Transcript Maryland Medicaid Pharmacy Programs Claims Processing Training

Maryland Pharmacy Programs
Claims Processing Training
January 2007
Affiliated Computer Services (ACS)
Agenda
 Implementation Information
 Call Center Information
 Operational Information (All Programs)
 Operational Information (By Program)
 Clinical Information (By Program)
 Coordinated ProDUR – MCO/PBM
Information
 Conclusion
Program Learning Objectives
 Understand and explain how the POS system
works.
 Know the differences between the old and new
POS processing system
 Be able to operate the system at Provider level and
educate Providers Staff
 Understand processing procedures on PDL,
Mental Health drugs, HIV, and drugs requiring PA
ACS
Prescriptions Benefit Management (PBM)
 Serve 32 programs nationwide – including
Medicaid, senior programs, and workers’
compensation programs
 Process more than 200 million pharmacy claims
annually.
 Manage States’ drug spend of more than $14
Billion.
 Manage 14 million covered lives, or 1 in every 3
Medicaid eligibles nationwide.
ACS
Prescriptions Benefit Management (PBM)
 Process over 2 million calls and faxes in our call
centers annually
 Process an average of 100,000 prior authorizations
each month.
 Manage a retail pharmacy network of 56,000
providers, approximately 80% of all pharmacies
nationwide.
 Administer federal and supplemental rebate
programs and collect over $100 million in
manufacturer rebates
ACS
Prescriptions Benefit Management (PBM)
 Call Center
Our call center is open 24/7/365 and includes
multi-lingual support services.
 (800) 932-3918
 Aetna
 Humana
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Implementation Information
 February 4, 2007 is the official implementation
date.
 Down time – FH will cease processing at 11PM
February 3, 2007.
 ACS will be processing no later than noon on
February 4, 2007.
 Follow internal downtime procedures during this
outage
Implementation Information
 BIN
610084
 PCN
OOEP
 MDKDP
 MDBCCDT
 MDMADAP
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DRMDPROD
DRKDPROD
DRDTPROD
DRMAPROD
Implementation Information
 Group IDs
OOEP
 MDKDP
 MDBCCDT
 MDMADAP
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MDMEDICAID
MARYLANDKDP
MDBCCDT
MADAP
MCO /PBM Implementation
Information
 BIN
610084
 Use current PCN for Coordinated ProDUR.
ACS Call Center
All Programs
 Call Center
PA Call Center number
 Phone: 1-800-932-3918
 Fax: 1-866-440-9345
 Technical Call Center number
 Phone: 1-800-932-3918
 Fax: 1-866-440-9345
 Hours of Operation: 24/7/365
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ACS Call Center
Technical Call Center
 Program Inquiries
 General Inquiries
 Prior Authorizations
ACS Call Center
 Staffed by Customer Service Representatives and
Pharmacy Technicians
 Pharmacist on site 8:30 am to 5:00 pm and on call
24 hours per day
 Staffed 24/7/365
Will Handle:
 Claims inquiries
 Clinical inquiries
 Program specific and general inquiries
 Prior Authorizations
ACS Call Center
 Henderson facility handles overflow and after
hours
 PAC Eligibility Services Call Center information
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Call Center Number – (800) 226-2142
General questions about the PAC Program
Maryland residents requesting an application
Maryland residents who have applied but no
decision has been made - questioning status of
application
Applicant questioning a determination decision
Operational Program Changes
General Information
 Claims will only be accepted in the NCPDP
Version 5.1 Claim Format via POS
 There is no batch claim submissions accepted
Maryland Medicaid
(OOEP)
Medicaid Pharmacy Program
Specific Information
BIN
PCN
Group ID
Provider ID
Prescriber ID
Recipient ID
610084
DRMAPROD
MDMEDICAID
NCPDP Number
DEA Number
Medicaid ID Number
Copays
 Fee for Service = $1.00 / 3.00
PAC copays = up to $2.5 for generics and up to $7.5
for brand name drugs
NH = NO copays;
 Pregnancy = NO copays (PA type = 4)
 Family Planning medications = no copay
MMI State Funded Foster copay = $1.00 / 3.00 (no
exceptions)
 MCO/HMO copay - up to $1 for generics and up to
$3 for brand name drugs
Copay Exceptions
Patient is pregnant
 Patient drug is a family planning medication.
 LTC claims
 PDL – 3 day emergency supply
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Dispensing Fees
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Brand not on PDL: $2.69
 PDL and generic: $3.69
 LTC/Hospice
Brand not on PDL: $3.69;
PDL and generic: $4.69
 Partial Fills:
 ½ dispensing fee at initial fill
 ½ dispensing fee at completion fill
 Copay paid on initial fill.
Age Limitations
Maryland Medicaid will enforce the following age
restrictions:
 Non-legend chewable tablets of any ferrous salt
when combined with vitamin C, multivitamins,
multivitamins and minerals, or other minerals in
the formulation
 Topical Vitamin A Derivatives, HIC3 = L9B; and
Route = Topical
 Ferrous sulfate covered for recipients < 12 years
Generic Mandatory
 The system will deny brand drugs when a generic is
available
 Edit 22 (M/I /DAW code) and the message text:
“Generic Available – Physician to call State at 410767-1755, Medwatch form required”
 When submitted as Brand Medically Necessary
(DAW = 1) with the exception of the following (pay
at EAC):
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Levothyroxine
Brimonidine eye drops
Generic Mandatory
 The system will cover brand drugs billed as
generic with DAW=5 without preauthorization
 Claims for brand drugs will be rejected with
NCPDP edit 22 (M/I DAW code) and the message
text: “Generic Available – Physician to call State
at 410-767-1755, Medwatch form required”
 The system will accept the following Dispense as
Written (DAW) values (NCPDP field 408-D8):
0 - Default, no product selection
1 - Physician request
5 - Brand used as generic
6 - Override
Partial Fill
Claim Submission Guidelines:
 Dispensing status = P or C
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Cannot submit a P and C transaction the same day
Cannot submit a C transaction before a P
transaction
 Qty Intended to be dispensed
 Days Supply Intended to be Dispensed
 Quantity Dispensed.
Coordination of Benefits (COB)
ACS will process a claim for TPL when:
 There is presence of COB on the Recipient
Eligibility file
 There is presence of COB submitted on a claim
with an Other Payer Amt. Paid.
 Claims that are submitted without COB
information when there is presence of COB on the
eligibility file will deny with NCPDP reject 41 –
Submit claim to other payer.
 Claims submitted with an Other Coverage Code 8
– Copay Only – are not accepted by Maryland
Medicaid.
LTC / Hospice
The system will determine LTC claims by the
following conditions:
 Claim contains Patient Location Code = “04”
(NCPDP field 307-C7)
 Facility ID (NCPDP field # 336-8C) is on list of
institutions
 Pharmacy Provider ID is on the list of LTC
providers
 Note: Existing "NH" provider numbers = LTC
providers / institutions
LTC / Hospice
The system will determine Hospice-Only claims by
the following conditions:
 Claim contains Patient Location Code = “11” (NCPDP
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field 307-C7)
Client Specific Reporting field on Recipient Eligibility file
= "HI"
The Date of Service is within an active coverage span on
the Recipient Eligibility file
Facility ID (NCPDP field # 336-8C) is on list of
institutions (see appendix in Provider Manual)
Note: The system will deny Hospice claims that do not
have both a Patient Location code = “11” and a Client
Specific Reporting field on Recipient Eligibility file =
"HI”
LTC / Hospice
ACS will determine RECIPIENTS with BOTH
LTC/HOSPICE
LTC/Hospice claims will be determined by the
following distinct conditions:
 Client SPECIFIC REPORTING field = "HI" on the
recipient's enrollment record with a date span that includes
DOS, AND
 PATIENT LOCATION (NCPDP field # 307-C7) = "11",
AND
 FACILITY ID (NCPDP field # 336-8C) any value on the
list of institutions, AND
LTC / Hospice
ACS will determine RECIPIENTS with BOTH
LTC/HOSPICE
LTC/Hospice claims will be determined by the
following distinct conditions:
(continued from previous slide)
 Designated LTC providers in the SERVICE PROVIDER
ID (NCPDP field # 201-B1)
 The system will deny non-LTC claims for unit dose
medications with certain exceptions; claims will deny with
error 70 (drug not covered) and message text: “Unit Dose
Package Size”
Prior Authorizations
Methods to obtain a Prior Authorization:
 Call specified Call Center
 Complete and fax a Prior Authorization request
form
 Smart PA
Prior Authorizations
 Maryland Medicaid Staff
 Days supply exceeding maximums
 Growth Hormones
 Synagis (Palivizumab)
 Female Hormones for a male and vice versa
 Nutritional supplements (see MD PA form for
clinical criteria)
 Recipient Lock-In
 Price (long-term PAs only)
 OxyContin Quantity (during business hours)
 Antihemophilic Drugs (claim pended in X2 and
evaluated manually by State)
Prior Authorizations
 Maryland Medicaid Staff (continued)
 Duragesic Patch excess quantity (during business
hours)
 Topical Vitamin A Derivatives
 Opiate Agonists for Hospice and Hospice/LTC
 Antiemetic excess quantities
 Serostim
 Botox
 Orfadin
 Revlimid
 Revatio
 Brand Medically Necessary
Prior Authorizations
 ACS ProDUR Call Center Prior Authorizations
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Quantity (Note Oxycontin, Duragesic Patch
exceptions)
CNS Stimulants
Actiq
Anti-Migraine excess quantities
Atypical Antipsychotics (dosing quantity)
Oxycontin, Duragesic Patch Qty for after
hours/weekends
Prior Authorizations
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ACS Technical Call Center
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PDL - Non-Preferred drugs
Early Refill
Maximum dollar limit per claim ≥ $2,500
Age Restrictions
Maximum Quantity overrides
Prior Authorizations
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Maryland CAMP Office
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Depo Provera
Lupron Depot
SmartPA
SmartPA
New Clinical PA rules engine
 ACS stores both medical and pharmacy claims
history.
 Claim is submitted, looks at both while reading the
rule. Smart PA will issue a PA if claim and history
meet criteria without pharmacy or physician
intervention.
SmartPA
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Prior Authorizations handled by SmartPA
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CNS Stimulants
Actiq
Anti-Migraine excess quantities
Atypical Antipsychotics (dosing quantity)
Serostim
Botox
Synagis
Growth Hormones
SmartPA
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Prior Authorizations handled by SmartPA
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Anti-emetic
Topical Vitamin A
Orfadin
Revlamid
Revatio
Nutritional Supplements
Oxycodone
Breast and Cervical Cancer Diagnosis
and Treatment Program (BCCDT)
BCCDT Program Specific Information
BIN
PCN
Group ID
Provider ID
Prescriber ID
Recipient ID
610084
DRDTPROD
MDBCCDT
NCPDP ID Number
DEA Number
BCCDT Recipient ID
Copays / Dispensing Fee
BCCDT Recipients do not have copays
Dispensing fee structure:
 BRAND products = $2.69
 Generic Products = $3.69
 Partial Fill dispensing fee will be paid ½ at the
initial fill and ½ at the completion fill
Generic Mandatory
 BCCDT has a generic mandatory program in place.
 The system will deny brand drugs when a generic is
available with NCPDP Reject 22 (M/I Dispense As
Written/DAW code) when submitted as Brand
Medically Necessary (DAW = 1).
 The system will accept the following Dispense as
Written (DAW) values (NCPDP field 408-D8):
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0 - Default, no product selection
1 - Physician request
5 - Brand used as generic
Coordination of Benefits / Medicare D
 BCCDT will cost avoid for Medicare D recipients
 Providers are required to ensure COB claims for
Medicare D to contain “77777” in the Other Payer
ID (NCPDP field 340-7C).
 The Other Payer ID is not required for nonMedicare D carriers
Coordination of Benefits / Copay Only
Rules for copay only claim submission:
 $60.00 maximum on all copay only claims.
Amounts greater than $60.00 will have to be
approved by BCCDT
 BCCDT will pay copays for PAC recipients only if
claims contain an "8" in NCPDP field 308-C8,
Other Coverage Code.
 The system will reject PAC claims where the Other
Coverage Code is not equal to ‘8’ (Copay Only)
with reject code edit 70 (Drug Not Covered) and the
message text “BCCDT Only Reimburses Copayments – Please bill PAC
Coordination of Benefits / Copay Only
The following fields must be populated when submitting
a copay only claim:
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Other Coverage Code (308-C8) = 8
Other Amount Claimed Submitted Count = 1
Other Amount Claimed Submitted Qualifier = 99
Other Amount Claimed Submitted = copay amount and
must equal the amount in Gross Amount Due
Gross Amount Due = copay amount and must equal the
amount in the Other Amount Claimed Submitted
 **No COB Segment is submitted with a Copay only claim.
Coordination of Benefits / QMB
 QMB recipients have pharmacy coverage except for drugs
covered by Medicare B such as Xeloda- then BCCDT
pays only denied claims. Pharmacies then must bill
Medicare and then Medicaid and BCCDT will be the payer
of last resort for coinsurance.
 BCCDT will pay coinsurance for QMB recipients if claims
contain an other coverage code of 3 or 4 for Med-B
covered drugs only.
 The system will reject claims for Medicare B covered
drugs for QMB recipients where the other coverage code is
not equal to “3 or 4”; the response will contain reject code
edit 70 (Drug Not Covered) and the message text “BCCDT
Only Reimburses Non-Covered Medicare B covered
drugs"
Coordination of Benefits / Medicare B
ACS will deny COB claims for Medicare B covered
drugs such as Xeloda, if the Other Coverage Code
is not equal to “2” with edit 41 (bill other
insurance) and the message text: “Bill Medicare
B”.
Drug Coverage (BCCDT)
 OTC drugs are generally not covered except for
the drug listed in the grid in your pharmacy
provider Manual.
 Unit drugs are generally not covered except for
noted exceptions.
 Don't cover meds for pts in LTC facilities
Prior Authorizations
BCCDT providers can obtain prior authorizations
from two sources:
 BCCDT Office
 ACS Technical Call Center
Prior Authorizations
The MD BCCDT staff will handle the following
prior authorization requests:
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Early Refill - For requests outside established criteria
PA/Medical Certification - authorization based on
diagnosis
DME/DMS for HCFA 1500 billing - exception: needles,
syringes that are paid through POS
PA denials handled by MD BCCDT will return the
following message text in the response: “Prior
Authorization Required, call MD BCCDT (410) 7676787, M-F, 8:30 am – 4:30 pm”.
Prior Authorizations
The ACS Call Center will handle the following prior
authorization requests on behalf of MD BCCDT:
 Early Refill
 Maximum dollar amt ≥ $2500
 Brand Medically Necessary - DAW 1, with exceptions
 Day supply for approved situations
 PA denials handled by ACS will return the following
message text in the response: “Prior Authorization
Required, Call ACS at 1-800-932-3918 (24/7/365)”
Maryland AIDS Drug Assistance
Program (MADAP)
MADAP General Information
BIN
PCN
Group ID
Provider ID
Prescriber ID
Recipient ID
610084
DRMAPROD
MADAP
NCPDP ID Number
DEA Number
MADAP Recipient ID
Copay / Dispensing Fee
MADAP recipients do NOT have a copay
Dispensing Fee
 Brand Products = $3.69
 Generic Products = $4.69
 Partial fills = ½ + ½ dispensing fee.
Drug Coverage
 The MADAP maintenance drug list = antiretroviral
therapies (NNRTIs, NRTIs, PIs, Fusion Inhibitors).
 Nutritional Supplies and OTC drugs are NOT
covered.
 All drugs included in the MADAP formulary are
covered. This list can be found in the Pharmacy
Provider Manual.
Prior Authorizations
Providers can obtain a PA from one of the following
entities, depending on the drug being denied:
 ACS Technical Call Center
 ACS PA Call Center
 MADAP
 SmartPA
Prior Authorizations
The ACS Technical Call Center will handle the following
prior authorization requests for MADAP:
 Early Refill
 Quantity Limits
 Price - Per claim limit = $2500.00
The ACS PA Call Center will handle the following prior
authorization requests for MADAP:
 Epoetin Alpha (Epogen, Procrit)
 Filgrastim (Neupogen)
 Oxandrolone (Oxandrin)
MADAP Handles all other PA requests.
Prior Authorizations
The following drugs will be handled through SmartPA first,
then if more information is needed – the ProDUR Call
Center will handle the request.
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Epoetin Alpha (Epogen, Procrit)
Filgrastim (Neupogen)
Oxandrolone (Oxandrin)
Very specific exceptions will be returned when a claim is
denied by SmartPA. A list will be included in the provider
manual for your reference.
Smart PA Exception Codes
4701 PA required, Call ACS at 800-932-3918
4702 Required diagnosis not met
4703 Non-PDL. Try preferred agent. Call ACS at 800-932-3918
4704 No documentation of risk
4656 Max quantity allowed is exceeded
4669 Medication may be inappropriate for patient
4680 Recipient had not failed alternate treatment
Smart PA Exception Codes
4697 Recipient does not have Hx of recommended concurrent therapy
4698 Drug should not be used as montherapy for required indication
4877 No indication of continuation therapy
4731 Drug should be billed to Encounter
4706 Age requirement not met
4707 Specialty Prescriber required
Coordination of Benefits / Copay only
MADAP will allow the submission of copay only
claims.
The following guidelines must be followed in order
for a claim to be processed correctly. If the
guidelines are not followed, the claim will deny
for one of many reasons.
Coordination of Benefits / Copay Only
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NO COB SEGMENT SUBMITTED
OCC = 8
Other Amount Claimed Qualifier = 99
Other Amount Claimed = Amount of copay –
must equal the Gross Amount Due
Gross Amount Due = Equal Other Amount
Claimed/Amount of copay
Maryland Kidney Disease Program
(KDP)
General Information
BIN
PCN
Group ID
Provider ID
Prescriber ID
Recipient ID
610084
DRKDPROD
MARYLANDKDP
NCPDP Number
DEA Number
Medicaid ID
Generic Mandatory
KDP has a generic mandatory program in place that
must be followed. When providers submit a claim
for a drug that has a generic equivalent and there
is no active PA on file or appropriate DAW code,
the claim will deny with an NCPDP Reject code
“22” – M/I DAW Code.
Generic Mandatory
 KDP accepts the following DAW codes:
 ACS will ensure that the only valid DAW codes
will be 0, 1, 5 and 6:
 0 - default, no product selection
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1 - Physician request
5 - Brand used as generic
6 – Client Override (see next slide for the use of
DAW Code 6)
DAW 6
KDP allows the use of DAW 6 for medications
determined by KDP as follows (pay at EAC):
 Duragesic NDCs: 50458003305, 50458003405,
50458003505, 50458003605, 50458003705
 Rebetol NDCs: 00085119403, 00085132704, 00085135105,
00085138507
 Flonase NDCs: 00173045301
LTC
 The KDP system has no LTC recipients
 Claims will reject when submitted with LTC
identifiers (NCPDP field 307-C7, Patient Location
= 3 – Nursing Home or 4-Long Term/Extended
Care) with NCPDP edit 70 and message text:
“LTC Claims Not Allowed for Reimbursement”.
Maximum Quantity
A max quantity limit of 350 for the following
Immunosuppressive Oral tablets/capsules will be
enforced.
 Azathioprine
 Cyclosporine
 Mycophenolate Mofetil (Cellcept)
 Sirolimus (Rapamume)
 Tacrolimus (Prograf)
 HSN = 004523, 004524, 010086, 010012, 020519,
008974; and Route = Oral
Maximum Quantity
The max quantity limit for OxyContin is 120.
(GSN = 024505, 024506, 025702, 024504, 045129)
Note: This is a per fill quantity limit, not an
accumulation limit.
Minimum Quantity
 There is a minimum quantity limit of 100 tablets
for Ferrous sulfate 325mg tablets (GSN = 001645,
001646, 017378).
 A minimum quantity limit of 480 ml for Ferrous
sulfate elixir (220mg/5ml), GSN = 001639) will
be applied.
 KDP will enforce a minimum quantity limit of 60
tablets for non-legend chewable tablets of any
ferrous salt when combined with vitamin C,
multivitamins, multivitamins and minerals, or
other minerals in the formulation (HIC3 = C3B;
and Dosage form = TC)
Unit Dose
The system will deny claims for unit dose
medications with the exception of drugs listed
with error 70 (drug not covered) and message text:
“Unit Dose Package Size”.
Copays/Dispensing Fee
Maryland KDP has NO copays for it’s recipients.
Dispensing Fees:
 Brand Products = $2.69
 Generic Products = $3.69
 Partials fills = ½ + ½ dispensing fee
Prior Authorizations
Providers can obtain a Prior Authorization from one
of the entities listed below:
 ACS Technical Call Center
 KDP-Nutritional Supplements
Prior Authorizations
The ACS Technical Call Center will handle the
following prior authorization requests for KDP:
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Early Refill
Quantity Limits
Price - Per claim limit = $2500.00
Prior Authorizations
The KDP staff will handle the following prior
authorization requests:
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Nutritional supplements for specific NDCs
DME/DMS for HCFA 1500 billing - Exception:
needles, syringes, blood glucose test strips
Providers can reach the KDP prior authorization staff
at 410-767-5000 or 5002, M-F, 8:00 am – 4:30
pm.
Coordinated ProDUR
The ACS POS system has a mechanism, which at the
pharmacy level, with one transmission, will
electronically link the payer with all recipient drug
information necessary to perform Coordinated
PRO-DUR.
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MCO Services
Specialty Mental Health Services
Medical Assistance Program Services
Providers will submit a single transmission only.
Coordinated ProDUR editing is “message only”
Coordinated ProDUR
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ACS will process claims for the Mental Health
Carve-out drugs then send any drug that are
denied to the MCO for processing. All claims
MUST be sent to the following:
PCN: Use what is currently being submitted
 BIN: 610084
 Group ID – Use what is currently being
submitted
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Other Information
Maryland Pharmacy Programs Website:
http://mdrxprograms.com
Pharmacy Provider Manual is located on the
website
ACS looks forward to working with you and
the programs of Maryland DHMH to make
this a very successful program.
Questions ?