit Clarif. Code UP Up a Line PT Print List
ED Edit Rx FS First Screen SL Search List
PA Submit Prior Auth. LS Last Screen ADPL Auto Display(On/Off)
+ Next Screen GO Go to Page QU Quit
- Previous Screen RD Re Display Screen ARI View Addtnl Rej Info
This is a screen shot of the Reject Information screen, showing the Submit Clarification Codes action I referred to. It will be modified so up to 3 different codes may be submitted. Currently only one can be submitted.

17. Phase 5/D.0 – Multiple Clarification Codes cont.
Reject Status : OPEN/UNRESOLVED
Payer Message : 1-ABOVE GERIATRIC MAX QTY/DAY,MAX DAILY QTY 2.0,DUR REJECT ERRO R
Reason : HD (HIGH DOSE ALERT )
DUR Text : 1-ABOVE GERIATRIC MAX QTY/DAY
INSURANCE Information
Insurance : MEDCO HEALTH DIRECT CLAIMS
Contact : (800)
Group Name : ECME TEST INS
Group Number : GROUP
Cardholder ID : #############
Enter ?? for more actions
VW View Rx IGN Ignore Reject OVR Submit Override Codes
MP Medication Profile RES Resubmit Claim CSD Change Suspense Date
Select: Quit// CLA CLA
Submission Clarification Code 1: OTHER OVERRIDE
Submission Clarification Code 2: VACATION SUPPLY
Submission Clarification Code 3: THERAPY CHANGE
When you confirm, a new claim will be submitted for
the prescription and this REJECT will be marked resolved.
Confirm? YES//
This screen shot shows what the Submit Clarification Codes action showing a case were three codes were entered. It is doubtful we will see many rejects that will require three of these codes to resolve

18. D.0 v2
Development and testing for D.0 V2 will be combined with our Phase 6 enhancements
Testing is expected to start in September and Phase 6/D.0 V2 software expected to be released in February 2012
Expand electronic transmissions to include CHAMPVA pharmacy claims.
Submit all mandatory NCPDP fields, required NCPDP fields, and situational required NCPDP fields to PBMs/Payers regardless of payer sheet specifications.
Accurately utilize NCPDP fields for pricing of VHA outpatient pharmacy claims. Include capability to allow for this pricing on paper claims as well.
D,0 v2 will start eDevelopment and testing later this year
This software will expand electronic transmissions to include CHAMPVA pharmacy claims.
As a result we will also be able to submit all mandatory NCPDP fields, required NCPDP fields, and situational required NCPDP fields to PBMs/Payers regardless of payer sheet specifications.
(If needed – This is required because the ingredient cost and the administrative fee (used interchangeably with dispensing fee when talking to different folks) are currently being sent as one price in the NCPDP field 409-D9 Ingredient Cost Submitted effective 3/18/11. )
We will be accurately utilizing the correct NCPDP fields for pricing of VHA outpatient pharmacy claims. Include capability to allow for this pricing on paper claims as well.

19. Phase 6
Field names that display on both the Third Party Payer Rejects - Worklist Pharmacy Worklist) and ECME User screen (OPECC Worklist) will be standardized
Information that shows on the Pharmacy Reject Information screen will also show on the ECME User screen log
The BIN number will be added to the Pharmacy Worklist Reject Information and View/Process Information screens
Phase six development is underway and expected to be released by the beginning 2012
We standardize field names that display on both the Third Party Payer Rejects - Worklist Pharmacy Worklist) and ECME User screen (OPECC Worklist)
If information is displayed on the Pharmacy Reject Information screen, it will also show on the ECME User screen log
The BIN number will replace the Group Name on the Reject Information and View/Process Information screens

20. Phase 6 cont
The ‘Reason For Service’ field of the Submit Override Codes action of the Reject Information screen will be editable
Users will be able to enter multiple Reject Action codes from the Reject Information screen if needed.
A new action will be added to the Reject Information screen that will calculate the next date of fill based on the last ePharmacy date of service and days supply.
ePharmacy screens using ‘Fill Date’ labels will be changed to ‘Date of Service’ when appropriate.
Currently, you cannot edit the ‘Reason For Service’ field when using the Submit Override Codes action of the Reject Information screen and this will be changed to allow editing. The Reason For Service code is the first of the 3 code set used for DUR Overrides. The other codes are Professional Service and Result of Service.
Users will be able to enter multiple Reject Action codes from the Reject Information screen if needed.
Another helpful feature will be a new action to the Reject Information screen that will calculate the next date of fill based on the last ePharmacy date of service and days supply.
Fill Date will no longer be used to reflect the date of service, and so all ePharmacy screens using ‘Fill Date’ labels will be changed to ‘Date of Service’ when appropriate.

21. Reject Information Screen Changes
Reject Information(UNRESOLVED)Apr 06, Page: 1 of 1
Division : ECMETEST DIV NPI#: XXXX
Patient : PATIENT, TESTONE(###-##-####) Sex: M DOB: MMM, ##, ####(##)
Rx# : #####713I/ ECME#: #### Fill Date: MMM ##, ####
CMOP Drug: DIAZEPAM 10MG TAB NDC Code:
REJECT Information
Reject Type : 88 - DUR Reject Error- received on APR 06,
Reject Status : OPEN/UNRESOLVED
Payer Addl Msg : 1-ABOVE GERIATRIC MAX QTY/DAY,MAX DAILY QTY 2.0,DUR REJECT ERROR
Reason Code : HD (HIGH DOSE ALERT )
+ DUR Text : 1-ABOVE GERIATRIC MAX QTY/DAY
INSURANCE Information
Insurance : MEDCO HEALTH DIRECT CLAIMS
Contact : (800)
BIN Number
Group Number : GROUP
Cardholder ID : ############
Enter ?? for more actions
VW View Rx IGN Ignore Reject OVR Submit Override Codes
MP Medication Profile RES Resubmit Claim CSD Change Suspense Date
Select: Quit// Select: Quit// Select: Quit// OVR Submit Override Codes
Reason for Service Code : DD DRUG-DRUG INTERACTION
Professional Service Code:
Here is a screen shot showing some of what I just discussed.
Informational field names will be standardized with the ECME User screen
BIN number will replace Group Name
Reason For Service Code of the Submit Override Codes action will be editable
Multiple reject action codes will be allowed if needed but I don’t have a screen shot of that.

22. Reject Information Screen Changes cont
INSURANCE Information
Insurance : MEDCO HEALTH DIRECT CLAIMS
Contact : (800)
Group Name : ECME TEST INS
Group Number : GROUP
Cardholder ID : #############
Enter ?? for more actions
VW View Rx IGN Ignore Reject OVR Submit Override Codes
MP Medication Profile RES Resubmit Claim CSD Change Suspense Date
Select Item(s): Quit// SDC Suspense Date Calculation
LAST DATE OF SERVICE: Jan 01, 2011//
LAST DAYS SUPPLY: 60//
NEW SUSPENSE DATE: Feb 15, 2011//T+4 (FEB 11, 2011)
When you confirm, this REJECT will be marked resolved. A
new claim will be re-submitted to the 3rd party payer
when the prescription label for this fill is printed
from suspense on Feb 11, 2011.
Note: THE LABEL FOR THIS PRESCRIPTION FILL WILL NOT BE
PRINTED LOCAL FROM SUSPENSE BEFORE Feb 19, 2011.
Confirm? ? YES// [Closing...OK]
Please wait...
Here is how the new hidden action - SDC - Suspense Date Calculation will work.
It will use the date of service and days supply from the last ePharmacy transmission to calculate the new suspense date. This will be helpful for those times that the third party does not provide the date of last fill or date of next fill.

23. Phase 6 cont
The ¾ days supply hold calculation will round up for any partial day
Fill Date will no longer be used to determine the date of service – only Current Date and Release Date will be used
A screen reminder to obtain a signature when prescriptions are picked-up will be provided when ePharmacy window prescriptions are released
A reminder to obtain signature will also be provided when removing a patient’s name from the Bingo Board
I am not sure how many of you are experiencing this, but after the first of the year, my RTS rejects have increased. We are not sure what is responsible for this. One factor is the introduction of FEP claims. I am seeing RTS rejects for many prescriptions however that have been suspended by the ¾ days functionality, pulled 1 day earlier than a fill is allowed. As a solution to the issue, we are changing the ¾ days supply hold calculation to round up for any partial day.
Fill Date will no longer be used to determine the date of service – only Current Date and Release Date will be used
A screen reminder to obtain a signature when prescriptions are picked-up will be provided when ePharmacy window prescriptions are released
The another reminder to obtain signature will be provided when removing a patient’s name from the Bingo Board

24. Phase 6 cont
An indicator for ePharmacy prescriptions will be provided via OPAI
A new option ‘View ECME Rx’ will be available that will provide a user all the information regarding an ePharmacy prescription
The Issue Date transmitted on claims for ePharmacy prescriptions entered with a future ‘Issue Date’ will be changed to the current date
Claims submitted by the OPECC using the Process Secondary/TRICARE Rx to ECME option, will reflect that in the Prescription activity log
For Pharmacies using outpatient automation, an indicator for ePharmacy prescriptions will be provided via OPAI. The automation vendor would still need to take it and make it into something helpful to the sites, but the indicator will be there.
A new option ‘View ECME Rx’ will be available that will provide a user all the information regarding an ePharmacy prescription. This will be helpful when trying to figure out what happened with regard to an ePharmacy prescription.
We occasionally get rejects because the Issue Date of the prescription is in the future, which according to NCPDP logic is impossible. So the Issue Date transmitted on claims for ePharmacy prescriptions entered with a future ‘Issue Date’ will be changed to the current date
Claims submitted by the OPECC using the Process Secondary/TRICARE Rx to ECME option, will reflect that in the Prescription activity log. Right now the Activity Log entries can appear as if the OPECC refilled a prescription, which is never the case.

25. Pop Quiz – DUR Reject
Reject Information(UNRESOLVED)Apr 06, Page: 1 of 1
Division : ECMETEST DIV NPI#: XXXX
Patient : PATIENT, TESTONE(###-##-####) Sex: M DOB: MMM, ##, ####(##)
Rx# : #####713I/ ECME#: #### Fill Date: MMM ##, ####
CMOP Drug: DIAZEPAM 10MG TAB NDC Code:
REJECT Information
Reject Type : 88 - DUR Reject Error- received on APR 06,
Reject Status : OPEN/UNRESOLVED
Payer Message : 1-ABOVE GERIATRIC MAX QTY/DAY,MAX DAILY QTY 2.0,DUR REJECT ERRO R
Reason : HD (HIGH DOSE ALERT )
DUR Text : 1-ABOVE GERIATRIC MAX QTY/DAY
INSURANCE Information
Insurance : MEDCO HEALTH DIRECT CLAIMS
Contact : (800)
Group Name : ECME TEST INS
Group Number : GROUP
Cardholder ID : ############
Enter ?? for more actions
VW View Rx IGN Ignore Reject OVR Submit Override Codes
MP Medication Profile RES Resubmit Claim CSD Change Suspense Date
Select: Quit// Select: Quit//
I have 2 pop quizzes and this is the first.
How would you resolve this DUR reject returned from Medco
Have been seeing these mainly for benzodiazepines and hypnotics, but also for antidepressants and anticonvulsants
Started seeing in March

26. Pop Quiz – DUR Reject - answer
VW View Rx IGN Ignore Reject OVR Submit Override Codes
MP Medication Profile RES Resubmit Claim CSD Change Suspense Date
Select: Quit// CLA CLA
Clarification Code: OTHER OVERRIDE
When you confirm, a new claim will be submitted for
the prescription and this REJECT will be marked
resolved.
Confirm? YES//
The answer is: Once you
have reviewed the clinical implications, contacted the provider if needed and have decided to go ahead with the fill, you would enter a ‘2’ using the Submit Clarification codes action.
2. Document provider contact or other pertinent information in the comments section of the Reject Information screen.
I am told that many of these are being caught by the dosing checks afforded by MOCHA 2

27. Billing Methodology Change

28. Why the Change?
VA published a rule in the Federal Register to implement a new billing methodology to provide VA with a more accurate billing methodology in relationship to the actual cost of prescription drugs.
The new billing methodology is more in line with the way the private sector bills.
Key points to remember are:
The new billing methodology requires VA to bill the actual cost of the drug plus an administrative fee
The new billing methodology was implemented with prescriptions filled beginning March 18, 2011
The rule was published in the Federal Register on October 6, 2010 and is available at:
The VA needed a more accurate billing methodology for prescriptions. We needed a method that more closely reflected the actual cost of the drugs dispensed and the cost of dispensing prescriptions. To meet this need VA published a rule in the Federal Register to implement a new billing methodology.
The new billing methodology requires VA to bill the actual cost of the drug plus an administrative fee
The new billing methodology will be implemented with prescriptions filled beginning March 18,
We have provided an internet link to the rule that was published in the Federal Register on October 6, 2010 :
This change is guided by the Department of Veterans Affairs' (VA) mission of providing exceptional health care that improves Veterans’ health and well-being.
NOTE: Prescriptions filled prior to March 18, 2011 will be billed under the current methodology of the average $51 rate per prescription.

29. Administrative Fee Calculation
The administrative fee will be calculated annually based on experience from a prior fiscal year (October through September)
Drug Indirect Costs + Dispensing Costs
Total RX Fills
Updates to the administrative fee will be implemented and updated via a patch in January of each year with the exception of this year
For example:
The administrative fee of $11.40 (calculated for FY09) will apply to prescriptions filled beginning March 18, 2011 through December 2011
The administrative fee calculated for FY10 will apply to prescriptions filled for the calendar year January to December 2012
The administrative fee will be calculated annually based on experience from a prior fiscal year (October through September)
The formula for the administrative fee is listed in this slide.
The components of the administrative fee calculation are defined as follows:
The Drug Indirect Cost in the formula is calculated by taking the Actual Total Cost for a drug, which includes all costs, direct and indirect, associated with the drug product, and subtracting its Variable Supply Cost, which is the supply cost of the drug. The Drug Indirect Cost does not include the labor cost of dispensing the prescription.
Dispensing Costs in the formula include the labor and other associated indirect costs of dispensing the prescription. For Consolidated Mail Order Pharmacy (CMOP) prescriptions it is the monthly CMOP dispensing fee charged to the VA medical center.
For prescriptions filled by a VA facility, it is the cost of the labor products used to dispense the prescription. These labor products include counseling the patient, the cost of mailing a prescription locally, and even costs for maintaining records for investigational drugs.
The denominator in the formula, the Total Rx Fills, includes the number of prescription fills, refills, or partial fills in the report timeframe.
The ingredient cost and the administrative fee (used interchangeably with dispensing fee when talking to different folks) are sent as one price in the NCPDP field 409-D9 Ingredient Cost Submitted effective 3/18/11.

30. Drug File Cost Methodology
Here is how the prescription cost will be determined:
For original fills, the UNIT PRICE OF DRUG field (#17) of Prescription File (#52) will be used for the drug cost 
For refills, the CURRENT UNIT PRICE OF DRUG field (#1.2) of the Prescription File REFILL multiple (#52.1) will be used for the drug cost
The administrative charge (currently $11.40) will be added to these costs and used for the ePharmacy claim
The Prescription file fields mentioned above will obtain their costs from the Drug File entry for the item
The next few slides go into detail about how the charges for a particular prescription fill will be obtained.
For original fills, the UNIT PRICE OF DRUG field (#17) of Prescription File (#52) will be used for the drug cost. 
For refills, the CURRENT UNIT PRICE OF DRUG field (#1.2) of the Prescription File REFILL multiple (#52.1) will be used for the drug cost.
We mentioned previously that the administrative charge (currently $11.40) will be added to these costs and used for the ePharmacy claim.
The next two slides will provide the Drug file origin of these prescription file costs.

31. Drug File Cost Methodology Cont.
The drug cost that will be transmitted to the third party will be the drug file cost for the NDC chosen for the prescription when the claim is submitted 
In most cases the NDC chosen by the software will be the Last Local NDC, or Last CMOP NDC 
For local fills, if the NDC chosen for the prescription is the default NDC (Drug file field #31 NDC):
The drug cost used will be the value of the PRICE PER DISPENSE UNIT field (#16) of DRUG file (#50)
If the NDC selected is a synonym:
The PRICE PER DISPENSE UNIT field (#404) of the SYNONYM multiple (#9) of the DRUG file (#50) will be used
The origin of the drug cost that will be transmitted to the third party will be the cost residing in the drug file for the NDC chosen for the prescription at the time the prescription claim is submitted.  In most cases the NDC chosen by the software will be the Last Local NDC, or Last CMOP NDC.  If the Last Local NDC, or Last CMOP NDC fields are null, then the default NDC (Drug file field #31 NDC), will be used.
For local prescription fills, if the NDC chosen for the prescription is the default NDC (Drug file field #31 NDC), the drug cost used will be the value of the PRICE PER DISPENSE UNIT field (#16) of DRUG file (#50).  If the NDC selected is a synonym, the PRICE PER DISPENSE UNIT field (#404) of the SYNONYM multiple (#9) of the DRUG file (#50) will be used. 

32. Drug File Cost Methodology Cont.
In the case of CMOP fills, the default NDC price will be used, which is taken from PRICE PER DISPENSE UNIT field (#16) of DRUG file (#50)
Functionality currently doesn’t exist to allow CMOP drug costs to be shared between VistA and CMOP. 
Drug cost values are stored at the same time as drug file updates to the NDC occur, for example through the Drug Accountability process 
In the case of CMOP fills, the default NDC price will be used, which is taken from the PRICE PER DISPENSE UNIT field (#16) of DRUG file (#50), this is because functionality currently doesn’t exist to allow CMOP drug costs to be shared between VistA and CMOP.
Basically as you know, drug costs are updated through the Drug Accountability process.
We realize the above costing methodology is not perfect.  For example, we still have no method of receiving the CMOP cost associated with a product used to fill a CMOP prescription, so CMOP prescriptions will be priced using the default NDC costs.  Until further software enhancements are determined necessary and then developed, this is the process that will be used.
Optional:
The basic functionality I described in these previous slides was released to the field in August 2008 in patch PSO*7*287. That patch introduced the prescription cost calculations used to submit TRICARE prescription claims at those facilities approved to process TRICARE prescriptions. (FYI - TRICARE prescription claims use a different administrative fee in addition to the drug cost.)  The changes made regarding how the drug costs were determined and stored however, affects all VA facilities.   Without going into detail, several facilities reported problems with the functionality that occasionally resulted in a particular drug cost being inaccurate. after the above functionality was released to the field.  Remedy Tickets were submitted and the nature of the problem was assessed.  A patch will be forthcoming to correct the issues raised. We do not know the release date for this patch.

33. Reimbursement by PBMs and TPPs
Impact of PBM Agreements
PBMs will continue to pay under the terms and conditions of their current agreements with VA
Some agreements are written with “lesser of” logic using reimbursement methodologies such as:
Average Wholesale Price (AWP) less a discount
Maximum Allowable Cost (MAC) pricing
Usual and Customary (U&C) pricing
The payment we receive may still be different than the amount we billed. This is because the third party payers will continue to pay under the terms and conditions of their current agreements with VA.
Some agreements are written with “lesser of” logic, and use reimbursement methodologies such as:
Average Wholesale Price (AWP) less a discount
Maximum Allowable Cost (MAC) pricing
Usual and Customary (U&C) pricing
The next slide provides an example.

34. Reimbursement by PBMs and TPPs cont.
Example of PBM reimbursement to facilities:
The PBMs agreement is written that they will pay the lower of:
(a) the pharmacy Usual & Customary (U&C) charge which combines the drug cost and administrative fee; or
(b) the AWP less a discount
For this example, the AWP less a discount is lower than the U&C. The payment returned to VHA will be the lower amount, which in this example is the AWP less the discount and not the U&C billed by VHA.
Example:
If a PBM’s agreement is written that they will pay the lesser of (a) the billed charge of the drug or (b) the AWP less a discount, and the AWP less the discount is a lower amount, their payment will be based on this amount, not the charge billed by VHA
In case this comes up as a question:
The ingredient cost and the administrative fee (used interchangeably with dispensing fee when talking to different folks) are sent as one price in the NCPDP field 409-D9 Ingredient Cost Submitted effective 3/18/11.

35. Potential for Additional Revenue
A high level analysis completed prior to the publication of the billing methodology rule indicated that it would result in approximately a 3% increase in revenue
The new methodology of billing the actual cost of the prescription plus an administrative fee will provide potential for increased revenue with regard to high cost medications
Instead of a maximum of $51 per prescription, VA has the potential of receiving a much larger payment amount on some high-end prescriptions
Facilities who are the most successful at ensuring prescriptions are billed and claims are approved will benefit the most
It is possible that the new methodology of billing the actual cost of the prescription plus an administrative fee will provide potential for increased revenue with regard to high cost medications
Instead of a maximum of $51 per prescription, VA has the potential of receiving a much larger payment amount on the higher end products we dispense.
To be reimbursed by third parties, many high cost medications require prior authorizations.
Most prior authorization rejects are worked by the OPECC from the ECME User screen. Sometimes however a reject that requires prior authorization follow-up will be returned as a DUR reject which is sent to the Pharmacy Third Party Payer rejects – Worklist for resolution. In these cases the rejects are usually Ignored with an appropriate comment back to the OPECC.
Facility revenue departments and the Consolidated Patient Account Centers have been informed of the need to ensure prior authorization processes are incorporated into daily revenue activities so facilities will be reimbursed for these high cost prescriptions.
A version of this training is also being presented to revenue staff that service VA facilities.
Facilities have reported there are some expensive products that are not actually reimbursable to VA, for example those products that the third party plan requires be dispensed from one of their specialty pharmacies.

36. Need for Prior Authorizations
Many high cost medications require prior authorizations
Most third party prior authorization rejects are returned with reject code 75 : Prior Authorization, and are followed up by the OPECC
Some rejects for prior authorization are returned as 88: DUR and are seen on the Third Party Payer Rejects – Worklist
These are usually Ignored by the pharmacists with an appropriate comment back to the OPECC
Proper follow-up on prior authorizations rejects is a must to maximize revenue for prescriptions
It is possible that the new methodology of billing the actual cost of the prescription plus an administrative fee will provide potential for increased revenue with regard to high cost medications
Instead of a maximum of $51 per prescription, VA has the potential of receiving a much larger payment amount on the higher end products we dispense.
To be reimbursed by third parties, many high cost medications require prior authorizations.
Most prior authorization rejects are worked by the OPECC from the ECME User screen. Sometimes however a reject that requires prior authorization follow-up will be returned as a DUR reject which is sent to the Pharmacy Third Party Payer rejects – Worklist for resolution. In these cases the rejects are usually Ignored with an appropriate comment back to the OPECC.
Facility revenue departments and the Consolidated Patient Account Centers have been informed of the need to ensure prior authorization processes are incorporated into daily revenue activities so facilities will be reimbursed for these high cost prescriptions.
A version of this training is also being presented to revenue staff that service VA facilities.
Facilities have reported there are some expensive products that are not actually reimbursable to VA, for example those products that the third party plan requires be dispensed from one of their specialty pharmacies.

37. Prior Authorization Process
Prior Authorization processes are determined at the facility level and vary from facility to facility
Most sites currently have a method to follow-up on claims that need Prior Authorization
Prior Authorization process at many facilities pre-dates ePharmacy, as a process was needed when the VA billed prescription claims on paper as well
At some facilities Revenue is in charge of following up on Prior Authorizations
Some facilities have Utilization Review nurses handle the process
Still other processes involve Pharmacy
Prior Authorization processes are determined at the facility level and vary from facility to facility. Most sites currently have a method to follow-up on claims that need Prior Authorization.
Prior Authorization process at many facilities pre-dates ePharmacy, as a process was needed when the VA billed prescription claims on paper as well.
At some facilities Revenue is in charge of following up on Prior Authorizations.
Some facilities have Utilization Review nurses handle the process.
Still other processes involve Pharmacy.
As I have stated previously, facility revenue departments and the Consolidated Patient Account Centers have been informed of the need to ensure prior authorization processes are incorporated into daily revenue activities so facilities will be reimbursed for these high cost prescriptions.
At this point I am going to turn things over to Ellen Giglia to present the rest of our training.

38. ECME returned status: Cannot find price for Item
Facilities started reporting this problem shortly after the Billing methodology change went into effect.
Claims are not generated when the above error is returned
Reported for prescriptions for drug with very low prices, e.g. HCTZ 25/TRIAMTERENE 37.5MG TAB, GLYBURIDE 2.5MG TAB
It appears the Price Per Dispense unit calculated field value for some of these is less than $0.00, and the Integrated Billing software needs a price of at least $0.01 to bill the prescription
At this time the issue is still being investigated, but a fix will be implemented
I just wanted to mention this issue that facilities started reporting this problem shortly after the Billing Methodology change went into effect.
Claims are not being generated when the above error is returned
Reported for prescriptions for drug with very low prices, e.g. HCTZ 25/TRIAMTERENE 37.5MG TAB, GLYBURIDE 2.5MG TAB
It appears the Price Per Dispense unit calculated field value for some of these is less than $0.00, and the Integrated Billing software needs a price of at least $0.01 to bill the prescription
At this time the issue is still being investigated, but a fix will be implemented, probably via Remedy.

39. Pharmacy Actions to Maximize Revenue

40. Pharmacy Actions to Maximize Revenue
Ensure all prescriptions are billed
Make sure pharmacy and medical staff understand that service designation is not only important for VA copay determination but also determines whether we bill for prescription or not.
any prescription that is not service connected can be billed
Encourage prescribers to accurately mark prescriptions as SC or NSC
Ensure prescriptions are properly marked as SC or NSC when finishing prescription
As a result of the dollars at stake some Pharmacies are desiring to become more involved with regard to the prescription reimbursement process. Here are some ideas about increasing you involvement.
First of all it is vital that all prescriptions that can be billed are billed.
You can help make sure pharmacy and medical staff understand that service designation is not only important for VA copay determination but also determines whether we bill for prescription or not.
As long as all other criteria are met, any prescription that is not service connected can be billed
I think we can encourage prescribers to accurately mark prescriptions as SC or NSC, as well as ensure prescriptions are properly marked as SC or NSC when finishing prescriptions. I know you may encounter some oblivious situations where the incorrect designation is made and can be changed at finish.

41. Pharmacy Actions to Maximize Revenue
Take an active role in Reject Resolution
Remember that Rx reimbursement is important to the veteran as well because of VA copay reduction
Work closely with your OPECC
Even the best OPECCs do not have the overall knowledge of products and medication therapy required to evaluate some prescription rejects they receive
Consider setting up additional rejects to transfer to your Pharmacy Worklist
Some facilities can step up their involvement in Reject Resolution
Keep in mind that prescription reimbursement is important to the veteran as well because of VA copay reduction
Work closely with your OPECC
Even the best OPECCs do not have the overall knowledge of products and medication therapy required to evaluate some prescription rejects they receive. I will provide an example or two in a minute.
A great way to get more involved is to set up additional rejects to transfer to your Pharmacy Worklist and I have some screen shots a little later to show what I am talking about.
Ensure drugs used exclusively for the sensitive conditions are properly marked in your drug file with the ‘U’, so they will bill if an ROI is on file for the patient. Many of these drugs are expensive.
Work with your OPECC to ensure patient’s on these drugs have ROI’s entered into VistA. An ROI must be obtained from the patient then the information entered into VistA to enable billing.

42. Pharmacy Actions to Maximize Revenue cont.
Ensure you have your parameters set-up to generate the ePharmacy - OPEN/UNRESOLVED REJECTS LIST messages
Ensure appropriate staff are enrolled in theG.PSO REJECTS BACKGROUND MESSAGE so the messages will be received
Periodically evaluate the ‘Ignored Rejects Report’ too ensure staff are only ‘Ignoring’ appropriate rejects
Ensure that the quantity dispensed for ePharmacy prescriptions is appropriate for the days supply
You can make sure rejects are being resolved by setting-up your ePharmacy site parameters to generate the ePharmacy - OPEN/UNRESOLVED REJECTS LIST messages, and then ensure appropriate staff are enrolled in theG.PSO REJECTS BACKGROUND MESSAGE so the messages will be received
Periodic review of the ‘Ignored Rejects Report’ can ensure staff are only ‘Ignoring’ appropriate rejects
To avoid having to refund monies already received for prescriptions, ensure that pharmacists are finishing prescriptions correctly by ensuring the quantity dispensed for ePharmacy prescriptions is appropriate for the days supply

43. Pharmacy Actions to Maximize Revenue cont.
Billing for AIDS medications is more lucrative now because of their high cost
Ensure drugs used exclusively for the sensitive conditions are properly marked in your drug file
Work with your OPECC to ensure patients on these drugs have ROI’s entered into VistA
Some pharmacies are interested in billing for medications administered in the clinic
If the patient picks up the prescription from the Pharmacy and brings it to clinic it can be billed through ePharmacy
If Pharmacy delivers the medication to the clinic the prescription is billed as part of the clinic visit
Because of their high cost it is more important now to bill for AIDS medications.
Ensure drugs used exclusively for the sensitive conditions are properly marked in your drug file with the ‘U’, so they will bill if an ROI is on file for the patient. Many of these drugs are expensive.
Work with your OPECC to ensure patient’s on these drugs have ROI’s entered into VistA. An ROI must be obtained from the patient then the information entered into VistA to enable billing.

44. ePharmacy Menu Screen IR Ignored Rejects Report
MP ePharmacy Medication Profile (View Only)
NV NDC Validation
PF ePharmacy Medication Profile Division Preferences
SP ePharmacy Site Parameters
VP Third Party Payer Rejects - View/Process
WL Third Party Payer Rejects - Worklist
TC TRICARE Bypass/Override Report
Select ePharmacy Menu Option: sp ePharmacy Site Parameters
Regardless of any parameters defined, Refill-Too-Soon, Drug Utilization
Review(DUR) and Tricare rejects will always be placed on the Third Party
Payer Rejects - Worklist, also known as Pharmacy Reject Worklist. These
parameters are uneditable and are the default parameters.
Division: ECMETEST DIV
...OK? Yes//
Here is a screen shot showing the location of the ePharmacy Site Parameters

45. ePharmacy Site Parameter Screen
Division: ECMETEST DIV
...OK? Yes// (Yes)
ALLOW ALL REJECTS: NO//
REJECT WORKLIST DAYS: 7//
Previously defined override reject codes:
Code Description Auto Send
M/I Dispense As Written (DAW)/Product Selection Co YES
M5 Requires Manual Claim YES
Host Processing Error YES
Select REJECT CODE: Prior Authorization Required
CODE: 75//
AUTO SEND: ??
Enter Yes for auto update or No for requires OPECC intervention.
Choose from: NO
YES
AUTO SEND: 0 NO
Here is what you see when you go into those parameters.
Whatever you do please do not answer yes to the ‘Allow All rejects’ question.
The reject Worklist days is where you can set the number of days that will elapse before an unresolved reject will generate an ePharmacy - OPEN/UNRESOLVED REJECTS LIST message.
The next section is where you can mark additional reject to appear on the Pharmacy Worklist. They can be marked to automatically be shown each time they are received from the payer, or to be manually transferred by the OPECC.

46. Reject Transfer Screen
Code Description Auto Send
M/I Dispense As Written (DAW)/Product Selection Co YES
M5 Requires Manual Claim YES
Discontinued Product/Service ID Number NO
Non-Matched Pharmacy Number NO
M/I Days Supply NO
EU M/I Prior Authorization Type Code YES
M/I Product/Service ID NO
EV M/I Prior Authorization Number Submitted YES
Prior Authorization Required NO
Non-Matched Product/Service ID Number NO
E7 M/I Quantity Dispensed YES
Non-Matched Product Package Size YES
M/I Prescriber ID NO
E4 M/I Reason For Service Code YES
E5 M/I Professional Service Code YES
E6 M/I Result Of Service Code YES
Here are some that I have set-up to transfer at my facility that you might want to consider.
Code Description Auto Send
M/I Dispense As Written (DAW)/Product Selection Co YES
M5 Requires Manual Claim YES
Host Processing Error YES
Discontinued Product/Service ID Number NO
Time Out NO
Scheduled Downtime YES
Payer Unavailable YES
Connection To Payer Is Down YES
Non-Matched Pharmacy Number NO
M/I Days Supply NO
EU M/I Prior Authorization Type Code YES
M/I Product/Service ID NO
EV M/I Prior Authorization Number Submitted YES
Non-Matched Product/Service ID Number NO
E7 M/I Quantity Dispensed YES
Non-Matched Product Package Size YES
M/I Prescriber ID NO
E4 M/I Reason For Service Code YES
E5 M/I Professional Service Code YES
E6 M/I Result Of Service Code YES

47. Reject Information Screen – E4 Reject
Reject Information(UNRESOLVED)Mar 28, Page: 1 of 2
Division : ECMETEST DIV NPI#: XXXX
Patient : PATIENT,ECME ONE(###-##-####) Sex: M DOB: MMM 24,####(##)
Rx# : ####1594A/ ECME#: ### Fill Date: Mar 25, 2011
CMOP Drug: ALBUTEROL 90MCG (CFC-F) 200D ORAL INHL NDC Code:
REJECT Information
Reject Type : E4 - M/I Reason For Service - received on MAR 25,
Reject Status : OPEN/UNRESOLVED
Payer Message : USE VENTOLIN HFA OR OV 5555/08,M/I REASON FOR SERVICE CODE, REQ
UIRED ON DUR/PPS BILLING
Reason : PP (PLAN PROTOCOL )
DUR Text : FOR LOWER COPAY OPTION
COMMENTS
- MAR 25, - Automatically transferred due to override for reject
code. (RPH,ONE)
INSURANCE Information
Insurance : MEDCO HEALTH DIRECT CLAIMS
Enter ?? for more actions
VW View Rx IGN Ignore Reject OVR Submit Override Codes
MP Medication Profile RES Resubmit Claim CSD Change Suspense Date
Select: Next Screen//
Here is an example of the value of setting some of these additional rejects up to transfer.
It was a prescription where we did not use the brand of albuterol inhaler that the third party would like us to use. In these cases the third party returns an E7 reject. This reject for would have been closed by the OPECC. Because it was for reject code that transferred to my worklist, I resolved it using the 5555 PA reject code provided and it came back payable -$ Another way to handle these is by communicating with the OPECC that they should resolve them.

48. DUR Reject for Valtrex cont
Prescription rejected because we were using brand name Valtrex when a generic is available
Changing the DAW from 0 NO PRODUCT SELECTION INDICATED, to 5 SUBSTITUTION ALLOWED-BRAND DRUG DISPENSED AS A GENERIC, produced a payable claim
We billed the default cost of $ X 180 = $ $11.40 = $585.55
The insurance reimbursed the following way:
Ingredient cost pd $548.05
Patient copay $25.00
Dispensing fee $1.25
Total amt pd $524.30
This slide illustrates the importance of trying to resolve a reject, ans also serves as an example for the impact of the new billing methodology.
The prescription rejected for DUR, but it was because we were using brand name Valtrex when a generic is available. Show screen shot.
In this case changing the DAW from 0 NO PRODUCT SELECTION INDICATED, to 5 SUBSTITUTION ALLOWED-BRAND DRUG DISPENSED AS A GENERIC, produced a payable claim
We billed the default cost of $ X 180 = $ $11.40 = $585.55
The insurance reimbursed the following way:
Ingredient cost pd $548.05
Patient copay $25.00
Dispensing fee $1.25
So the total amount paid was $524.30, much higher than the $51 we would have received prior to the Billing Methodology change.

49. Reject Information Screen – Valtrex
Reject Information(UNRESOLVED)Mar 28, Page: 1 of 2
Division : ECMETEST DIV NPI#: XXXX
Patient : PATIENT,ECME ONE(###-##-####) Sex: M DOB: MMM 24,####(##)
Rx# : ####8819B/ ECME#: Fill Date: Mar 30, 2011
CMOP Drug: VALACYCLOVIR HCL 500MG TAB NDC Code:
REJECT Information
Reject Type : 88 - DUR Reject Error- received on MAR 21,
Reject Status : CLOSED/RESOLVED
Payer Message : TRY VALACYCLOVIR FIRST.DRUG IS NON-COMPLIANT WITH STEP THERAPY.
TO DISPUTE CLAIM, CALL FOR FORMS/INSTRUCTIONS
Reason :
DUR Text :
INSURANCE Information
Insurance : AETNA PHARMACY MANAGEMENT
Contact : (800)
Group Name : ECME TEST INS
Group Number : GROUP
Cardholder ID : ############
VW View Rx IGN Ignore Reject OVR Submit Override Codes
MP Medication Profile RES Resubmit Claim CSD Change Suspense Date
Select: Next Screen//
The hint that the third party provides is in the payer message - TRY VALACYCLOVIR FIRST.DRUG

50. ePHARMACY TRAINING

51. ePharmacy Training
ePharmacy for Pharmacists 101 training were presented in June 2011
ePharmacy for Pharmacists 201 and 301 sessions are being planned
Similar training is being provided to the OPECCs
TRICARE training will be provided to new facilities prior to implementation
ePharmacy Support Calls are held the second Monday of each Month
Please visit our ePharmacy Training Page
I just wanted to remind you that we are committed to making sure that staff know ePharmacy. Here are some of the ways we educate.
We will be presenting via Live Meeting ePharmacy for Pharmacists 101 training in June 2011, so if you know any new pharmacists, especially new ePharmacy site managers suggest strongly that they attend.
ePharmacy for Pharmacists 201 and 301 sessions are being planned
Similar training is being provided to the OPECCs
TRICARE training will be provided to new facilities prior to implementation
ePharmacy Support Calls are held the second Monday of each Month
I want to encourage you all to keep our ePharmacy Training Page in mind, and I have a slide showing some of the information available there.

52. Pharmacy Section of ePharmacy Training Site
List of ePharmacy VISN Points of Contact (POCs) (April 2011)
ePharmacy Helpful Hints (updated January 2011)
ePharmacy Issue Reporting Form (updated July 2009)
ePharmacy Issue Reporting Form Instructions (June 2009)
ePharmacy Checklist for New ePharmacy Site Managers (02/10)
Advanced Pharmacy Reject Resolution Training (February 2010)
Advanced Training – ePharmacy Options & Bulletins (February 2010)
DEA Special Handling Field Instructions (August 2010)
NCPDP Dispense Unit and Quantity Multiplier Instructions (updated May 2010)
Pharmacy Benefits Management Services Clinical INFORMatics Share Point Site
Click on NCPDP Document folder to access the NCPDP Disp Unit & Qty Mult Exceptions List spreadsheet.
As you can see the list of covered issues is quite extensive.

53. Pharmacy Section of ePharmacy Training Site cont
e-Pharmacy NDC Validation (06/13/06)
ePharmacy Quick Reference Card for finishing & releasing staff (01/08)
ePharmacy Quick Reference Card for ePharmacy Site Manager
e-Pharmacy Rejects & Resolutions Guide v6 (revised Nov 2010 )
Pharmacy Roles & Responsibilities (03/08)
List of Drugs Used for Sensitive Diagnoses (08/09/09)
Third Party Audits (01/10)
VeHU e-Pharmacy - Basic Training (08/07)
VeHU e-Pharmacy - Advanced Training (08/07)
The National Council for Prescription Drug Programs (NCPDP) web site NCPDP Provider ID application form
Dispensing Pharmacy Information Spreadsheet (06/14/06 ) (To be completed only when a pharmacy is obtaining a new NCPDP number. )
How to Identify and Resolve Stranded ePharmacy Claims (Sep 2009)
Here is a continuation of just the Pharmacy section of the training page.

54. TRICARE
OK now I would like to switch course and talk a little about TRICARE processing

55. TRICARE Implementation
The only pharmacies currently authorized to process TRICARE prescriptions are Dallas, Louisville, Loma Linda, Long Beach, Palo Alto and Topeka.
Other facilities will need to be approved for processing.
Facilities must follow the national VA Memorandum of Understanding (MOU) with the Department of Defense (DoD) in order to process TRICARE prescription claims.
Express Scripts, the PBM for TRICARE, has system checks in place that will reject TRICARE claims submitted by any VA pharmacy that has not been authorized through the ePharmacy Implementation Team.
Possibly the most important point I need to make is that the only pharmacies currently authorized to process TRICARE prescriptions are Dallas, Louisville, Loma Linda, Long Beach, Palo Alto and Topeka.
Other facilities will need to be approved for processing.
Facilities will need to follow the national VA Memorandum of Understanding (MOU) with the Department of Defense (DoD) in order to process TRICARE prescription claims.
You will not be able to process the prescriptions even if you try, as Express Scripts, the PBM for TRICARE, has system checks in place that will reject TRICARE claims submitted by any VA pharmacy that has not been authorized through the ePharmacy Implementation Team.

56. ePharmacy TRICARE Processing Rules
TRICARE claims are submitted electronically in real-time when …
The patient’s only eligibility is TRICARE, Sharing Agreement, or Active Duty.
The patient has separate active TRICARE insurance plan entry with pharmacy coverage set to yes (no other Rx plans)
TRICARE claims are submitted manually by the TRICARE OPECC when …
The patient has dual eligibility (e.g., Veteran and TRICARE or TRICARE and Employee, etc.)
-- or --
The TRICARE beneficiary has Other Health Insurance (OHI) primary to TRICARE.
Activating TRICARE allows pharmacy claims for TRICARE patients to be submitted electronically in real time when:
The patients whose only Eligibility entered into our VistA patient file eligibility fields calculates to TRICARE only.
Claims for Dual eligible patients (patients with eligibilities such as Veteran & TRICARE or Veteran and Employee) or TRICARE patients who have other health insurance that is primary to TRICARE, must be processed manually by the TRICARE OPECC using ePharmacy options specific for this process.

57. Processing differences
Veteran 3rd Party Claims
TRICARE Claims
Submitted charge equals drug cost plus admin fee ($11.40 for 2011)
Submitted charge equals drug cost plus dispensing fee (currently $8)
Only time Prescription label will not print is if claim rejects for DUR/RTS
Prescription label will NOT print if claim rejects for any reason
Prescription processed and dispensed to veteran even if claim rejects
Any reject must be resolved to a payable status or Ignored before prescription can be filled
Pharmacy staff are not notified of non-DUR/RTS rejects
Pharmacy staff given choice to Discontinue, Quit or Ignore processing for non-DUR/RTS rejects
DUR/RTS & site-defined rejects are only rejects on Pharmacy Worklist
ALL TRICARE rejects appear on Pharmacy Worklist (Non-DUR/RTS rejects appear in a separate section)
This table summarizes the differences between billing veterans via ePharmacy and billing for TRICARE Rxs.
Please review each difference line by line.

58. TRICARE Rules for Pharmacy Processing OTC & Supplies
Certain medications (most OTC and supply items) are not covered under the TRICARE contract (will not reimburse).
Facilities lose money by filling TRICARE prescriptions for these products.
Pharmacy should notify patient and/or provider if a prescription can not be filled due to limitations of TRICARE contract (i.e., OTC and supplies).
Per the patient’s TRICARE policy, the patient is responsible for buying these items at a retail pharmacy.
Pharmacy finishing & releasing staff will see new “TRICARE - NON-BILLABLE” message.
Certain medications (most over the counter and supply items) are not covered under the TRICARE contract. This means VA will not be reimbursed for these products should Pharmacy choose to dispense them to patients..
It is important that Pharmacy notify patient and/or provider if a prescription can not be filled due to limitations of TRICARE contract (i.e., OTC and supplies)
Per the patient’s TRICARE policy, the patient is responsible for purchasing these items at a retail pharmacy.
The software will show the Non-Billable Notification screen if a product is TRICARE Non-Billable.

59. Non-Billable TRICARE products
The DEA, Special HDLG field of the Drug file is used to determine which products can be dispensed to TRICARE patients.
Drug file entries at facilities should already be marked for ePharmacy claims processing and therefore no additional updating is required.
Prescriptions for non-billable OTC and supply items will not be allowed to be processed by Outpatient Pharmacy software.
Pharmacy staff holding the PSO TRICARE security key can Override a TRICARE reject if there is an immediate medical need to dispense the medication.
TRICARE Bypass/Override Report tracks TRICARE Ignore actions
ePharmacy uses the DEA, Special HDLG field of the drug file to determine which products are non-billable OTC and supply items.
Since VA will not be reimbursed, we do not want to process prescriptions that may be written for these non-billable products. The software will therefore not allow prescriptions for these items to be finished for TRICARE patients.
Pharmacy has the ability to ‘Ignore’ the “stop” placed on prescriptions for TRICARE non-billable products. The user must hold the PSO TRICARE security key to Ignore the TRICARE Non-billable notification.
The TRICARE Bypass/Override Report is used to monitor instances where a pharmacist chose to bypass ePharmacy in order to dispense a TRICARE non-billable medication.

60. TRICARE Non-Billable Rejects – Non TRICARE Sites
Sites should have at least one or more staff with the PSO TRICARE key
For example:
Cannot print a label to fill a prescription for a non-billable product, e.g. a vaccine marked with M or 0
Check with local revenue staff - patient Insurance may not be entered correctly
If insurance is correct and you still want to fill the prescription, the reject can be Ignored and the Rx filled
Need the PSO TRICARE to Ignore a TRICARE claim and fill Rx
TRICARE Non-Billable Rejects - We get occasional inquiries from sites that cannot print a label to fill a prescription because the patient has been entered as a TRICARE patient and the item trying to be dispensed is a non-billable product, e.g. an OTC or supply product. In some cases the patient’s insurance may be entered incorrectly, and so the software is applying the TRICARE billing rules when they should not be applied. Contact your OPECC if you should encounter one of these situations. If the insurance needs to be changed they can coordinate the change, however a new prescription for the product will need to be entered once the insurance changes are made.
There are times when the insurance on file is correct and the patient is a TRICARE patient. In most cases it is not appropriate to fill these prescriptions, for example because you are not a TRICARE site, or because you are a TRICARE site but will not be reimbursed by DoD. Nevertheless pharmacy may still want to process the prescription, for example if there is an emergent need. Our TRICARE Active Duty software now installed at all sites provides functionality that can assist in these situations where the pharmacy has decided the prescription should still be processed.
With our TRICARE Active Duty software, labels will be allowed to print for TRICARE non-billable prescriptions if either the ‘Fill Rx’ or ‘Ignore Reject’ action is performed from the Third Party Payer Rejects – Worklist by someone holding the PSO TRICARE key.
The most recent of these cases we were consulted about was a site that had the DEA, SPECIAL HDLG field for a vaccine marked with ‘M’ - BULK COMPOUND ITEMS. As you may remember, claims will not transmit for prescriptions entered for drugs marked with either the ‘M’ or the ‘0’ (zero) – MANUFACTURED IN PHARMACY. The patient insurance for the prescription indicated TRICARE, and so the software would not allow a prescription label to print. In these non-billable cases an actual third party claim is not transmitted, however an internal reject is applied, so the reject can go to the Third Party Payer Rejects – Worklist. The pseudo reject you will see for these is eT.
If pharmacy still wants to dispense the prescription, a user holding the PSO TRICARE key can use the ‘Fill Rx’ or ‘Ignore Reject’ actions from the Third Party Payer Rejects – Worklist. We suggest each site assign the PSO TRICARE key to at least one person and a back-up so prescriptions like this can be processed if pharmacy needs to.

61. ePharmacy TRICARE Processing Rules – Dual Eligibility
TRICARE sites have reported challenges surrounding Dual Eligibility
Pharmacy does not know veteran is using TRICARE eligibility until Rx rejects
Patient could receive prescription if using veteran eligibility, but Rx not covered by TRICARE
Guidance at this time is to process under TRICARE billing rules
If the prescription reject cannot be resolved to payable, TRICARE will not pay, and the site needs to make a decision to provide the prescription or not.
Activating TRICARE allows pharmacy claims for TRICARE patients to be submitted electronically in real time when:
The patients whose only Eligibility entered into our VistA patient file eligibility fields calculates to TRICARE only.
Claims for Dual eligible patients (patients with eligibilities such as Veteran & TRICARE or Veteran and Employee) or TRICARE patients who have other health insurance that is primary to TRICARE, must be processed manually by the TRICARE OPECC using ePharmacy options specific for this process.

62. Outpatient Rx for TRICARE Inpatients
Outpatient medications for TRICARE inpatients:
The software will not create an ePharmacy claim for a Outpatient Rx filled for a TRICARE eligible who is an inpatient. (e.g. patient is on a self-medication, a “pass” med or the provider has written a discharge medication order)
These prescriptions are not billable per the VA/DoD TRICARE MOU, and are billed as part of the inpatient stay
Since no claim is sent, no rejects will be received and prescriptions are always allowed to be filled.
TRICARE Bypass/Override Report tracks these TRICARE Inpatient “bypassed” prescriptions. This report is locked with the PSO TRICARE MGR security key.
The software will not create an ePharmacy claim for a Outpatient Rx filled for a TRICARE eligible who is an inpatient. (ePharmacy claim generation is “bypassed”.)
Outpatient Rx’s are processed when the patient is on a self-medication, a “pass” med or the provider has written a discharge medication order.
Per the VA/DoD TRICARE MOU, these prescriptions are not billable.
The bypass prevents ePharmacy claims from being generated if the patient has an Inpatient status as of the Issue Date of the prescription. 
TRICARE Bypass/Override Report tracks these TRICARE Inpatient “bypassed” prescriptions.

63. Pop Quiz – TRICARE True or False?
Any facility that wants to process TRICARE prescriptions can do so right now.
OK here is my last Pop-Quiz
It is a true-false statement
Any facility that wants to process TRICARE prescriptions can do so right now.

64. Pop Quiz Question – TRICARE - answer
The answer is false. Only 6 facilities are currently approved for TRICARE prescription processing. Others will need to be approved.
And the answer is false. Only 6 facilities are currently approved for TRICARE prescription processing. Others will need to be approved.

65. Educational Resources
ePharmacy TRICARE Support Calls – VANTS
3rd Wednesday of each 2 pm Eastern
VistA University – ePharmacy Training Page
Live Meeting Sessions
e-Pharmacy Checklists
Show-Me videos
Reject & Resolution Guide
ePharmacy Simulation Training located on VA LMS
How to access ePharmacy web courses on VA LMS
Link to VA LMS
The TRICARE Eligibility instructions are in  Procedure Guide 1601D.01: TRICARE, Chapter 2:
We have listed some additional web sites and contact information here for reference purpose. We encourage you to access these and learn as much as you can.
Send a message to the VHA ePharmacy Implementation Team mail group if you have any questions.

66. Questions? VHA ePharmacy Implementation Team
Send your questions to the
VHA ePharmacy Implementation Team
mail group in Outlook