Maryland Pharmacy Programs Claims Processing Training

1
Maryland Pharmacy Programs Claims Processing
Training

• January 2007

2
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

3
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

4
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.

5
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

6
ACSPrescriptions Benefit Management (PBM)

• Call Center
• Our call center is open 24/7/365 and includes
  multi-lingual support services.
• [phone]
• Aetna
• Humana

7
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

8
Implementation Information

• BIN 610084
• PCN
• OOEP DRMDPROD
• MDKDP DRKDPROD
• MDBCCDT DRDTPROD
• MDMADAP DRMAPROD

9
Implementation Information

• Group IDs
• OOEP MDMEDICAID
• MDKDP MARYLANDKDP
• MDBCCDT MDBCCDT
• MDMADAP MADAP

10
MCO /PBM Implementation Information

• BIN 610084
• Use current PCN for Coordinated ProDUR.

11
ACS Call Center

• All Programs
• Call Center
• PA Call Center number
• Phone [phone]
• Fax [phone]
• Technical Call Center number
• Phone [phone]
• Fax [phone]
• Hours of Operation 24/7/365

12
ACS Call Center

• Technical Call Center
• Program Inquiries
• General Inquiries
• Prior Authorizations

13
ACS Call Center

• Staffed by Customer Service Representatives and
  Pharmacy Technicians
• Pharmacist on site 830 am to 500 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

14
ACS Call Center

• Henderson facility handles overflow and after
  hours
• PAC Eligibility Services Call Center information
• Call Center Number [phone]
• 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

15
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

16

• Maryland Medicaid
• (OOEP)

17
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

18
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

19
Copay Exceptions

• Patient is pregnant
• Patient drug is a family planning medication.
• LTC claims
• PDL 3 day emergency supply

20
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.

21
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 lt 12 years

22
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

23
Generic Mandatory

• The system will cover brand drugs billed as
  generic with DAW5 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

24
Partial Fill

• Claim Submission Guidelines
• Dispensing status P or C
• 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.

25
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.

26
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

27
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

28
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

29
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

30
Prior Authorizations

• Methods to obtain a Prior Authorization
• Call specified Call Center
• Complete and fax a Prior Authorization request
  form
• Smart PA

31
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)

32
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

33
Prior Authorizations

• 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

34
Prior Authorizations

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

35
Prior Authorizations

• Maryland CAMP Office
• Depo Provera
• Lupron Depot

36
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.

37
SmartPA

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

38
SmartPA

• Prior Authorizations handled by SmartPA
• Anti-emetic
• Topical Vitamin A
• Orfadin
• Revlamid
• Revatio
• Nutritional Supplements
• Oxycodone

39

• Breast and Cervical Cancer Diagnosis and
  Treatment Program (BCCDT)

40
BCCDT Program Specific Information

• BIN 610084
• PCN DRDTPROD
• Group ID MDBCCDT
• Provider ID NCPDP ID Number
• Prescriber ID DEA Number
• Recipient ID BCCDT Recipient ID

41
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

42
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

43
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
  non-Medicare D carriers

44
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

45
Coordination of Benefits / Copay Only

• 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.

46
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"

47
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.

48
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

49
Prior Authorizations

• BCCDT providers can obtain prior authorizations
  from two sources
• BCCDT Office
• ACS Technical Call Center

50
Prior Authorizations

• 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, 830 am 430 pm.

51
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)

52

• Maryland AIDS Drug Assistance Program (MADAP)

53
MADAP General Information

• BIN 610084
• PCN DRMAPROD
• Group ID MADAP
• Provider ID NCPDP ID Number
• Prescriber ID DEA Number
• Recipient ID MADAP Recipient ID

54
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.

55
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.

56
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

57
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.

58
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.
• 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.

59
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
60
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
61
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.

62
Coordination of Benefits / Copay Only

• 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

63

• Maryland Kidney Disease Program
• (KDP)

64
General Information

• BIN 610084
• PCN DRKDPROD
• Group ID MARYLANDKDP
• Provider ID NCPDP Number
• Prescriber ID DEA Number
• Recipient ID Medicaid ID

65
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.

66
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 (see next slide for the use
  of DAW Code 6)

67
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

68
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.

69
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

70
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.

71
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)

72
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.

73
Copays/Dispensing Fee

• Maryland KDP has NO copays for its recipients.
• Dispensing Fees
• Brand Products 2.69
• Generic Products 3.69
• Partials fills ½ ½ dispensing fee

74
Prior Authorizations

• Providers can obtain a Prior Authorization from
  one of the entities listed below
• ACS Technical Call Center
• KDP-Nutritional Supplements

75
Prior Authorizations

• The ACS Technical Call Center will handle the
  following prior authorization requests for KDP
• Early Refill
• Quantity Limits
• Price - Per claim limit 2500.00

76
Prior Authorizations

• 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, 800 am
  430 pm.

77
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.
• MCO Services
• Specialty Mental Health Services
• Medical Assistance Program Services
• Providers will submit a single transmission only.
• Coordinated ProDUR editing is message only

78
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
• PCN Use what is currently being submitted
• BIN 610084
• Group ID Use what is currently being submitted

79
Other Information

• Maryland Pharmacy Programs Website
• http//mdrxprograms.com
• Pharmacy Provider Manual is located on the
  website

80

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

81

• Questions ?