Maryland Pharmacy Programs Claims Processing Training January 2007

Maryland Pharmacy Programs Claims Processing Training

January 2007

Affiliated Computer Services (ACS)

Agenda Implementation Information Coordinated ProDUR – MCO/PBM

Information Call Center Information Operational Information (All Programs) Operational Information (By Program) Clinical Information (By Program) 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

ACSPrescriptions 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.

ACSPrescriptions 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

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

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

Coordinated ProDUR - MCO/PBM Information

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 ProDUR.

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

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:

BIN: 610084 PCN: Use current ACS code submitted Group ID – Use current number submitted

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

Includes multi-lingual support servicesWill Handle: Claims inquiries Clinical inquiries Program specific and general inquiries Prior Authorizations

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

ACS Call Center

Henderson facility handles overflow and after hours

PAC Eligibility Services Call Center information 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

Maryland Medicaid

(OOEP)

Medicaid Pharmacy Program Specific Information

BIN 610084

PCN DRMAPROD

Group ID MDMEDICAID

Provider ID NCPDP Number

Prescriber ID DEA Number

Recipient ID Medicaid ID Number

Copays

Fee for Service = $1.00 / 3.00

PAC copays = up to $2.50 for generics and up to $7.50 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 $1.00 for generics and up to $3.00 for brand name drugs

Copay Exceptions

Patient is pregnant Patient drug is a family planning medication. Long Term Care (LTC) claims Preferred Drug List (PDL) – 3 day emergency

supply

Dispensing Fees

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.

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 410-767-1755, Medwatch form required”

When submitted as Brand Medically Necessary (DAW = 1) with the exception of the following (pay at EAC): 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 selection1 - Physician request5 - Brand used as generic 6 - Override

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 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”

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

Prior Authorizations

Methods to obtain a Prior Authorization: Contact the specified Call Center Complete and fax a Prior Authorization request

form Smart PA


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)


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


ACS ProDUR Call Center Prior Authorizations 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)


ACS Technical Call Center PDL - Non-Preferred drugs Early Refill Maximum dollar limit per claim ≥ $2,500 Age Restrictions Maximum Quantity overrides


Maryland CAMP Office 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

Prior Authorizations handled by SmartPA CNS Stimulants Actiq Anti-Migraine excess quantities Atypical Antipsychotics (dosing quantity) Serostim Botox Synagis Growth Hormones

SmartPA

Prior Authorizations handled by SmartPA 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 610084

PCN DRDTPROD

Group ID MDBCCDT

Provider ID NCPDP ID Number


Recipient ID 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): 0 - Default, no product selection 1 - Physician request 5 - Brand used as generic

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 Co-payments – Please bill PAC”

The following fields must be populated when submitting a copay only claim:

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 /Qualified Medicare Beneficiary (QMB)

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 / QMB

QMB recipients have pharmacy coverage except for drugs covered by Medicare B such as Xeloda- then BCCDT pays only denied claims. Pharmacies must bill Medicare and then Medicaid and BCCDT will be the payer of last resort for coinsurance.

ACS will deny COB claims for Medicare B covered drugs such as Xeloda, if the Other Coverage Code (OCC) is not equal to “2” with edit 41 (bill other insurance) and the message text: “Bill Medicare B”.

Coordination of Benefits / QMB

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 non-Medicare D carriers

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


BCCDT providers can obtain prior authorizations from two sources:

BCCDT Office ACS Technical Call Center


The MD BCCDT staff will handle the following prior authorization requests:

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) 767-6787, M-F, 8:30 am – 4:30 pm”.


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 610084

PCN DRMAPROD

Group ID MADAP

Provider ID NCPDP ID Number


Recipient ID 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.

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.


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

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.


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


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 following drugs will be handled through SmartPA first, then if more information is needed – the ACS PA Call Center will handle the request:

Epoetin Alpha (Epogen, Procrit) Filgrastim (Neupogen) Oxandrolone (Oxandrin)

MADAP Handles all other PA requests.

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

Maryland Kidney Disease Program

(KDP)

General Information

BIN 610084

PCN DRKDPROD

Group ID MARYLANDKDP

Provider ID NCPDP Number


Recipient ID Medicaid ID

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

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 1 - Physician request 5 - Brand used as generic 6 – Client Override

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)

Maximum Quantity

The maximum quantity limit for OxyContin is 120.

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

A minimum quantity limit of 480 ml for ferrous sulfate elixir (220mg/5ml) 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

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”.


Providers can obtain a Prior Authorization from one of the entities listed below:

ACS Technical Call Center KDP-Nutritional Supplements


The ACS Technical Call Center will handle the following prior authorization requests for KDP:

Early Refill Quantity Limits Price per claim limit ≥ $2500.00


The KDP staff will handle the following prior authorization requests: 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.

Conclusion

Maryland Pharmacy Programs Website:

http://mdrxprograms.com

Available on the website: Pharmacy Provider Manual Forms to fax prior authorizations

Maryland Medicaid MADAP

ACS looks forward to working with you and the programs of Maryland DHMH to make this a very successful program.

Questions ?

Documents

Maryland Pharmacy Programs Claims Processing Training January 2007