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
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