RPMS POS – Working RPMS POS – Working RejectionsRejections

Christina HarrisChristina HarrisPharmacy BillerPharmacy BillerClaremore Comprehensive Health Claremore Comprehensive Health CenterCenterApril 2006April 2006

Topics to CoverTopics to Cover

RPMS POS UpdateRPMS POS Update POS and Medicare Part DPOS and Medicare Part D NPI UpdateNPI Update Understanding Rejections and Understanding Rejections and

how to correct themhow to correct them

Key Components to Key Components to Using RPMS POSUsing RPMS POS Coordinated effort: Business Office, Coordinated effort: Business Office,

IT, PharmacyIT, Pharmacy– Best – “hire or assign pharmacy biller”Best – “hire or assign pharmacy biller”

Having the necessary menus/keysHaving the necessary menus/keys Network participating agreementsNetwork participating agreements Staying current with software Staying current with software

patchespatches Drug file clean-upDrug file clean-up Patient registrationPatient registration

POS UpdatePOS Update

Over 130 sites using RPMS POSOver 130 sites using RPMS POS POS v1 patch 16POS v1 patch 16

– POS v1 patch 16 works with Patient Registration POS v1 patch 16 works with Patient Registration v7.1 patch 1v7.1 patch 1

– Medicare Part D report that provides total $ and Rx Medicare Part D report that provides total $ and Rx count over a selected time periodcount over a selected time period

– Includes BIN numbers on SUMI report (report that Includes BIN numbers on SUMI report (report that shows which insurers are sending claims shows which insurers are sending claims electronically via POS)electronically via POS)

FTP site has resources for using POS FTP site has resources for using POS (including this presentation) (including this presentation) ftp://ftp.ihs.gov/rpms/POS/ftp://ftp.ihs.gov/rpms/POS/

ftp://ftp.ihs.gov/rpms/POftp://ftp.ihs.gov/rpms/POS/S/

Medicare Part D - Medicare Part D - Order of what needs to Order of what needs to be done:be done: 1. Verify patches have been installed (Patient 1. Verify patches have been installed (Patient

Reg v7.1, patch 1 and POS v1 patch 16)Reg v7.1, patch 1 and POS v1 patch 16) 2. Enter Insurers (use recommended naming 2. Enter Insurers (use recommended naming

convention)convention) 3. Tie POS format to appropriate Insurer3. Tie POS format to appropriate Insurer 4. Enter patient with Medicare Part D in 4. Enter patient with Medicare Part D in

Patient RegistrationPatient Registration– Determine duel-eligible membersDetermine duel-eligible members– Run E1 to determine plan nameRun E1 to determine plan name

4. Backbill 90+ days4. Backbill 90+ days

Medicare Part D - KEY Medicare Part D - KEY HANDOUTS ON FTP HANDOUTS ON FTP SITESITE General Instructions for Billing Medicare General Instructions for Billing Medicare

Part D Using RPMS POSPart D Using RPMS POS Patient Registration Instructions Patient Registration Instructions

(Addendum) for patch 1 – PDF file(Addendum) for patch 1 – PDF file POS Formats SORT BY PLANPOS Formats SORT BY PLAN POS Medicare Part D Formats – SORTED POS Medicare Part D Formats – SORTED

BY BINBY BIN Setting up POS Format – Medicare Part Setting up POS Format – Medicare Part

DD

Medicare Part D – Medicare Part D – Helpful SuggestionsHelpful Suggestions

– Use Plan Names as Insurer NamesUse Plan Names as Insurer Names Eg. D-Silverscript versus CaremarkEg. D-Silverscript versus Caremark

– Do NOT enter Person Code on page 4 of Do NOT enter Person Code on page 4 of Patient RegistrationPatient Registration

– ALWAYS tie a Medicare Part D format to ALWAYS tie a Medicare Part D format to the insurer. the insurer.

Medicare Part D formats have been altered to Medicare Part D formats have been altered to send 1 claim for each transaction, as required. send 1 claim for each transaction, as required. Commercial formats send 4 claims at a time.Commercial formats send 4 claims at a time.

POS Medicare Part D report only works if the POS Medicare Part D report only works if the Medicare Part D formats are used.Medicare Part D formats are used.

Medicare Part D – Medicare Part D – Helpful SuggestionsHelpful Suggestions ALWAYS add Priority Points – recommend ALWAYS add Priority Points – recommend

at least 605; 650 preferred.at least 605; 650 preferred. To verify Part D plans are set up correctly:To verify Part D plans are set up correctly:

– Send a copy of SUMI report (POS / RPT / SET / Send a copy of SUMI report (POS / RPT / SET / SUMI) to OIT help desk at SUMI) to OIT help desk at support@ihs.govsupport@ihs.gov

– It will be reviewed and feedback will be It will be reviewed and feedback will be provided.provided.

Use the E1 – a good tool verify what plan Use the E1 – a good tool verify what plan the patient is enrolled in. the patient is enrolled in.

Eligibility (E1) Eligibility (E1) TransactionTransactionPOS / RPT / ELIGPOS / RPT / ELIG

On: FEB 07, 2006@15:19:40On: FEB 07, 2006@15:19:40Patient Name: Patient Name: Status: AStatus: AAuthorization #: Authorization #: Insurance Level: PRIMARYInsurance Level: PRIMARY BIN: 007382BIN: 007382 PCN: SHSPCN: SHS GROUP: 0001GROUP: 0001 CARDHOLDER ID: 123456789CARDHOLDER ID: 123456789 PERSON CODE: 1PERSON CODE: 1 PHONE NUMBER: 8001234567PHONE NUMBER: 8001234567

The plan name can be determined by using one of the Excel The plan name can be determined by using one of the Excel spreadsheets on the ftp site.spreadsheets on the ftp site.

National Provider National Provider Identifier (NPI)Identifier (NPI) NCPDP will be providing NCPDP will be providing

enumeration for Pharmacy NPI. enumeration for Pharmacy NPI. Taxonomy assigned to: Taxonomy assigned to:

Pharmacy – Indian Health Pharmacy – Indian Health Service/Tribal/Urban: 332800000XService/Tribal/Urban: 332800000X

Plan to start testing in the fall of Plan to start testing in the fall of 20062006

Rejection CodesRejection Codes

Rejection codes are NCPDP standard Rejection codes are NCPDP standard codes used by processors. codes used by processors.

Complete list of rejection codes is Complete list of rejection codes is located on the ftp site (NCPDP located on the ftp site (NCPDP folder)folder)

M/I = Means Missing/InvalidM/I = Means Missing/Invalid All the rejection codes can by found All the rejection codes can by found

on the ftp siteon the ftp site

Common Rejections Common Rejections and how to Correct and how to Correct ThemThem

Helpful ReportsHelpful Reports

Reports to run on a daily basis include:Reports to run on a daily basis include:– REJ- which includes all of the rejections. It is REJ- which includes all of the rejections. It is

good to run this report everyday to stay good to run this report everyday to stay current with your rejections and prevent a current with your rejections and prevent a rejection for claim too old.rejection for claim too old.

– URM- Once you are finished working on your URM- Once you are finished working on your rejections it is imperative to run the urm to rejections it is imperative to run the urm to update the dollar figures in your day/ins update the dollar figures in your day/ins reports.reports.

– When working on these reports it is helpful When working on these reports it is helpful to coordinate between the business office to coordinate between the business office and the pharmacy.and the pharmacy.

POS Rejection Report POS Rejection Report (POS / RPT / CLA / REJ)(POS / RPT / CLA / REJ) **************************************************************************************** * PHARMACY POINT OF SALE V1.0 ** PHARMACY POINT OF SALE V1.0 * * ** * * Pharmacy electronic claims reports * * Pharmacy electronic claims reports * ****************************************************************************************

CLA Claim results and status ...CLA Claim results and status ... SET Setup (Configuration) reports ...SET Setup (Configuration) reports ... SURV Surveys of RPMS database ...SURV Surveys of RPMS database ... ELIG Eligibility TransactionELIG Eligibility Transaction OTH Other reports ...OTH Other reports ...

REJ - Rejected claims reportREJ - Rejected claims report

POS REJECTED claims for prescriptions RELEASED on FEB POS REJECTED claims for prescriptions RELEASED on FEB 9,2001 02/10@04:069,2001 02/10@04:06

SAN FELIPE NCPDP (NABP) #3209219 Medicaid #B3713SAN FELIPE NCPDP (NABP) #3209219 Medicaid #B3713

MEDICAID EXEMPT Help Desk:(505)246-9988 opt 3 opt 1MEDICAID EXEMPT Help Desk:(505)246-9988 opt 3 opt 1

Trans. Date/Time Claim ID Presc/Fill NDC Trans. Date/Time Claim ID Presc/Fill NDC NumberNumber

Cardholder ID Group Number Qty $billedCardholder ID Group Number Qty $billed

**** DUCK,RONALD**** DUCK,RONALD

FEB 9,2001 11:22 P01-610084-104611 `947794/0 FEB 9,2001 11:22 P01-610084-104611 `947794/0 5111104889351111048893

525340572 24 4.11 ACETAMINOPHEN 525340572 24 4.11 ACETAMINOPHEN 325 MG TAB325 MG TAB

70:NDC NOT COVERED70:NDC NOT COVERED

REJ - Rejected claims reportREJ - Rejected claims reportPOS REJECTED claims for prescriptions RELEASED on FEB POS REJECTED claims for prescriptions RELEASED on FEB 9,2001 02/10@04:069,2001 02/10@04:06SAN FELIPE NCPDP (NABP) #3209219 Medicaid #B3713SAN FELIPE NCPDP (NABP) #3209219 Medicaid #B3713MEDICAID EXEMPT Help Desk:(505)246-9988 opt 3 opt 1MEDICAID EXEMPT Help Desk:(505)246-9988 opt 3 opt 1

Trans. Date/Time Claim ID Presc/Fill NDC Trans. Date/Time Claim ID Presc/Fill NDC NumberNumberCardholder ID Group Number Qty $billedCardholder ID Group Number Qty $billed

**** DUCK,RONALD**** DUCK,RONALD

FEB 9,2001 11:22 P01-610084-104611 `947794/0 FEB 9,2001 11:22 P01-610084-104611 `947794/0 5111104889351111048893 525340572 24 4.11 ACETAMINOPHEN 525340572 24 4.11 ACETAMINOPHEN 325 MG TAB325 MG TAB70:NDC NOT COVERED70:NDC NOT COVERED

Rejection codes – Rejection codes – Header SegmentHeader Segment Ø1 M/I BinØ1 M/I Bin Ø2 M/I Version NumberØ2 M/I Version Number Ø3 M/I Transaction CodeØ3 M/I Transaction Code Ø4 M/I Processor Control NumberØ4 M/I Processor Control Number

Problem: the wrong format is being used.Problem: the wrong format is being used. To correct: contact the insurer to To correct: contact the insurer to

determine the correct BIN/PCN. Use the determine the correct BIN/PCN. Use the POS Format Master List on ftp site or POS Format Master List on ftp site or Emdeon web site.Emdeon web site.

Rejection Code – Rejection Code – Patient SegmentPatient Segment Ø8 M/I Person CodeØ8 M/I Person Code Ø9 M/I Birth DateØ9 M/I Birth Date 1Ø M/I Patient Gender Code1Ø M/I Patient Gender Code 11 M/I Patient Relationship Code11 M/I Patient Relationship Code 53 Non-Matched Person Code53 Non-Matched Person Code

Problem: information in insurer’s system is Problem: information in insurer’s system is different than what is on page 4 of Patient different than what is on page 4 of Patient Registration.Registration.

To correct: call processor pharmacy help To correct: call processor pharmacy help desk to determine where discrepancy is.desk to determine where discrepancy is.

Rejection codes – Rejection codes – Insurance SegmentInsurance Segment Ø6 M/I Group NumberØ6 M/I Group Number Ø7 M/I Cardholder ID NumberØ7 M/I Cardholder ID Number 51 Non-Matched Group ID51 Non-Matched Group ID 52 Non-Matched Cardholder ID52 Non-Matched Cardholder ID

Problem: there is information missing or Problem: there is information missing or there is an eligibility issue.there is an eligibility issue.

To correct: check a current card or call the To correct: check a current card or call the pharmacy help desk. The phone number is pharmacy help desk. The phone number is usually on the rejection report. Once correct usually on the rejection report. Once correct in Patient Registration (page 4), the claim in Patient Registration (page 4), the claim can be resubmitted in POS.can be resubmitted in POS.

POS User ScreenPOS User Screen

Rejection codes – Rejection codes – Claim SegmentClaim Segment 21 M/I Product/Service ID21 M/I Product/Service ID 22 M/I Dispense As Written (DAW)/Product Selection 22 M/I Dispense As Written (DAW)/Product Selection

Code Code 28 M/I Date Prescription Written28 M/I Date Prescription Written 54 Non-Matched Product/Service ID Number54 Non-Matched Product/Service ID Number 55 Non-Matched Product Package Size55 Non-Matched Product Package Size 77 Discontinued Product/Service ID Number77 Discontinued Product/Service ID Number 78 Cost Exceeds Maximum78 Cost Exceeds Maximum

Problem: Pharmacy issueProblem: Pharmacy issue To correct: have pharmacy verify the drug is entered To correct: have pharmacy verify the drug is entered

correctly in drug file.correctly in drug file.

Rejection codes – Rejection codes – Claim SegmentClaim Segment 7Ø Product/Service Not Covered7Ø Product/Service Not Covered 81 Claim Too Old81 Claim Too Old

Usually uncorrectableUsually uncorrectable

Rejection codes – Rejection codes – Prescriber SegmentPrescriber Segment 25 M/I Prescriber ID25 M/I Prescriber ID 56 Non-Matched Prescriber ID56 Non-Matched Prescriber ID 71 Prescriber Is Not Covered71 Prescriber Is Not Covered

Problem: Provider number needs to be Problem: Provider number needs to be verified or format is not submitting verified or format is not submitting correct provider number.correct provider number.

To solve: If provider number is correct; To solve: If provider number is correct; refer to RPMS Help desk to verify refer to RPMS Help desk to verify format is correct.format is correct.

Over-rides/Prior AuthOver-rides/Prior Auth

Prior Authorization RequiredPrior Authorization Required 79 Refill Too Soon79 Refill Too Soon 76Plan Limitations Exceeded76Plan Limitations Exceeded 8E M/I DUR/PPS Level Of Effort8E M/I DUR/PPS Level Of Effort 8Ø Drug-Diagnosis Mismatch8Ø Drug-Diagnosis Mismatch 88 DUR Reject Error88 DUR Reject Error

Rejection Codes - Rejection Codes - ProcessingProcessing 85 Claim Not Processed85 Claim Not Processed 87 Reversal Not Processed87 Reversal Not Processed 91 Host Response Error91 Host Response Error

Problem: claims were not processedProblem: claims were not processedTo correct: try resubmitting claim. To correct: try resubmitting claim.

If still not working for several If still not working for several claims, notify RPMS Help Desk.claims, notify RPMS Help Desk.

Design a Process for Design a Process for Working RejectionsWorking Rejections Review rejection report dailyReview rejection report daily Run URM (POS / RPT / CLA / URM) to clear Run URM (POS / RPT / CLA / URM) to clear

rejections from reportrejections from report If time is limited, focus on high cost drugsIf time is limited, focus on high cost drugs To maximize collections, involve To maximize collections, involve

pharmacists.pharmacists. Between the business office and the Between the business office and the

pharmacy each facility should decide on a pharmacy each facility should decide on a plan of action to optimize the amount of plan of action to optimize the amount of collections received from the rejected claims.collections received from the rejected claims.

Questions?Questions?