1. Point of Sale Pharmacy Billing Basics
Christina Brady
POS User Support Specialist
Office of Information Technology
CNI Technology - Contractor
Albuquerque, New Mexico

2. Objectives POS Billing Process RPMS packages used with POS billing
POS Tips
Current patches
Emdeon
POS Master Format List

4. RPMS Packages Used with POS
Patient Registration – Eligibility Information
Third Party Billing – Enter/Edit insurers and group numbers
Accounts Receivable (A/R) – Posting of Remittance Advice/Explanation of Benefit
Outpatient Pharmacy Package – Enter prescription to process electronically

5. Patient Registration
Patient Registration allows users to add, edit, view, delete, or print information related to their facility’s patient.
Page 1 - Allows the viewing of the patient’s demographic information which is required when calling the processor/insurer. For POS purposes you will need the ability to view this page.
Page 4 - Allows you to add/edit insurers that have been created in table maintenance of TPB to patient’s profile. For POS purposes you will need the ability to view/edit this page.

6. Third Party Billing
The Table Maintenance Menu in TPB allows you to add/edit the Insurer File Menu and the Group Insurance Plans Menu
Adding an insurer in table maintenance
ABM – TMTP – INTM – EDIN – 2 Add New Insurer
Enter the name of your new insurer
Enter the mailing address and phone number of insurer
Insurer Status – “BILLABLE”
Type of Insurer – “PRIVATE” for commercial plans and “MD” for Medicare Part D plans
RX Billing Status – “P” to bill POS, “U” to make unbillable, and “O” for outpatient drugs only

7. Third Party Billing Cont.
Add/Edit a group number in table maintenance
ABM – TMTP – GRTM – EDGR
Enter group name
Do Group Numbers vary – Leave as default of “NO”
Enter Group Number located on card (recommendation to have the group name and number the same)
Example:
Group Name: XYZ-RX
Group Number: XYZ-RX (the group number is what crosses over on the claim not the group name)

8. Accounts Receivable (A/R)
Payable POS claims and reversals will create a charge automatically in the A/R package through the POS interface to Third Party Billing.
Charges are automatically posted to A/R when:
An electronic claim transaction completes
The insurer indicates that the claim is payable
The insurer indicates that the claim has been “Captured”
Charges that are not automatically posted to A/R are:
Charges for patients without insurance
Charges for patients with insurance, but the insurance can’t be billed electronically
Charges for patients with insurance, but the drug is unbillable
Unsuccessful electronic claims (rejected by the insurance)

9. Outpatient Pharmacy Package
Enter prescription details under patient’s pharmacy profile
Print prescription label to screen or to label printer to start the process of sending the claim to the insurer
Maintain/Update the drug file on a monthly basis

10. Pharmacy Tips
When entering a NEW prescription, a REFILL, or RENEWING a prescription, a “call to bill the claim” is made to the POS package when the label is printed.
The reprinting of a label (REPRINT AN OUTPATIENT LABEL) does not affect the POS software.
CANCELLING a prescription is used when a patient has a drug discontinued for some reason or if the prescription is replaced by another drug of a different dosage or strength. If a prescription is canceled NO call is made to the POS software because the patient received the prescription.

11. Pharmacy Tips
To DELETE a prescription means the prescription is to be marked as not given to this patient. It is used when a prescription was given to a patient by mistake and caught before the patient got it. Using this option causes the POS software to automatically reverse the claim.
RETURN MEDICATION TO STOCK option is to be used when a patient does not pick up a prescription. This process will automatically make a call to the POS to reverse the claim.
You cannot dispense a 90 day supply for a 30. The dispensed amount is to equal the billed amount.

12. Tips for Contacting the Help Desk
Research the claim first it will save time for you and the Help Desk if all the information required to solve the problem is available during the call
Have the pharmacy’s NCPDP or NPI number available. This is normally the first question they ask
The insurer recognizes claims by the internal rx number the one with the ` sign prior to the number displayed on the rejection report or at the end of the claim on the POS user screen

13. Design a Process for Working Rejections
Review rejection report daily
Run URM (POS / RPT / CLA / URM) to clear rejections from report before and after working rejections or running reports
If time is limited, focus on high cost drugs
To maximize collections, involve pharmacists.
The business office and the pharmacy at each facility should decide on a plan of action to optimize the amount of collections received from the rejected claims. This is a joint effort and will take involvement from both departments as well as IT.

14. Current Patch Information
Patient Registration – Version 7.1 patch 3 released nationally 4/17/2007
Third Party Billing – Version 2.5 patch 15 released nationally 9/25/2008
Accounts Receivable – Version 1.8 patch 7 released nationally 9/26/2008
Outpatient Pharmacy – Version 7.0 patch 6 released nationally 6/25/2008
Point of Sale – Version 1.0 patch 27 released nationally 9/8/2008

15. Master Format List Nationally used list for all POS Formats
List updated with each patch and sent out on the POS Listserv
Verify bin/pcn combination on master format list to determine the POS Format Name
Sorting Excel sheet by bin, pcn, or format name makes it easier to locate correct plan
Pay attention to comments when selecting a plan

16. Emdeon When to use Emdeon?
After viewing the Master Format List and not able to find the bin/pcn combination that you need.
Log into website and enter bin or pcn to identify plan needed
Copy and paste plan into an and send to requesting a new format be added to the Master Format Sheet
Login: indianhealth
Password: admin280

17. Q&A