Point of Sale (POS) Pharmacy Billing

Housekeeping

Verify you can log into you facility Verify that you have the POS menus (if you are

using POS) Verify you can print to the printer in the room

Objectives Describe the general principals of pharmacy

billing. Describe processes that need to be in place

to be successful at pharmacy billing List the reports are available in RPMS POS? Describe how to correct different types of

rejections using the POS software.

Training Plan

Reference – FTP site: ftp://ftp.ihs.gov/rpms/POS/

Understand RPMS software – POS set-up Learning business end of pharmacy billing to

maximize collections Network agreements (contracts), review

insurers set-up Audits, HIPAA, programming plans/projects

RPMS system

Switch

Third Party Billing &Accounts receivable packages

Processor Response

Outpatient Pharmacy package

Point of Salepackage

Point of Sale Pharmacy Billing

Patient Registration package

Patient Care Component (PCC) - visit files

Key Components to Using RPMS POS

Coordinated effort: Business Office, IT, Pharmacy– Best – “hire or assign pharmacy biller”

Having the necessary menus/keys Network participating agreements Staying current with software patches

– Outpatient Pharmacy 6.0, patch 5 or Outpatient Pharmacy 7.0, patch 3

– POS version 1, patch 13– AWP (APSA) and Patient Education (APSE) updates– http://www.ihs.gov/Cio/RPMS/index.cfm?module=home&option=index

Drug file clean-up Patient registration

Pharmacy Benefit Management (PBM’s)

An organization that manages pharmaceutical benefits for employers, other providers or managed care organizations

Involved in: Benefit plan design, Claims processing, Formulary management, Manufacturer rebates, DUR review

Examples of PBM’s: Medco Health, Caremark, Express Scripts, First Health (Coventry), Rx America

PBM Web Site

See handout with links

Network Agreements

Patient Insurance Card Network enrollment application Vendor Information

Software vendor: Indian Health Service 5300 Homestead Rd, Albuquerque, NM 87110

Software: RPMS POS, NCPDP V5.1 Addendum

Status of Agreements - IHS

National Express Scripts, First Health (Mail Handlers), Medicare Drug Card (PCA,

Criterion) Medco Health Medicare Part D – January 1, 2006 (several)

In the works: Tricare/Express Scripts – signing process Caremark - review Aetna – review MedImpact – review Argus – signing process PCN – signing process Pharmacare - review

Outpatient Pharmacy Package

SFUN / SITP / IHSP - location of POS “switch” Drug file

– AWP monthly updates http://www.ihs.gov/CIO/InfoTech_index.asp APSA APSE – Patient Education - quarterly Status of patches – Outpatient Pharmacy Supervisor Menu

- Maintenance

Outpatient Pharmacy Package – Drug File, continued….

Mailman message – lists unmatched drugs– EAWP – Outpatient 6.0– AWP Manual Update– Outpatient Pharmacy v 6.0 patch 5– Outpatient Pharmacy v7.0 – new version (10/2004)

– 46 sites using

AWP Manual Update

Subj: Outpatient Pharmacy AWP Automatic Update [#12914] 16 Nov 04 12:21 200 LinesFrom: OUTPATIENT PHARMACY DEVELOPER in 'IN' basket. Page 1 **NEW**------------------------------------------------------------------------------An Average Wholesale Pricing update was performed on your system on 3041116.The total number of records updated = 924 Listed below are the active drugs that were not updated and the error codes.Please review and correct all errors before attempting to run the manualAWP update option.Note: any 'missing 660 node' errors means that information like Order Unit, Price Per Order Unit, Dispense Units Per Order unit, Price Per Dispense Unit, etc) is missing! ACETAZOLAMIDE 500MG INJ - DISP UNITS DON'T MATCH - Medi = 90 / Local = 1ACYCLOVIR 200MG/5ML SUSP,ORAL - DISP UNITS DON'T MATCH - Medi = 473 / Local =480

Drug AWP Edit - EAWPSelect DRUG GENERIC NAME: GLYBURIDE 5MG TABORDER UNIT: BT// DISPENSE UNIT: TAB// DISPENSE UNITS PER ORDER UNIT: 1000// AWP PER ORDER UNIT: 825.69// AWP PER DISP UNIT is .82569AWP EFFECTIVE DATE: JUN 5,2001// NDC: 00009-0171-07// DEA, SPECIAL HDLG: 6// LAST PRICE UPDATE: INACTIVE DATE: PRICE PER ORDER UNIT: 17.31// PRICE PER DISPENSE UNIT is 0.017

Formats

NCPDP field names/numbers – POS / RPT / OTHR– Or see handout

WebMD: switch company –– GSA contract - $ 0.025/transaction

Information needed when adding a new insurer/format:– Processor– BIN number– Plan name/number– Processor Control Number (PCN) or carrier ID– Help desk phone number

Requesting a new format

Patient Registration

Insurer Name Employer Group name/number

– Table Maintenance

Person code Ideas for collecting patient registration

information

POS Set-up

POS / MGR / Set-up BAS Pharm INS BILL PROV SUMI

POS Menu’s

Reports– CLA / PAY, REJ, PAP, URM, DAY, INS– Survey

Setting up an Insurer

– POS / MGR / SET / INS INS – RPMS insurer, POS Format (use Excel spreadsheet) ADV – assign priority points RPMS – set to P

Using POS

User Menu Live Claims

– Payable claim to RPMS A/R package

POS Rejections

How often to run reports?– Ideally – rejection report daily

Need process to address them. Coordinated between Business office and

Pharmacy See Reject codes

Rejection Handout

POS Rejections

Cardholder ID, Group number, eligibility Refill too soon, NDC, Day supply, drug not

covered DUR, Prior Auth, Prescription Clarification code

Resources

Web Links – handout Payer Help Desk – see POS rejection report

for phone number. – Before calling, have claim pulled up: POS / U / EV /

3-Patient name / REC

POS Rejections

DUR override: Show Rx Bill or POS / U / N– 439 REASON FOR SERVICE CODE– 440 PROFESSIONAL SERVICE CODE– 441 RESULT OF SERVICE CODE

See handout for DUR codes

Prior authorization

Can be input in either of these packages:– Show Rx Bill (Pharmacy package) or POS / U / N

(POS package)– Example

Refill too soon due to dosage change: 98798798798

Backbilling

Electronic limitations (# days to backbill) Prescription number POS / U / N

Troubleshooting

RPMS support Network issues, changing internet providers,

maintenance by payers. Taskmanager Cache conversion

Network Agreements

Verify processor, patient name, employer Addendum National contracts, Regional, Facility contracts NCPDP Provider Number update

Universal Claim Form (UCF)

– Part of 3PB package– Need to order forms:

Moore North America, Inc. Moore National Customer Service Center: (800) 635-9500For version 5.1, HIPAA compliant item # DAH2PT:

1500 forms per carton – 9 ½’’ x 11”, continuous pin feed; $56.21 per carton ($0.04 per form) + shipping

Audits

Three to five years of records, payable claims – read contract to verify.

Copy of Rx– Hard copy readily retrievable

Copy of Prior Auth (PA) Signature log

HIPAA – Pharmacy

Policy and Procedures addressing the following:– Privacy consultation area– Staff Training on HIPAA– Medication pick-up by proxy– Disposal or destruction of patient drug history information– Leaving information on patient’s home or work answering

machines– Confidentiality Forms

Wrap-Up

Action plan