Pharmacy Tech Topics - July 2017 by Leann Nelson

Home-Study Continuing Pharmacy Education Modules for Pharmacy Technicians

Insurance and Billing Primer for Pharmacy Technicians

July 2017 Volume 22 Number 3 Expires July 1, 2020 This module must be successfully completed by June 30, 2020 (at 11:59PM CT)

to receive CPE Credit.

Pharmacy Tech Topics™ VOLUME 22 NO. 3 | JULY 2017

Insurance and Billing Primer for Pharmacy Technicians AUTHORS:

Heather Horton, Pharm.D., MS

PEER REVIEWERS: Huda-Marie Kandah, Pharm.D., BCPS Tonae Shaffer, CPhT EDITOR: Patricia M. Wegner, BS Pharm, PharmD, FASHP DESIGN EDITOR: Leann Nelson Pharmacy Tech Topics™ (USPS No. 014-766) is published quarterly for $50 per year by the Illinois Council of Health-System Pharmacists, 4055 N. Perryville Road, Loves Park, IL 61111-8653. Phone 815-227-9292. Periodicals Postage Paid at Rockford, IL and additional mailing offices. POSTMASTER: Send address changes to: Pharmacy Tech Topics™, c/o ICHP, 4055 N. Perryville Road, Loves Park, IL 61111-8653 COPYRIGHT ©2017 by the Illinois Council of Health-System Pharmacists unless otherwise noted. All rights reserved. Pharmacy Tech Topics™ is a trademark of the Illinois Council of Health-System Pharmacists. This module is accredited for 2.5 contact hours of continuing pharmacy education and is recognized by the Pharmacy Technician Certification Board (PTCB). Cover image property of ©2017 Adobe Stock. LEARNING OBJECTIVES Upon completion of this module, the subscriber will be able to: 1. Identify the types of entities that pay for prescription medications. 2. Define commonly used terms in prescription claim billing. 3. Explain common prescription claim rejections, corrective action that can be taken, and audits that can result from improperly billed claims. 4. List the steps involved in obtaining a prior authorization. 5. Discuss billing for special services such as immunizations and medication therapy management (MTM). ACCREDITATION Pharmacy Tech Topics™ modules are accredited for Continuing Pharmacy Education (CPE) by the Illinois Council of Health-System Pharmacists. The Illinois Council of HealthSystem Pharmacists is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. The intended audience is pharmacy technicians. This module will provide 2.5 contact hours of continuing pharmacy education credit for pharmacy technicians. ACPE Universal Activity Number: 0121-0000-17-003-H04-T | Type of Activity: Knowledge-based Release Date: 07/01/17 | Expiration Date: 7/01/2020 (Must be completed by 6/30/2020 at 11:59PM CT)

PHARMACY TECH TOPICS — JULY 2017 TM

Meet the Author Heather D. Horton, PharmD, MS Heather Horton Pharm.D., M.S. obtained her Doctor of Pharmacy degree from Purdue University and her Master of Science in Health Informatics from the University of Illinois at Chicago. She has held positions in retail, long-term care, and hospital pharmacy. She is currently a Clinical Assistant Professor and External Revenue Coordinator at the University of Illinois at Chicago College of Pharmacy.

FACULTY DISCLOSURE. It is the policy of the Illinois Council of Health-System Pharmacists (ICHP) to ensure balance and objectivity in all its individually or jointly presented continuing pharmacy education programs. All faculty participating in any ICHP continuing pharmacy education programs are expected to disclose any real or apparent conflict(s) of interest that may have any bearing on the subject matter of the continuing pharmacy education program. Disclosure pertains to relationships with any pharmaceutical companies, biomedical device manufacturers, or other corporations whose products or services are related to the subject matter of the topic. The intent of disclosure is not to prevent the use of faculty with a potential conflict of interest from authoring a publication but to let the readers know about the relationship prior to participation in the continuing pharmacy education activity. It is intended to identify financial interests and affiliations so that, with full disclosure of the facts, the readers may form their own judgments about the content of the learning activity. The author’s submission has been peer reviewed with consideration and knowledge of these potential conflicts and it has been found to be balanced and objective. The author has no real or apparent conflict(s) of interest that may have any bearing on the subject matter of this continuing pharmacy education program.

NOTICE: Medicine is an ever-changing science. As new research and clinical experience broaden our knowledge, changes in treatment and drug therapy are required. The author and the publisher of this work have checked with sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication. However, in view of the possibility of human error or changes in medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from use of such information. Readers are encouraged to confirm the information contained herein with other sources. For example and in particular, readers are advised to check the product information sheet included in the package of each drug they plan to administer to be certain that the information contained in this module is accurate and that changes have not been made in the recommended dose or in the contraindications for administration. This recommendation is of particular importance in connection with new or infrequently used drugs. Always refer to changes in federal law and any applicable state laws.

Pharmacy Tech Topics™ Steering Committee*

Laura Acevedo, PharmD Margaret DiMarco Allen, PhD Amanda D. Daniels, BS, CPhT

Sandra Durley, PharmD Ana Fernandez, CPhT Clara Gary, CPhT Jo Haley

Jan Keresztes, PharmD, RPh Scott Meyers, RPh, MS, FASHP Elina Pierce, CPhT

Patricia Wegner, BS Pharm, PharmD, FASHP

*Acting committee for 2015, responsible for selecting 2017 module topics.

Insurance and Billing Primer for Pharmacy Technicians

Insurance and Billing Primer for Pharmacy Technicians Introduction Healthcare costs are on the rise. According to the Centers for Disease Control and Prevention (CDC), the total health expenditure in the United States (US) in 2014 was $3.0 trillion dollars; up from $1.37 trillion in 2000.1 Total expenditure is expected to reach $5.6 trillion by 2025.2 Prescription costs are also rising, accounting for $121.0 billion of the 2000 expenditure and $297.7 billion of the 2014 expenditure.1 These increasing costs are compelling Americans to look for help covering the costs of their healthcare, including prescription medication. For pharmacy staff, this means learning how to correctly bill prescription insurance to ensure payment for the pharmacy, the correct copay amount for the patient, and to protect the pharmacy against audits. This module will cover the different payer types and terms used in pharmacy billing. Common reasons for claim rejections, audits, and billing for services and products in addition to medications will also be covered.

Who Pays for Prescription Medications?

prescriptions do not typically require any additional billing but store discount clubs, manufacturer coupons, or discount cards may be applied to reduce the amount patients pay for these prescriptions. Many of these discounts are processed in the same manner as third party claims in most pharmacy computer systems.

Commercial Third Party A Commercial Third Party is what most people think of as insurance. These third party plans are often provided by an employer as a benefit of employment or can be purchased by an individual if they do not have other insurance coverage. The top five largest health insurers in the US are WellPoint, CIGNA, Aetna, Humana, and United Healthcare4; all of these third party payers offer a wide array of prescription coverage. Pharmacy claims are quite different than medical claims. Some information contained in the claim for a prescription medication will be the same as in a medical claim, such as patient name, date of birth, address, and Figure 1. Prescription Drug Spending by Payer Type3

Understanding the different types of payers can help the pharmacy staff determine the correct way to bill a claim. According to the California Health Care Foundation (CHCF), only 15% of spending on prescription medication in the US was paid out-of-pocket by the patient in 2014.3 The same CHCF survey further breaks down prescription spending (by dollar amount spent) in 2014 as shown in Figure 1. Out-of-pocket spending by patients can further be broken down into two categories: 1) patient copays/co-insurance and 2) patients that pay the full cost of the medication with no assistance from any third party payer. Copays and coinsurance will be discussed later in this module.

Patient Self Pay Patient Self Pay is a term used for a prescription where the patient pays the full cost of their medication. These

Private Insurance

Medicare

Medicaid

Other Public Payers

Other

Patient Out of Pocket

Created with information from the California Health Care Foundation3

PHARMACY TECH TOPICS — JULY 2017 TM

other demographic information. Pharmacy claims require additional information such as name of product written, name of product dispensed, national drug code (NDC) of product dispensed, quantity dispensed, instructions for use, and days supply.

Pharmacy Benefit Manager (PBM) Most health insurance companies have opted to contract with a Pharmacy Benefit Manager (PBM) to handle their prescription claims. PBMs contract with pharmacy providers, process the claims submitted by pharmacies, provide payments to pharmacies for claims submitted, recommend and administer member copays, formularies, and limitations or restrictions on prescription coverage on behalf of the insurance plan, manage clinical pharmacy programs, and negotiate rebate contracts with pharmaceutical companies. FOR MORE INFORMATION ABOUT PHARMACY BENEFIT MANAGERS (PBMs): PHARMACEUTICAL CARE MANAGEMENT ASSOCIATION

http://thatswhatpbmsdo.com

Copay and Coinsurance Copay and coinsurance both refer to the portion of a claim that the patient is responsible for paying. Copays are a flat fee (like $10 per prescription) where coinsurance is a percentage of the total claim price (like 15% of the cost of the prescription). Many insurance plans require the patient to pay a deductible. A deductible is the amount the patient must pay out of pocket before the insurance company will pay anything toward the patient’s claims. Often the pharmacy deductible is separate from any medical coverage deductible and can be an individual deductible or a family deductible. The deductible is separate from, and in addition to, any premium the member pays. The premium is the amount paid to the insurance company to provide the member with coverage. For many commercial plans, this cost is paid by the member directly to the insurance company, by the member’s employer, or might be paid by payroll deduction if the employer only pays part of the premium for the employee. PBMs and other payers determine what prescription medications will be covered for beneficiaries. This listing of covered medications is called a formulary. The formulary can be, and frequently is, multi-tiered. In a multi-tiered formulary, different medications have different coverage or copays. The most common example of this is a brand tier and a generic tier, where more

expensive, brand name medications have a higher copay than less expensive, generic medications.

Medicaid Medicaid is a joint state and federally funded health insurance plan for low income and other at risk populations. Federal money is given to the state and the state is responsible for paying providers. Each state determines its specific eligibility criteria and type of coverage available to its beneficiaries. Nearly 20% of Americans had coverage through Medicaid in 20155. Many, but not all, Medicaid programs have prescription coverage. There are different types of Medicaid coverage. Traditional Fee-For-Service (FFS) Medicaid coverage, where the state directly reimburses the provider for each service provided, is being replaced in many areas by Managed Medicaid programs. In Managed Medicaid programs, the state contracts with one or more health insurance providers, or managed care organizations (MCO), to provide services to their beneficiaries. Typically the state pays the MCO a per member, per month rate and the MCO determines rates paid to providers, copays/ coinsurance charged to members, formularies, and other covered services.

Medicare Medicare is the federally funded health plan for seniors over 65 years of age and for younger persons with specific disabilities or kidney failure. Medicare Part A covers hospital stays. Medicare Part B covers office visits, some vaccines, medical equipment and supplies, and some prescription medications. Medicare Part B covered medications include oral anti-cancer drugs, oral anti-emetic drugs, immunosuppressants, nebulizer medications, end stage renal disease (ESRD) related medications, drugs administered by infusion via a pump system. Many of these medications will require a prior authorization to determine Part B or Part D coverage (prior authorizations will be discussed in detail later in this lesson). For example, insulin that is administered via an insulin pump is covered by Medicare Part B while the same insulin dispensed to a patient without a pump, that will be injected with a syringe and needle, will be covered by Medicare Part D. The syringes, alcohol swabs, home glucose meter, and other supplies associated with the insulin are a Part B benefit. For additional information about what is covered by Medicare Part B visit https:// www.medicare.gov/what-medicare-covers/part-b/whatmedicare-part-b-covers.html.

Insurance and Billing Primer for Pharmacy Technicians Most prescription medications are covered by Medicare Part D, which requires a separate enrollment by the member in addition to their Part A/B coverage. Medicare Part D has confounded beneficiaries and providers since its introduction in 2006. Pharmacy providers bill claims to Pharmacy Benefit Managers (PBMs) who are in turn paid by Medicare to manage the drug coverage for beneficiaries. Medicare establishes some minimum standards for coverage but leaves the details of each plan up to the PBM, resulting in a wide range of available options for patients and a complex sea of details for patients and the pharmacy staff to navigate. Patients can enroll, change, or drop coverage in Medicare Part D when they turn age 65 years and become eligible for Medicare Part A and Part B; when they become Medicare Part A and Part B eligible due to a disability; during the annual open enrollment period; or when they qualify for Extra Help. Extra Help reduces copays for Part D covered medications and may reduce monthly premiums and deductibles. Individuals with income below $18,090 per year ($24,360 for a married couple) may qualify for Extra Help in 20176. Most plans have a monthly premium, a yearly deductible, per prescription copays or coinsurance, and a coverage gap, also known as the â&#x20AC;&#x153;donut-hole.â&#x20AC;? See Figure 2. The coverage gap is a source of frustration for members and pharmacy staff alike. Once drug spending by the patient and the plan has reached a specified level, the individual pays most of the cost of their medications until the catastrophic limit is reached. Once patient spending has reached the catastrophic limit, the Part D plan pays most of the cost of the medications for the rest of the year. In 2017, Part D beneficiaries will enter the coverage gap when they and their plan have paid a total of $3,700. While in the gap, individuals pay no more than 40% of the plan cost for brand medications and 51% of the plan costs for generic drugs. Patients receive catastrophic coverage when spending has reached $4,950.7 Medicare pays 95% of drug costs for the rest of the year once a patient is out of the coverage gap and into catastrophic coverage. Beneficiaries can pay a higher Test Your Knowledge 1. Fill in the Blanks Who Pays the Third Party Pharmacy? 1. State Government Managed Medicaid PBMs Medicare Part B 2. Medicare Part D 3. 4. PBMs

Figure 2. The 2017 Medicare Part D Coverage Gap (aka "Donut-Hole")

Jan 1

Dec 31

monthly premium to reduce or eliminate deductibles, copays, and the coverage gap. Some members choose to enroll in a Medicare Advantage plan (also referred to as Medicare Part C) that combines Medicare Parts A and B coverage. Part C plans can include Part D coverage (referred to as MAPD plans) but not all Part C plans do. Patients that are eligible for both Medicaid and Medicare, often referred to as Dual Eligibles, receive their prescription benefit through a Medicare Part D plan. Premiums, deductibles, and copays are typically lower for dual eligible patients than for patients covered only by Medicare.

Example Illinois Department of Healthcare and Family Services (IHFS) Family Health Network Medicare Part B SilverScript United Health Care Answers on page 19

PHARMACY TECH TOPICS — JULY 2017 TM

Other Public Payers Other state or federal programs that pay for prescription medication (“other public payers” Figure 1 on page 3) include Tricare and the Veteran’s Administration (VA) for military personnel, Children's Health Insurance Program (CHIP) for children and pregnant women, and various other state funded plans. Drug manufacturers, local or national charities, and many other organizations can also be sources of funding to pay for prescription medications.

Billing Third Party Payers for Prescription Medications Billing and payment for prescription medications has its own vocabulary. Understanding the following terms will ensure correct billing and proper payment for prescriptions processed in the pharmacy. Pharmacy claims are processed and a determination of coverage is made at the time of service. This process of comparing the submitted claim to the patient’s benefits and paying or denying the claim is called adjudication. In order to accomplish this, information about the patient and the medication being dispensed must be sent to the insurance company or PBM. In 1988, payers and pharmacies, along with telecommunications and software vendors, developed the National Council for Prescription Drug Programs (NCPDP) Telecommunication Standard Version 1.0 to allow for real time communication between the pharmacy and payer.8 NCPDP D.0 is the standard version/release currently in use. All third party claims go

REQUIRED CLAIM INFORMATION Patient Name Patient Date of Birth Patient ID Number Payer BIN Payer PCN Drug Name Drug NDC Quantity Dispensed Directions for Use (SIG) Days Supply

through a switch (or hub) so that each pharmacy does not need to establish a connection to each individual payer. See Figure 3. The pharmacy NCPDP number or National Provider Identifier (NPI) number are used to identify the pharmacy submitting the claim. A 6-digit NCPDP Processor ID number, known as the BIN, is used by the switch to identify the payer and appropriately route the claim. The PCN (Processor Control Number) and patient Group Number further identify which program within the PBM the patient belongs to since the PBM may handle claims for multiple insurance companies and multiple plans for each insurance company. The group number is not used by all payers and is considered optional information with a claim. Once routed to the correct PBM and plan, the specific patient needs to be identified to make final coverage determination for the prescription claim. Insurance plans assign a Patient Identification Number to each covered member. The patient identification number is also referred to as a member ID number, beneficiary ID number, or recipient ID number, among other names. Often, patients other than the covered member, are also eligible for benefits – the child or spouse of an employee given insurance through his employer for example. Some insurance plans will assign each covered patient his or her own patient identification number while others will use a Person Code to indicate the patient is someone other than the member. The person code is typically a 2 or 3 digit extension to the patient identification number. The required BIN, PCN, patient identification number, and group number (if used) can be found on the patient’s insurance card. There is not a standard layout for the information so it can often be difficult to find. Many pharmacies subscribe to an eligibility service that allows the pharmacy staff to search for the patient’s coverage in the event that the patient does not have his/her card or has an out of date card. Third party payers will occasionally need additional information in order to determine coverage for a particular claim. For example, Medicare Part B claims require the diagnosis for covered medications and supplies. This diagnosis is submitted with the claim as an ICD-10 code. ICD-10 is short-hand for International Classification of Diseases, Tenth Revision; a World Health Organization medical condition classification listing9. ICD-10 provides a standardized way to document a patient’s diagnosis. Another piece of information that may be required on a claim is a Healthcare Common

Insurance and Billing Primer for Pharmacy Technicians

Figure 3. Pharmacy-PBM Communication Through the Hub

Procedure Coding System (HCPCS) code (commonly pronounced “hick-picks”) code. The HCPCS code is a way of identifying the type of product dispensed to the patient. It is used for products and supplies such as “durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's office.”10 Pharmacies that bill Medicare Part B will need to include this code in the claim from the pharmacy for items such as diabetic testing strips or ostomy supplies. Often this is programmed into the pharmacy software and is done automatically with no technician input or is added by a billing clearinghouse that prepares the pharmacy’s Medicare Part B claims for submission to Medicare. Clearinghouses collect information about claims from the pharmacy, most often through the pharmacy management system, and prepare the claims for submission to the payer. The claims that are most often processed through a clearinghouse are claims for non-drug items billed through a pharmacy or for drugs that are covered by a patient’s medical insurance instead of by the pharmacy benefit.

Centers for Medicare & Medicaid Services (CMS) requires all Medicare Part D claims to include a code indicating the patient’s location. These Patient Residence Codes (formerly known as Location Codes), include options for home, long-term care facility, nursing home, and hospice care among others. Patients in the pharmacy may have more than one insurance plan that covers prescription medications. The primary payer for the patient is the one that is billed first and the secondary payer is billed after the primary pays its share. When billing more than one insurance for the same claim it is referred to as a Coordination of Benefits (or COB). There are codes in place to send information from the primary payer to the secondary payer. These Other Coverage Codes (OCC) tell the secondary payer what was covered by the primary payer and for what the secondary payer is being billed. Most pharmacy management systems have special fields where this information is entered for transmission to the payer. See Table 1 on page 8.

PHARMACY TECH TOPICS — JULY 2017 TM

Table 1. Other Coverage Codes 0

Not Specified by Patient

No Other Coverage

Other Coverage Exists - Payment Collected

Other Coverage Exists - Claim Not Covered

Other Coverage Exists - Payment Not Collected

Managed Care Plan Denial

Other Coverage Denied - Not a Participating Provider

Other Coverage Exists - Not in Effect at Time of Service

Claim is Billing for Patient Financial Responsibility Only

Claim Rejections Claim rejections are a frequent occurrence in the pharmacy workday and can be caused by an array of different issues. Many third party payers include messages in their online response detailing the cause for rejecting the claim but often the responses require a bit of investigation to get to the cause of the rejection. Some of these rejections are due to incomplete or incorrect information in the claim and can be easily corrected in the pharmacy. Others require additional documentation to achieve successful adjudication while some are hard stops, meaning the claim will not be adjudicated at all.

Refill Too Soon Rejection One of the most common rejections seen in the pharmacy is Refill Too Soon. In this scenario, the pharmacy is attempting to bill a claim for the same medication too close to the last time it was filled. Some plans will give a date that the prescription can be filled in the rejection message while others may not. Each plan can set their own definition of “too soon” but a good rule of thumb is the prescription will be able to be billed again when the patient has used about 85% of the medication supplied. For example, if a patient receives a 30 day supply, 85% use would be day 25 after the last fill. Payers may also reject if the cumulative days supply makes the refill too soon. If the patient or pharmacy fills the prescription 5 days early each month, the total days supply over multiple fills may result in a refill too soon rejection. This type of rejection is also known as a carryover days supply rejection. The resolution options for this claim rejection are to either wait until the fill date specified by the payer or call the payer to see if there is an override possible. There may be reasons the patient is requesting an early refill and the payer may allow the fill. Patients requesting an early fill before going out of town and change in dose (from one tablet daily to two tablets daily) are examples of reasons payers may allow an early refill.

Days Supply Exceeded Rejection Along with the refill too soon reject, another common rejection seen in pharmacies is Days Supply Exceeded. This reject occurs when the prescription is written for a longer time frame than the plan covers. For example, the prescription is written for 90 tablets to be taken once daily (a 90-day supply) and the payer only covers up to a 30-day supply each fill. To resolve this rejection and successfully adjudicate the claim, change the quantity dispensed to the accepted days supply and resubmit. It is prudent to make notation either on the face of the prescription or in the pharmacy computer system of the reason for the change in dispense quantity. Be sure when the dispense quantity is changed that the number of refills is changed appropriately so the patient ultimately receives what was prescribed.

Missing/Invalid Days Supply Rejection A rejection for Missing/Invalid Days Supply (also called a Maximum Daily Dose Exceeded rejection by some payers) is seen when the days supply submitted does not correctly correlate with the quantity dispensed and the instructions, or when the amount per day is correct based on the instructions but still exceeds an acceptable dose per day. This rejection is seen frequently with items such as inhalers where the pharmacy system struggles to calculate an accurate days supply. For example, a 17 gram albuterol inhaler contains 200 actuations (“puffs”) and is prescribed with instructions for the patient to use 1 puff four times daily. Many pharmacy computer systems will calculate the days supply as 4 (17g divided by 4 times daily) instead of the correct 25 days supply when calculated as 200 actuations divided by 4 times daily. Correcting the days supply will result in an adjudicated claim.

Plan Limitations Exceeded Rejection Payers may set limits regarding how many doses of a medication a patient can receive in a specific time frame. One of the most common examples of this is the payer limiting proton pump inhibitors such as omeprazole to 90 days per year. The message that is seen in the pharmacy on the rejected claim will read Plan Limitations Exceeded. The pharmacy may be able to obtain an override for this with a prior authorization (discussed in detail below) but often there is no way to receive a paid claim once a patient meets the maximum allowable quantity or days supply for the medication. A new rule for 2017 from CMS regarding Milligram Morphine Equivalents (MME) limits will

Insurance and Billing Primer for Pharmacy Technicians cause this type of rejection to be seen when a claim for opioid medications is submitted for a Medicare Part D beneficiary when either the daily dose or cumulative dose exceeds the limits set by CMS.

CMS rules about MME limits and other DUR information can be found at https://www.cms.gov/Medicare/PrescriptionDrug-coverage/PrescriptionDrugCovContra/ RxUtilization.html

Patient Not Covered Rejection Patient not covered is another commonly occurring rejection when billing prescription claims. This can be due to a change in the patient’s coverage status but can also be due to submission of incorrect information. If the date of birth submitted by the pharmacy does not match what is on file with the payer, the claim will reject with patient not covered. Some payers will not recognize commonly used nicknames such as Tom for Thomas or Cindy for Cynthia and will require the full name to be submitted in order to recognize the patient as covered. Similarly, hyphenated last names usually need to match what the payer has on file. The patient may prefer the last name Smith but if the patient’s last name with the payer is Jones-Smith, the hyphenated last name will need to be used. Be sure to check all patient information submitted in the claim (patient name – first and last – spelled correctly, date of birth, gender, ID number, group number, person code) before concluding that the patient is not covered. Payers may give more specific reject information such as Missing/Invalid Cardholder ID, Missing/Invalid Date of Birth, or Patient/Card Holder ID Name Mismatch.

Product/Service Not Covered Rejection Product/Service Not Covered rejects happen when the medication prescribed is not on the payer’s formulary. Some payers reject brand name products when a generic product is available. Changing from the brand to the generic, if approved by both the prescriber and the patient, will result in a paid claim for this scenario. Alternate products may be suggested in the reject

from the payer. These will typically require that the pharmacist contact the prescriber to authorize the change in therapy. When a product is purchased in an outer package containing multiple dispensing units (oral contraceptives, for example), the NDC numbers on the inner and outer packages are different. Most payers want the claim submitted with the outer package NDC and claims submitted with the inner package NDC may result in a rejection. Medicare Part D has a list of drug classes not covered for its beneficiaries. Any medication in one of these classes will not be covered. Members can file an appeal with their plan and ask for coverage.

Drugs Excluded from Medicare Part D Coverage: • Drugs used for anorexia, weight loss, or weight gain • Drugs used for infertility • Drugs used for cosmetic purposes or hair growth • Drugs used for cough and cold • Vitamins and mineral products (except prenatal vitamins and flouride preparations) • Nonprescription over-the-counter (OTC drugs

Updated information can be found on the CMS Website: www.cms.gov

Provider Not Covered Rejection Similar to patient not covered is the Provider Not Covered rejection. A payer may limit eligible prescribers or pharmacies for the plan. More often, the identifier for the prescriber or pharmacy is not being submitted correctly. Check that the prescriber’s NPI number and DEA number, if applicable, are correct. The same rule of thumb about hyphenated names discussed with patient not covered rejects applies to prescribers. If the prescriber is registered as Jones-Smith and the pharmacy submits the name as Smith, the claim may reject stating the

PHARMACY TECH TOPICS â&#x20AC;&#x201D; JULY 2017 TM

name and NPI or DEA number do not match. Many retail pharmacies subscribe to a web based provider look-up tool that allows the staff to search for the prescriberâ&#x20AC;&#x2122;s state license number, DEA number, and NPI number. Provider NPI numbers can be searched at https://npiregistry.cms. hhs.gov/. If there is no access to these types of tools, a phone call to the prescriber can help ensure the correct numbers are being submitted. There are instances where the patient is limited to a particular pharmacy, either for specific medications (such as specialty medications) or the payer may have a limited pharmacy network. These are almost always contracting issues and are not something that can be resolved in the pharmacy at the time of service.

Submit Bill to Other Processor or Primary Payer Rejection Patients may be covered by more than one insurance plan. A common situation is a patient that has employer provided coverage as primary and Medicaid as secondary coverage. If the pharmacy submits the claim to Medicaid without first submitting to the primary coverage,

Medicaid will reject the claim with a Submit Bill To Other Processor Or Primary Payer reject. If the pharmacy is set up to bill COB claims electronically, make sure the plans are being billed in the correct sequence. In situations where the medication is not covered by the primary, the correct OCC must be entered to transmit the information to the secondary payer. The codes are often automatically submitted by the pharmacy management system once the rejection from the primary payer is received. Patients enrolled in Medicaid and Medicaid Managed Care plans might switch between payers on a frequent basis; up to monthly in some cases. For a patient who had coverage in a traditional FFS Medicaid plan who has switched to a Managed Medicaid plan you may also receive a Submit Bill To Other Processor Or Primary Payer reject if you submit the claim to FFS Medicaid. This rejection is also seen when Medicare Part D beneficiaries switch plans, though most of these patients have fewer opportunities to change plans. Often in these Medicare Part D Bill to Other Payer rejections, the BIN and PCN of the new plan is given. To get a paid claim on this type of rejection, change the submitted insurance information to the current coverage

Test Your Knowledge 2. How would you correct this rejection?

NEXT LEVEL HEALTH INSURANCE Patient Name: Test Patient

How would you correct this rejection?

Identification Number: 123456 Group Number: 9876 BIN 610241 PCN RXMCDP

Answer on page 19

Insurance and Billing Primer for Pharmacy Technicians and resubmit the claim. Third party payers are not always aware of the patientâ&#x20AC;&#x2122;s new coverage and only know that the patient is no longer covered.

Coverage Terminated Rejection Claims submitted to a payer after the patientâ&#x20AC;&#x2122;s coverage period has ended for most commercial plans will result in a Coverage Terminated rejection.

Drug Utilization Review/Professional Pharmacy Services (DUR/PPS) Rejection Drug Utilization Review/Professional Pharmacy Services (DUR/PPS) rejections occur when there is a potential clinical issue with the medication billed to the third party. Common reasons for a DUR/PPS rejection from the payer include under or over utilization, drug-drug interaction, high dose, low dose, or excessive duration of therapy. These rejections require pharmacist intervention and there are codes indicating the action taken that need to be submitted to the payer for claim approval. Intervention codes are submitted in sets of three: Reason For Service Code, Professional Service Code, and Result Of Service Code. Each code is a two character, alpha-numeric value from a set list of options. Examples of these codes are found in Table 211. Many pharmacy management systems have drop-down menus that allow the pharmacy staff to choose from available options while others require text input. The Reason For Service Code details why an intervention is necessary and is included in the rejection from the payer. The type of intervention taken by the pharmacist is described by the Professional Service Code. Codes currently exist for 20 specific intervention types including patient consultation, prescriber consultation, literature review, and laboratory testing.

Prior Authorization Required Rejection Prior Authorization Required rejections have become more common in the last few years. A prior authorization, or PA, is an additional step in the coverage determination process. The payer is asking for additional information before deciding if the drug is covered for the beneficiary. PAs are most commonly seen with new and/or expensive medications but can be seen with older, inexpensive medications as well if there are preferred courses of treatment available. They are also seen frequently when the patient or prescriber prefers the brand name product in cases where a generic is available.

Table 2. Examples of DUR/PPS Codes11 Reason For Service Code DD Drug - Drug interaction ER Early refill EX Excessive quantity for time period HD High dose ID Ingredient duplication LD Low dose LR Under utilization TD Therapeutic duplication Professional Service Code GP Generic product selection M0 Prescriber consulted MR Medication review P0 Patient consulted PT Perform laboratory test R0 Pharmacist consulted other source SW Literature search/review TH Therapeutic product interchange Result Of Service Code 1A Filled as is, false positive 1B Filled prescription as is 1C Filled, with different dose 1F Filled, with different quantity 1G Filled, with prescriber approval 3G Drug therapy unchanged 3J Patient referral 3M Compliance aid provided Created from https://ushik.ahrq.gov/

While PAs are intended as tools to ensure use of the most cost effective therapy, the complicated process of obtaining authorization often leads to prescription abandonment. It has been estimated that 40% of patients prescribed medications requiring a prior authorization did not ultimately receive any treatment12. Understanding the PA process and effectively communicating it to both the patient and the prescriber can have a tremendous impact on patient drug therapy. The time it takes from initiation of the PA process to approval or denial of the claim varies depending on payer and on method used to submit the PA. The PA may be decided in as little as 24 hours or it can take up to a week or more. Although there are a few different

PHARMACY TECH TOPICS — JULY 2017 TM

Test Your Knowledge 3: DUR/PPS Rejection After receiving the below Low Dose (LD) rejection from the payer, the pharmacist speaks with the prescriber. The prescriber states that the low dose is appropriate due to this patient's kidney function. What Professional Service Code and Result of Service Code should be submitted to the payer?

Answers on page 19

ways to submit the PA to a payer, the basic steps remain the same. Informing the patient that a PA is required and explaining the expected time to approval or denial is one of the first things that should be done in the pharmacy. Explaining that a PA means the payer is requesting more information, and not necessarily that the payer is denying the claim, will help alleviate patient frustration and decrease the risk of prescription abandonment. PAs usually require information that is not readily available in the pharmacy and/or the prescriber’s signature, meaning the pharmacy will usually have to contact the prescriber regarding the PA. The pharmacy can contact the prescriber’s office via phone, fax, or electronically. While not necessary, many pharmacies find that they have more success when they complete as much of the PA form as possible before sending it to the prescriber. There are online portals, some free to use, where the pharmacy can find nearly all available PA forms. The pharmacy staff can fill in some of the information and the partially completed form will be faxed or delivered electronically to the prescriber for completion. In some pharmacies, this web service is integrated into the pharmacy management system. This integration allows the pharmacy system to send the information to the web service and on to the prescriber with little to no interaction from the pharmacy staff. Without the use of

a service like this, the pharmacy staff or the prescriber’s office staff must reach out to individual payers to obtain the forms necessary for the PA. Once completed, forms must be returned to the payer for final determination of coverage for the patient’s medication. If all the steps are completed electronically, the PA can be completed in 24 hours or less. As more steps are done manually, the time from initiation to determination increases. Frequently, notification of approval or denial of the PA is not sent to the pharmacy and the pharmacy staff must follow up with the payer to learn the final outcome of the PA request. See Figure 4.

Third Party Audits Third party payers periodically conduct Audits to ensure the pharmacy is following the terms of the contract between the pharmacy and payer, to identify any overpayment by the PBM, and to deter abuse13. Audits are typically one of two types: Desk Audits where the electronic claims data is reviewed by the PBM, or Field Audits where an auditor visits the pharmacy in person13. In a desk audit, the pharmacy is typically sent a fax or email with a list of prescriptions included in the audit. The requested information is detailed in the notification and typically includes copies of original prescriptions, proof

Insurance and Billing Primer for Pharmacy Technicians Figure 4. The Prior Authorization Process

PHARMACY Pharmacy receives rejection during claim processing

PRESCRIBER'S OFFICE Pharmacy notifies Prescriber that PA is required

Prescriber completes PA form

of delivery (patient signature or courier information if shipped to the patient), notations of any changes on the prescription, and prescriber notes. The audit request will also detail how to respond and the deadline for responding. Field audits are more complex and time consuming than desk audits. The pharmacy is notified in advance and is given a timeframe or list of prescriptions that the auditor will review. A best practice for a field audit is to assign a staff member to the auditor for the duration of the audit as information needed is extensive. In addition to the items requested for a desk audit, the field auditor may review the pharmacyâ&#x20AC;&#x2122;s licenses, the staff licenses, refill procedures, drug purchasing invoices, return to stock procedures, compounding logs, expired medication processes, HIPAA compliance, and a wide range of other operational items. Auditors are often taking photographs of the pharmacy to submit to the PBM with the audit results. Audits are increasing in frequency and can result in significant financial loss to the pharmacy if the payer finds the pharmacy is not in compliance. The following section is a discussion of some common audit findings (Table 3) that result in financial loss to the pharmacy and how to avoid them.

Inconsistent Days Supply/Unclear SIG Anytime the days supply submitted is not appropriate for the amount dispensed, the third party may take back some or all of the reimbursement for a prescription in relation to an audit. For example, a pharmacy submits a 10 ml bottle of eye drops with instructions of 1 drop in each eye as a 30 day supply. The automated system that

PAYER Prescriber submits form to the payer

Payer makes coverage determination

approves claims may initially send a paid claim response to the pharmacy however the auditor correctly calculates the days supply as 50 days and marks this as an audit

Table 3. Common Audit Findings Inconsistent Days Supply for quantity dispensed Vague/unclear SIG Inappropriate DAW Code Dispense Quantity exceeds authorized quantity Missing/incomplete original prescription Incomplete documentation of changes to prescription Unapproved refills Incorrect package size/quantity Higher than expected usage Prescriptions billed but not dispensed

PHARMACY TECH TOPICS — JULY 2017 TM

finding subject to recovery of payment. Prescriptions with vague instructions that do not allow a correct calculation of days supply are also a common audit finding. Avoid submitting claims with a SIG of “As directed”, “Insulin per sliding scale”, or similar instructions that do not allow for calculation of the total quantity to be taken in a day. It may be necessary to contact the prescriber for clarification of these prescriptions in order to submit acceptable instructions to the payer. If the prescriber is contacted and the instructions are changed, be sure to document the discussion with the prescriber for audit purposes.

Innappropriate DAW Code Occasionally, either the patient or the prescriber prefers a brand name product to an available generic (Dispense As Written or DAW). The DAW code allows for the pharmacy to indicate who made the product selection. When the prescriber indicates on the prescription to use brand, select DAW 1 to pass that information to the payer. Use DAW 2 if the patient selects the brand name. Be aware that the third party may charge the patient a higher copay, require a PA, or reject the claim altogether depending on the plan limitation details. Auditors will look for appropriate DAW code usage when reviewing prescriptions and payers can recover payment if an incorrect DAW code was submitted.

Dispense Quantity Exceeds Authorized Quanitity Many patients are requesting, and many payers are covering, extended days supply prescription claims. Historically, payers limited patients to a one-month supply at each fill but three-month supply prescriptions are paid at a growing rate. The pharmacy needs to be aware, that in order to fill the extended days supply, the prescription must be written for the higher quantity. Some state pharmacy rules allow for filling more than the originally written quantity as long as there are sufficient refills available to cover the quantity dispensed. Payers do not generally accept that practice and the pharmacy will need to obtain a new prescription for the increased quantity. A prescription written for 30 tablets with 2 refills filled as 90 tablets with no refills may be legal by state board rule but will be an audit finding by most payers. When the prescriber is contacted to authorize the three month supply, best practice is to note on the face of the prescription who approved the change and what date the

authorization was made or to have the prescriber send a new prescription in the case of an e-prescription. Some payers will accept an electronic note in the pharmacy filling system as sufficient documentation, while others will not.

Missing/Incomplete Original Prescription A copy of the original prescription is the most common item requested in an audit. If the original cannot be located or is incomplete in any way, it will be considered a finding. Incomplete prescription findings can be the result of missing written date, missing prescriber signature, missing dispense quantity (unless it can be calculated based on the SIG: 1 BID x 10 days, for example), incomplete or unclear SIG, among other things. Incomplete or missing documentation of changes made to a prescription is another common audit finding. Any alterations on a prescription must be properly documented. Audit findings for unapproved refills are frequently reported by auditors. These can result from errors in data entry (wrong number of refills entered when processing the original prescription) or incomplete documentation of refills authorized by a prescriber. Best practice is to create a new prescription as opposed to adding refills to the current prescription when a prescriber authorizes refills on a medication.

Incorrect Package Size Incorrect pack size is also a frequent audit finding. Most items other than pills are dispensed and billed in grams or milliliters as appropriate. There are a few items that are dispensed as a package and using the incorrect quantity can result in over or under payment of a claim. Inhalers, nebulizer solutions, and vials or prefilled syringes for injection can be especially difficult to determine which quantity to use. Most inhalers are billed in grams or number of doses but some are billed as 1 unit. Correct billing for an Advair Discus with 60 doses may be “60” while correct billing for an Asmanex Twisthaler with 60 doses may be “1”. If the Asmanex product is billed as “60” it would result in a substantial overpayment and would be subject to payment recovery if discovered in an audit. Reviewing the pack size listed in the pharmacy filling system item file can help determine if the item is billed in milliliters or in number of packages dispensed.

Insurance and Billing Primer for Pharmacy Technicians

Higher Than Expected Usage Higher than expected usage may also be cause for an audit finding. The payer will likely question a 60 gram tube of cream submitted as a 7-day supply. If the patient uses the cream on 50% of the body three times a day and truly does use 60 grams per week, make sure that is documented appropriately so the days supply can be justified in an audit. Prescriptions billed to the third party but not delivered to a patient will result in an audit finding. Prescriptions filled and placed in will call should be reviewed on a regular basis and those that were filled more than a week prior should be considered for return to stock and reversal of the claim. In instances where the pharmacy does not have the full quantity to be dispensed in stock, the claim should not be billed to the payer until the full quantity is available. Billing for 30 tablets and dispensing 10, even with full intention of dispensing the other 20, is considered a major finding in an audit. Audits by third party payers cannot be avoided and can be quite costly if there are findings. There are many other issues that can cause payment recovery. Good documentation, careful days supply calculation and attention to dispensing quantities will go a long way toward avoiding findings and keeping payments in these audits.

Special Billing Situations Pharmacies often bill third party payers for items that are not medications. Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), immunizations, and medication therapy management (MTM) services are examples of non-drug billing in pharmacy and each of these have special requirements for submitting claims for payment.

Durable Medical Equipment, Prosthetics/ Orthotics & Supplies (DMEPOS) DMEPOS includes items such as diabetic blood glucose test strips and lancets, canes, walkers, wound care supplies, and ostomy supplies. These are covered by Medicare Part B for eligible beneficiaries and may be covered as a pharmacy benefit through state Medicaid programs and commercial plans. Medicare Part B requires a diagnosis code (ICD-10) and HCPCS code for all items that do not have an NDC. The NDC is used in place of the HCPCS code for any supplies that have one. With the addition

of the ICD-10 diagnosis code and HCPCS if needed, these claims are processed in a similar manner as drug claims. Individual commercial plans and state Medicaid programs may require additional information. Often pharmacies contract with a clearinghouse to complete billing to keep this process as seamless as possible in the everyday workflow. Those that do not work with a clearinghouse may need to complete additional steps in billing for these items. The payer help desk is the best source of information if there are questions about what is needed on supply claims.

Immunizations More and more third party payers are recognizing pharmacies as immunization providers. Immunization claims are also processed much like any other drug claim. In order to get reimbursement for the administration of the vaccine, and not only for dispensing, additional information may be required by the payer. Diagnosis code, DUR codes, and administration fee (sometimes called incentive fee) are the items most often needed on an immunization claim. ICD-10 has one code for administration of vaccines, Z2314. The DUR codes used to indicate administration of a medication if needed are as follows: Reason For Service Code PH (Preventive Health Care), Professional Service Code MA (Medication Administration), Result Of Service Code 3N (Medication Administered). The administration fee is the amount your pharmacy charges for administration of the vaccine in addition to the cost of the product and associated dispensing fee. Information entered in this field in the pharmacy filling software is accepted by some payers but will cause the claim to reject with other payers. The payer help desk or your contract with the payer can give details about what fields are required and what the acceptable values are for those required fields when billing for immunizations given at the pharmacy. Vaccine claims to major medical plans and Medicare Part B require a Current Procedural Terminology (CPT) code in addition to the ICD-10 code. Each vaccine, and often each manufacturer of a specific vaccine, has a unique CPT code. This is another situation where the information may be added in the background by the pharmacy management system, or by the clearinghouse if one is being used. If the information is not added by the pharmacy management system or a clearinghouse, the pharmacy staff billing for the vaccine will need to be sure this is included on the claim in order to get reimbursed.

PHARMACY TECH TOPICS — JULY 2017 TM

Medication Therapy Management (MTM) MTM includes a wide range of clinical services that can be provided by a pharmacist at the pharmacy. These services include, but are not limited to, Comprehensive Medication Review (CMR), Targeted Medication Review (TMR), Prescriber Consultations, and Patient Adherence Consultations. MTM claims by pharmacies may be seen with increasing frequency in coming years as payers are beginning to use CMR completion rate as a pharmacy performance measure. Medicare has set standards for providing MTM services to its beneficiaries. Some state Medicaid programs and commercial plans also reimburse for clinical services provided at the pharmacy. The documentation and billing for these services are typically done outside of the standard pharmacy filling system and can vary by payer. Most of the documentation and billing for these services are done through online portals. While the portals differ in layout and specific details, much of the required information for billing is the same. The reason for service, service rendered, and outcome of the service are required on all MTM claims. Each of the online documentation and billing portals have training available on how to document each type of service provided.

Inpatient/Clinic Billing Information provided thus far has focused primarily on prescription claims dispensed from a retail or outpatient pharmacy. Medications administered in hospitals and in provider clinics are often billed to a patient’s insurance as well. The billing for inpatient and clinic administered medications is very different than outpatient/retail billing and most often not the responsibility of the pharmacy staff. Medications administered in a hospital setting are not billed as individual items. Costs for medications are included in the diagnosis related group (DRG). DRGs are used by health insurers to determine the payment made to the hospital based on the type of patient, diagnosis, and expected resources needed for treatment. Conversely, most drugs administered in an outpatient clinic are billed as separate items. The required information for a clinic administered drug claim differs from that required on a

claim from a community pharmacy. Required information for a clinic administered medication includes: Patient Name and ID • • Date of Service HCPCS code • CPT code • • ICD-10 Code • NDC • Quantity Place of Service •

Healthcare Common Procedure Coding System (HCPCS) HCPCS codes for drugs often begin with the letter J and because of this are commonly called “J-codes.” The “quantity” submitted in a clinic administered drug claim is slightly different than the quantity submitted in a community pharmacy claim. Quantity here is expressed in billing units or service units. These billing units are frequently unrelated to package size and there is no standard unit between drugs. Some medications may be billed in increments of 10 mg (so “2” billing units is equal to 20 mg) while others are billed in 1 mg increments or in milliliters.

Insurance and Billing Primer for Pharmacy Technicians

Conclusion There are many emerging opportunities for pharmacy technicians who have a thorough understanding of insurance and billing. Pharmacies are beginning to employ Billing Specialist Technicians. Billing Specialist Technicians may be solely responsible for billing DMEPOS for a home health care pharmacy, or all dispensed medications from a Long-Term Care facility. These technicians are responsible for verifying eligibility, verifying coverage for specific medications or supplies, follow-up with payers regarding reimbursement issues, claims denial appeals, audit defense, and assuring compliance with billing regulations. Many pharmacies have specialized Prior Authorization Technician roles. The Prior Authorization Technician is responsible for initiation and follow-up on any PAs the pharmacy needs to send. For chain pharmacies, this may take place in a centralized call center away from the regular pharmacy workflow. PBMs also employ Prior Authorization Technicians to assist with approval or denial of PAs submitted by pharmacy providers. Tasks included in PBM Prior Authorization Technician positions are initial review of PA requests, gathering additional information from providers when needed, education for plan members and providers, identification of cost savings practices, and approval/denial of PA requests under supervision of the pharmacist.15,16 Currently there is no standard for billing MTM and other clinical services to the various MTM

companies, PBMs, and medical insurance companies. Technicians who can complete the billing for these services will be in high demand as models of billing for MTM and other pharmacy-based clinical services continue to evolve. Determining eligibility for services, pay rates to the pharmacy, and any applicable copays are additional important tasks that technicians can do to support the pharmacist in providing clinical services. Vaccine billing can be its own specialty role in pharmacies that provide immunization services. Pharmacies that provide travel vaccine services or help support public health efforts in their communities need technicians knowledgeable in determining patient eligibility, pharmacy/pharmacist eligibility as a provider of vaccines, and the different requirements of each payer for payment of each vaccine to run a successful vaccine practice. Knowledge about billing and insurance is not limited to specialized technicians. Pharmacy technicians who are not in a specialized billing role often voice frustration about insurance billing and the amount of time it takes up in their work day17. The number of prescriptions billed to third party payers continues to grow year after year. For better or worse, insurance billing will always be part of pharmacy. Understanding how to bill claims and avoid audit pitfalls will help make this inevitability less frustrating.

PHARMACY TECH TOPICS — JULY 2017 TM

References 1. National Center for Health Statistics. With special feature on racial and ethnic health disparities, (2016). https:// www.cdc.gov/nchs/data/hus/hus15.pdf. Accessed November 17, 2016. 2. Keehan SP, Poisal JA, Cuckler GA, et al. National health expenditure projections, 2015-25: Economy, prices, and aging expected to shape spending and enrollment. Health Affairs. 2016;35(8):1522–1531. doi:10.1377/ hlthaff.2016.0459. 3. California HealthCare Foundation. US health care spending: Who pays? http://www.chcf.org/publications/2015/12/ data-viz-hcc-national. Accessed November 17, 2016. 4. Baltazar A. Which 5 companies dominate the health insurance field? Verywell. https://www.verywell.com/thebig-five-health-insurance-companies-2663838. Updated January 31, 2017. Accessed February 5, 2017. 5. Jessica C Barnett, Marina S Vornovitsky. Table A-2.Households by total money income, race, and Hispanic origin of householder: 1967 to 2010, U.S. Department of Commerce, (2016). https://www.census.gov/content/dam/ Census/library/publications/2016/demo/p60-257.pdf. Accessed December 12, 2016. 6. U.S. Centers for Medicare & Medicaid Services. Medicare.gov. https://www.medicare.gov/your-medicare-costs/ help-paying-costs/save-on-drug-costs/save-on-drug-costs.html. Accessed April 14, 2017. 7. U.S. Centers for Medicare & Medicaid Services. Medicare.gov. https://www.medicare.gov/part-d/costs/coveragegap/part-d-coverage-gap.html. Accessed April 14, 2017. 8. National Council for Prescription Drug Programs. Pharmacy: A prescription for improving the healthcare system transformation and the use of HIT in pharmacy, (2010). https://www.ncpdp.org/NCPDP/media/pdf/wp/ RxforImprovingHealthcare_TransformationHIT.pdf. Accessed October 28, 2016. 9. WHO. International classification of diseases. World Health Organization. http://www.who.int/classifications/ icd/en/. Accessed January 10, 2017. 10. U.S. Centers for Medicare & Medicaid Services. Centers for Medicare & Medicaid Services. https://www.cms.gov/ Medicare/Coding/MedHCPCSGenInfo/index.html. Accessed December 12, 2016. 11. U.S. Department of Health & Human Services. United States Health Information Knowledgebase. https://ushik. ahrq.gov/mdr/portals?system=mdr&enableAsynchronousLoading=true. Accessed February 2, 2017. 12. Frost & Sullivan. The Impact of the Prior Authorization Process on Branded Medications: Physician Preference, Pharmacist Efficiency and Brand Market Share, White Paper, (2013). https://epascorecard.covermymeds.com/ images/FrostSullivanPrior%20AuthorizationWhitepaper%20FINAL.pdf. Accessed February 6, 2017. 13. Schafermeyer KW. Impact of managed care on pharmacy practice. In: Navarro RP. Managed Care Pharmacy Practice. 2nd ed. Sudbury, MA: Jones and Bartlett Publishers: 2008; 387-412 14. Donna Pickett, National Center for Health Statistics. ICD-10-CM official guidelines for coding and reporting FY 2017, (2016). https://www.cdc.gov/nchs/data/icd/10cmguidelines_2017_final.pdf. Accessed February 6, 2017. 15. Molina Healthcare. Job Description- Pharmacy Technician. https://molina.taleo.net/careersection/molina_ex/ jobdetail.ftl?job=173855&src=JB-10184. Accessed April 18, 2017 16. Magellan Health. Clinical Pharmacy Technician. https://magellanhealth.wd5.myworkdayjobs. com/en-US/magellan_health_careers/job/Phoenix-AZ-85034/Clinical-Pharmac y-Technician_ R00000008574?source=Indeed.com. Accessed April 18, 2017 17. Desselle SP. An in-depth examination into pharmacy technician worklife through an organizational behavior framework. Research in Social and Administrative Pharmacy. 2016;12(5):722–732. doi:10.1016/j. sapharm.2015.10.002.

Insurance and Billing Primer for Pharmacy Technicians

ANSWER KEY: TEST YOUR KNOWLEDGE EXERCISES Exercise #1: 1. 2. 3. 4.

Fee For Service Medicaid Federal Government PBMs Commercial Plan

Exercise #2: Change patient ID in the pharmacy system (12345) to match the patient ID on the insurance card (123456) Exercise #3: Professional Service Code: MO - Prescriber consulted Result of Service Code: 1G - Filled, with prescriber approval

PHARMACY TECH TOPICS â&#x20AC;&#x201D; JULY 2017 TM

2017 MODULES

Tests must be received by their expiration dates to receive continuing pharmacy education credit. Volume 22 #1 | January 2017

Medication Safety in the Older Adult**

Volume 22 #2 | April 2017

The Eyes Have It! Update on Common Conditions Affecting the Eye

Volume 22 #3 | July 2017

Insurance and Billing Primer for Pharmacy Technicians

Volume 22 #4 | October 2017

New Drugs 2017

Expires 1/01/20

(Must be completed by 12/31/19 at 11:59PM CT)

Expires 4/01/20

(Must be completed by 3/31/20 at 11:59PM CT)

Expires 7/01/20

(Must be completed by 6/30/20 at 11:59PM CT)

Expires 10/01/20

(Must be completed by 9/30/20 at 11:59PM CT)

**This module provides 2.5 contact hours of patient safety continuing pharmacy education credit for pharmacy technicians.

THE FOLLOWING 2015 AND 2016 MODULES ARE STILL AVAILABLE!

Tests must be received by their expiration dates to receive continuing pharmacy education credit. Volume 20 #3 | July 2015

Heart Failure and Its Symptoms, Risk Factors and Treatment

Expires 7/31/17 Expiring Soon!

Volume 20 #4 | October 2015

New Drugs 2015

Expires 10/31/17

Volume 21 #1 | January 2016

Medical Marijuana: Evaluating the Quality and Quantity of Evidence*

Expires 1/31/18

Volume 21 #2 | April 2016

Chemotherapy Symptom Management: Helping Each Patient with Their Journey

Expires 4/30/18

Volume 21 #3 | July 2016

Overview of Hyperlipidemia and Hypertension

Expires 7/31/18

Volume 21 #4 | October 2016

Health Literacy and Diversity

Expires 10/31/18

*This module provides 2.5 contact hours of law continuing pharmacy education credit for pharmacy technicians.

Instructions for Online Post-Test

Insurance and Billing Primer for Pharmacy Technicians

Subscribers that purchase paper modules by mail have the option to take their post-test online and download their CPE information sheet instantly on www.pharmacytechtopics.com! Unlimited test retakes - online or paper

For Paper Subscribers – If you want to take the Post-Test Online at www.PharmacyTechTopics.com, follow the steps below: 1. First you will need a personal email address. 2. Once you have your email address, you will need to email Jo Haley at jhaley@ichpnet.org, with “Online Post-Test Option” in the subject line. You must include the following information in your email: • First Name • Last Name • Mailing Address • City, State, Zip • Phone • Recertification Date • Email Address • NABP e-Profile ID number and Birthday as MMDD (for example, 1223 – meaning December 23) 3. We will set up an Online Account and EMAIL you a User Name and Password (which you may change at any time once you Log In). 4. Once you receive your Online Account User Name and Password, go to www.PharmacyTechTopics.com and Log In. 5. Click on My Modules (upper right corner under the Welcome), and you will see a list of the paper modules to which you have subscribed, but for which you have not yet taken the test. (You will have access to your subscriber modules ONLY.) 6. Once you see your module, you will see “Take This Test” in a box to the left of the Module title. Click on “Take This Test” and proceed to complete the post-test ONLINE, submit it, and you will know instantly if you passed and your score (or if you failed and which questions you missed). 7. If you pass, you will be able to download your CPE information sheet instantly Pharmacy technicians – either to print or to save on your computer, and your CPE will be automatically registered in Florida, please go reported to CPE Monitor. For official credit verification, all participants must now go to www.pharmacytechtopics.com to CPE Monitor at www.NABP.net and log in to your account to review and print an for information on uploading official statement of credit or official transcript. ICHP may only provide an informayour credit to CE Broker. tion sheet on your CPE, per ACPE rules.

CHANGED Your Mind? Once you have established an Online Post-Test Account, you may still choose to mail or fax your post-test instead. This Online option simply provides you with more flexibility based on your circumstances.

Pharmacy Tech Topics™ Replacement Module or CPE Information Sheet Policy:

Please be advised that if you misplace your module or CPE information sheet, Pharmacy Tech Topics™ will charge a fee of $7.50 for each replacement module and $5.00 for each replacement CPE information sheet. We do not fax CPE information sheets. Please allow 4 - 6 weeks for delivery via mail.

PHARMACY TECH TOPICS — JULY 2017 TM

IN ORDER TO RECEIVE A CPE INFORMATION SHEET VIA MAIL, PLEASE READ THE FOLLOWING SUBSCRIBER REQUIREMENTS… 1. We must receive the Insurance and Billing Primer for Pharmacy Technicians module’s completed EXAMINATION ANSWER SHEET AND EDUCATIONAL EVALUATION FORM by June 30, 2020 (at 11:59PM CT). A score of 70% must be achieved in order to receive credit. Answers to the self assessment questions on pages 24-26 should be circled in the space on page 27. Participants scoring below 70% will be notified and permitted to retake the exam within the limits of the validation dates. This course is valid from July 1, 2017 to June 30, 2020 (at 11:59PM CT). 2. Subscribers must keep the original examination sheet for your records and mail in a photocopy or fax to (815) 227-9294. 3. Be sure to complete the entire educational evaluation form and the examination answer sheet found on page 27, including the name and address section, especially any change of name, address, email, or phone number. Without a complete name and address on the exam sheet, it will be discarded.* 4. Pharmacy Tech Topics™ examination sheets will be graded in the order in which they are received. We do not fax back graded tests or CPE informations sheets. Please allow 4 - 6 weeks for delivery of your CPE information sheet via mail. 5. Only original Pharmacy Tech Topics™ subscribers are eligible to receive continuing pharmacy education credit for any Pharmacy Tech Topics™ module. 6. After completing the Educational Evaluation Form and Examination Answer Sheet, mail or fax it to: ICHP (Pharmacy Tech Topics™) 4055 N. Perryville Road Loves Park, IL 61111-8653 Fax: (815) 227-9294 Phone: 815-227-9292

TEST FEEDBACK

If you miss any questions on your test, we let you know which questions were wrong. If you pass your test (70% or better) but missed any questions, we provide you with the correct answers. This will help you complete the learning process.

*PLEASE NOTE:

ICHP does not give credit or CPE information sheets for those pharmacy technicians who do not have an NABP e-Profile ID# with Birthdate as MMDD, as part of your permanent record. For official credit verification, all participants must now go to CPE Monitor at www.NABP.net and log in to your account to review and print an official statement of credit or official transcript. ICHP may only provide an information sheet on your CPE, per ACPE rules. Please do not delay, get your NABP e-Profile ID#. Please go to: www.nabp.net and click on the CPE Monitor icon on this webpage for more information on the CPE Monitor project and acquiring your NABP e-Profile ID number.

Pharmacy Tech Topics™ Subscription Information ONLINE ONLY SUBSCRIPTION —

Go to www.pharmacytechtopics.com. You can place your order with your credit or debit card and have immediate access to read and complete published modules. Complete each post-test online and immediately receive your results. You must provide your NABP e-Profile ID# and birthdate as MMDD to complete your tests online. Upon successful completion of your test, your CPE will automatically be reported to CPE Monitor. By purchasing an online subscription, you will receive a $5.00 discount on a one-year subscription and a $10.00 discount on a two-year subscription versus a paper subscription! Recommended System Requirements for online subscribers: Operating Systems (minimum): Windows XP / Mac OS X 10.6; Internet Browsers (minimum): Chrome 4+, Internet Explorer 9+, Mozilla Firefox 4+, Safari 4+, Opera 15+, Edge 12+; Internet Browsers (recommended): Chrome 40+, Internet Explorer 10+, Mozilla Firefox 40+, Safari 8+, Opera 25+, Edge 13+; Browser Settings: Make sure cookies are enabled in your browser so all elements of our application work as expected. Pop-ups and JavaScript should be enabled in your browser, so you can view errors, alerts, and preview screens.

PAPER BY MAIL SUBSCRIPTION — You can now order paper modules online or complete the order form below and your modules will be mailed to you within 2-4 weeks. Subscribers that purchase paper modules by mail have the option to take their post-test online (NABP e-Profile ID# required) and receive test results instantly on www.pharmacytechtopics.com! If you prefer to mail in the paper post-test, notification of completion will be mailed within 4-6 weeks upon receipt of the successfully completed post-test and educational evaluation form. Your CPE will be reported to CPE Monitor within 2 weeks.

Pharmacy Tech Topics™ Order Form for Paper by Mail Subscription Only Only one technician subscriber per subscription. Institutions with more than one technician must purchase a separate continuing pharmacy education subscription for each technician. Pharmacy Tech Topics™ modules are copyright protected and cannot be reproduced in any form. The technician subscriber’s name must appear on this order form.

subscribe annually

pick and choose

q Please send me a one-year subscription (4 modules) for the year _________ at the one-year price of $50.00.*

Options (please choose): q 1 module at the single module price of $17.95.* q 4 modules at the discounted bundle price of $50.00.* q 8 modules at the discounted bundle price of $79.95.* Please choose your modules at right. ð

Please send me a two-year subscription (8 modules) for the years ____________ & ____________ at the two-year discounted price of $79.95.*

q q q

July 2015 October 2015 January 2016

q q q

April 2016 July 2016 October 2016

(law)

q q q q

January 2017 (patient safety)

April 2017 July 2017 October 2017

Please view the titles and expiration dates of each module on page 20 of this module.

Modules are published quarterly in January, April, July, and October of each year. When ordering the 2017 year modules, all the currently published 2017 modules will be available immediately, with the remainder of 2017 being placed online or mailed per the quarterly schedule. Module topics and order are tentative. Variations in programming may occur. *ILLINOIS RESIDENTS must include 8.25% state sales tax (total price of $54.13 for one-year, $86.55 for two-years, or $19.43 for a single module). OUT-OF-THE-COUNTRY SUBSCRIBERS are required to call the office (815-227-9292) when ordering for mailing prices. A price will be quoted over the phone for you.

technician information (Please complete all information and print neatly.)

Check here if you are a: q New subscriber q Continuing subscriber Check here if there is a change in your: q last name, q address, q email, or q phone. Technician Name: ____________________________________ Mailing Address: ___________________________________________ Apt. #: _____ City/State/Zip: _____________________________________________________ Email (required): ________________________________________ Work Phone: _____________________ Home Phone: ____________________ Year Certified: __________ Recertification Date: _____________ Primary Pharmacy Practice Site (Check one): q Community q Hospital q Mail Order q Home Health

q Long-Term Care q Pharmaceutical Industry q Other:_______________

NABP e-Profile ID # (required): ________________________ Birthday (MM/DD) (required): ___________

PLEASE NOTE: NO credit is issued without an NABP e-Profile ID #. Visit www.NABP.net to obtain your NABP e-Profile ID #.

method of payment

Orders placed with a credit card or purchase order may be faxed to (815) 227-9294. All orders must be accompanied by one completed order form for each technician. REFUNDS will not be issued on any processed subscriptions. Credit card orders will show up on your billing statement as an ICHP charge.

Please check one of the following: q Payment enclosed. A check or money order is enclosed for $________ q A company purchase order is attached. q Charge to: qAMEX qDISCOVER

qVISA

qMC

Account #: ______________________________________________ Exp. CVV2 Billing Date: ___________ Security Code #: __________ Zip Code: __________ Signature (required): ______________________________________

still have questions about pharmacy tech topics™? Call us at 815-227-9292 Visit www.pharmacytechtopics.com Like Pharmacy Tech Topics on Facebook Checks, money orders, and company purchase orders should be made payable to: Illinois Council of Health-System Pharmacists (ICHP) 4055 N. Perryville Road Loves Park, Illinois 61111-8653 Phone: (815) 227-9292 Fax: (815) 227-9294

FOR OFFICE USE ONLY

PHARMACY TECH TOPICS â&#x20AC;&#x201D; JULY 2017 TM

SELF ASSESSMENT QUESTIONS Note:

If you purchase a paper subscription, but complete the Self-Assessment Test online at pharmacytechtopics.com, you will be required to take the Pre-Test first, then the final test and evaluation. This Pre-Test does not affect your final test results but will be used to evaluate the effectiveness of the continuing education program.

1. ______% of prescription medication costs were paid out of pocket by patients in 2014. a. 9 b. 15 c. 18 d. 29 2. Which of the following is a function of PBMs? a. Determine patient eligibility b. Process pharmacy claims on behalf of multiple insurance plans c. Provide rebates to eligible members d. Process medical claims for insurance plans 3. The portion of a prescription cost the patient pays at the pharmacy is called a _____________. a. copay b. deductible c. premium d. formulary 4. The State government pays for prescription medications billed to __________. a. Medicare b. Tricare c. Medicaid d. Blue Cross

5. Patients referred to as Dual Eligibles are eligible for both _________ and ________. a. b. c. d.

Medicaid; Commercial Insurance Medicare; Commercial Insurance Medicare Part B; Medicare Part D Medicaid; Medicare

6. What is adjudication? a. An additional step in the coverage determination process b. Comparing a claim to the patientâ&#x20AC;&#x2122;s benefits and paying or denying the claim c. Transmission of a claim to the PBM d. The response of the PBM to the pharmacy 7. Which of the following may be optional information for a prescription insurance claim? a. b. c. d.

Patient Identification Number Patient Date of Birth Payer BIN Patient Group Number

8. The ICD-10 code is used to submit the ________ to the payer. a. b. c. d.

patient location item description patient diagnosis coordination of benefits information

Insurance and Billing Primer for Pharmacy Technicians

9. Which rejection can be corrected by changing the quantity dispensed to the accepted days supply? a. b. c. d.

Refill Too Soon Missing/Invalid Days Supply Days Supply Exceeded Plan Limits Exceeded

10. Which of the following should be checked when a Patient Not Covered rejection is received? a. b. c. d.

Patient Address Patient Date of Birth Patient Diagnosis Patient Zip Code

11. The DUR/PPS Professional Service Code for Prescriber Consulted is ______________. a. R0 b. PC c. M0 d. 3N 12. If the pharmacist counsels a patient on a DUR/ PPS under utilization rejection and then fills the prescription as written, the correct codes to submit for payment of the claim are___ ,___, ___. a. b. c. d.

LR, P0, 1B EX, PT, 3M TD, P0, 1B LR, M0, 3M

13. A Prior Authorization is_______________. a. the payer determining that the medication is not covered b. the payer determining that the patient is not covered c. the payer determining that the medication is covered, but not for this patient d. the payer asking for additional information before making a coverage determination 14. The correct order for steps in the Prior Authorization process is_______________. a. reject received at the pharmacy; Pharmacy contacts prescriber; Prescriber submits form to payer; Payer makes coverage determination b. reject received at the pharmacy; Prescriber submits form to payer; Payer makes coverage determination; Pharmacy contacts prescriber c. prescriber submits form to payer; Payer makes coverage determination; Reject received at the pharmacy; Pharmacy contacts prescriber d. pharmacy contacts prescriber; Prescriber submits form to payer; Payer makes coverage determination; Reject received at the pharmacy 15. Which of the following is not a reason pharmacies are audited by third party payers? a. b. c. d.

Ensure contract compliance Identify overpayment by the PBM Identify overpayment by the pharmacy Deter abuse

PHARMACY TECH TOPICS â&#x20AC;&#x201D; JULY 2017 TM

16. The main difference between a field audit and a desk audit is _______________. a. a desk audit is where an onsite auditor visits the pharmacy; a field audit is by email or fax b. a desk audit is by email or fax; a field audit is where an onsite auditor visits the pharmacy c. a field audit usually requires copies of original prescriptions; a desk audit does not d. a desk audit usually requires copies of original prescriptions; a field audit does not 17. Which of the following is a common audit finding? a. b. c. d.

Refill Too Soon Inconsistent Days Supply for Quantity Provider Not Contracted Plan Limitations Exceeded

18. One strategy to reduce payment recovery due to an audit is: a. b. c. d.

Good documentation Use "as directed" on prescriptions Submit DAW code 1 on all prescriptions Request prior authorization on all claims

19. What is the ICD-10 code for an influenza immunization administered in the pharmacy? a. V04.81 b. Z94 c. Z23 d. V23

20. How does the pharmacy bill for most MTM services? a. b. c. d.

Through online portals Through the pharmacy management system Through the clearinghouse In the same manner as other prescriptions

In order to receive your CPE information sheet, you MUST FILL OUT the Educational Evaluation Form Insurance and Billing Primer for Pharmacy Technicians AND the Answer Sheet below OR follow the instructions for completing your Test online! (Instructions for online test completion found on pg. 21 of this module.)

Educational Evaluation form PROVIDER: Illinois Council of Health-System Pharmacists TITLE OF MODULE: Insurance and Billing Primer for Pharmacy Technicians DATE(S): 07/01/17 to 06/30/20 (at 11:59PM CT)

ACPE Universal Activity Number: 0121-0000-17-003-H04-T TYPE OF ACTIVITY: Knowledge-based

COMPLETE THIS EVALUATION FORM USING THE RATING SCALE BELOW Use the following rating scale and circle the appropriate number: 5 - AGREE STRONGLY 4 - AGREE 3 - NO OPINION, NEUTRAL, DOES NOT APPLY 2 - DISAGREE 1 - DISAGREE STRONGLY As a result of this module, I feel I have achieved the following objectives: 1. 2. 3. 4. 5.

Identify the types of entities that pay for prescription medications .......................................................................................................................... 5 4 3 2 1 Define commonly used terms in prescription claim billing ........................................................................................................................................ 5 4 3 2 1 Explain common prescription claim rejections, corrective action that can be taken, and audits that can result from improperly billed claims ...... 5 4 3 2 1 List the steps involved in obtaining a prior authorization ........................................................................................................................................... 5 4 3 2 1 Discuss billing for special services such as immunizations and medication therapy management (MTM) ........................................................ 5 4 3 2 1

Please use the rating scale above to answer the questions below: 1. Rate the relationship of the objectives to the overall purpose or goal of the module. ........................................................................................ 5 4 3 2 1 2. The information presented will be useful in my work. ............................................................................................................................. 5 4 3 2 1 3. This program presented information in a balanced and unbiased manner. ................................................................................................ 5 4 3 2 1

Rate the expertise of the author(s): Authors

Demonstrates knowledge of subject matter

Heather Horton PharmD, M.S.

Uses appropriate teaching strategies

CONTINUING PHARMACY EDUCATION CREDIT REQUEST FORM

Insurance and Billing Primer for Pharmacy Technicians

JULY 2017 VOLUME 22 NO. 3 ACPE Universal Activity Number: 0121-0000-17-003-H04-T PLEASE CIRCLE ONE LETTER FOR EACH QUESTION FROM THE EXAMINATION SHEET:

1. A

6. A

11.

16.

2. A

7. A

12.

17.

3. A

8. A

13.

18.

4. A

9. A

14.

19.

5. A

10.

15.

20.

Name _________________________________________________________________________________________________________ Address _______________________________________________________________________________________ Apt No. __________ City/State/Zip ___________________________________________________________________________________________________ Daytime Phone (_________)________________________ E-MAIL ADDRESS ________________________________________________ THIS IS A CHANGE IN MY: q LAST NAME q ADDRESS q PHONE q E-MAIL REQUIRED: NABP e-Profile ID # _______________________________ Birthday (MMDD): ________ (Requirement of CPE Monitor Project) Visit www.myCPEmonitor.net for information about the CPE Monitor Project and to obtain your NABP E-Profile ID #. PLEASE NOTE: NO credit or CPE information sheets will be issued without an NABP e-Profile ID#.

FOR TECHNICIANS REGISTERED IN FLORIDA:

License/Registration # ____________________________________________________________________ (Please include full alphanumeric number)

MAIL FORMS TO: PTT; 4055 N Perryville Road; Loves Park, IL 61111 â&#x20AC;¢ FAX TO: 815-227-9294

FUTURE PHARMACY TECH TOPICS™ SURVEY What do you find most beneficial from subscribing to Pharmacy Tech Topics™?

_____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________ _____________________________________________________________________________

What changes or suggestions do you have for future Pharmacy Tech Topics™ modules?

What other topics would you like to see in future issues of Pharmacy Tech Topics™?

Please photo copy and return this completed survey with your answer sheet to help us improve Pharmacy Tech TopicsTM.

Fax: 815-227-9294

â&#x201E;˘

July 2017 | Volume 22 | Number 3 Insurance and Billing Primer for Pharmacy Technicians Expiration Date: July 1, 2020 (Must be completed by 6/30/2020 at 11:59PM CT)

Published by the Illinois Council of Health-System Pharmacists