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Routine: IBNCPDP

IBNCPDP.m

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IBNCPDP ;OAK/ELZ - APIS FOR NCPCP/ECME ;1/9/08  17:27

 ;;2.0;INTEGRATED BILLING;**223,276,363,383,384,411,435,452,550**;21-MAR-94;Build 25

 ;;Per VA Directive 6402, this routine should not be modified.

 ;

 ;Reference to $$PSSBILSD^PSS50 supported by IA# 6245

 ;

RX(DFN,IBD) ; IB Billing Determination

 ; this is called by PSO for all prescriptions issued, return is

 ; a response to bill ECME or not with array for billing data elements

 ; third piece of return is an Eligibility indicator for the prescription

 ;

 ; IBD("IEN")         = Prescription IEN

 ;    ("FILL NUMBER") = Fill number (0 is initial)

 ;    ("DOS")         = Date of Service

 ;    ("RELEASE DATE")= Date of the Rx release in FileMan format

 ;    ("NDC")         = NDC number for drug

 ;    ("DEA")         = DEA special handling info

 ;    ("COST")        = cost of medication being dispensed

 ;    ("AO")          = Agent Orange (0,1 OR Null)

 ;    ("EC")          = Environmental Contaminant (0,1 OR Null)

 ;    ("HNC")         = Head/neck cancer (0,1 OR Null)

 ;    ("IR")          = Ionizing radiation (0,1 OR Null)

 ;    ("MST")         = Military sexual trauma (0,1 OR Null)

 ;    ("SC")          = Service connected (0,1 OR Null)

 ;    ("CV")          = Combat Veteran (0,1 OR Null)

 ;    ("QTY")         = Quantity of med dispensed

 ;    ("EPHARM")      = #9002313.56 ien (E-PHARMACY division)

 ;

 ;

 ; IBD("INS",n,1) = insurance array to bill in n order (see SETINSUR^IBNCPDP1 for details)

 ;                  file 355.3 ien (group)^bin^pcn^Payer Sheet B1^group id^

 ;                  cardholder id^patient relationship code^

 ;                  cardholder first name^cardholder last name^

 ;                  home plan state^Payer Sheet B2^Payer Sheet B3^

 ;                  Software/Vendor Cert ID ^ Ins Name^Payer Sheet E1^

 ;                  Payer Sheet B1 ien^B2 ien^B3 ien^E1 ien^Pharmacy Person Code

 ;                  

 ;

 ;    ("INS",n,2) = dispensing fee^basis of cost determination^

 ;                  awp or tort rate or cost^gross amount due^

 ;                  administrative fee^ingredient cost^usual & customary charge

 ;                  (see RATEPRIC^IBNCPDP1 for details)

 ;

 ;   for basis of cost determination the following is used:

 ;      "07" would be sent for Usual & Customary

 ;      "01" would be sent for AWP

 ;      "05" would be sent for Cost calculations

 ;

 ;    ("INS",n,3) = group name^ins co ph 3^plan ID^

 ;                  insurance type (V=VETERAN, T=TRICARE, C=CHAMPVA)^

 ;                  insurance company (#36) ien^COB field (.2) in 2.312 subfile^

 ;                  2.312 subfile ien (pt. insurance policy ien)^

 ;                  maximum NCPDP transactions (366.03,10.1)

 ;                  (see SETINSUR^IBNCPDP1 for details)

 ;

 N IBRES,IBNB

 S IBRES=$$RX^IBNCPDP1(DFN,.IBD)

 ;remove "Not ECME billable: " from the reason text

 S IBNB="Not ECME billable: "

 I IBRES[IBNB S IBRES=$P(IBRES,U)_U_$P($P(IBRES,U,2),IBNB,2)_U_$P(IBRES,U,3)

 Q IBRES

 ;

 ;

STORESP(DFN,IBD) ; this is an API for pharmacy/ecme to use to relay

 ; results of billing using the ecme software.  If electronic billing is

 ; successful, then bills will be established.  If not, then we will

 ; flag the entry in ct for paper or not billable.

 ;

 ; IBD("STATUS")       = Bill status (PAID, REJECTED,REVERSED

 ;                        CLOSED,RELEASED,or SUBMITTED)

 ;    ("DOS")          = Date of Service

 ;    ("PRESCRIPTION") = Prescription IEN from drug file (#52)

 ;    ("FILL NUMBER")  = Fill or refill number

 ;    ("BILLED")       = Amount billed

 ;    ("PAID")         = Amount paid

 ;    ("BCID")         = Reference number to the claim for payment

 ;                       BCID stands for Bill Claim ID

 ;    ("PLAN")         = IEN of the the entry in the GROUP INSURANCE

 ;                       PLAN file(#355.3)(captured from the

 ;                       $$RX^IBNCPDP call)

 ;    ("COPAY")        = Patient's copay from ECME response

 ;    ("RX NO")        = RX number from file 52

 ;    ("DRUG")         = IEN of file #50 DRUG

 ;    ("DAYS SUPPLY")  = Days Supply

 ;    ("QTY")          = Quantity Dispensed (should be from the Rx fill or refill 52/52.1)

 ;    ("NDC")          = NDC

 ;    ("CLOSE REASON") = Optional, Pointer to the IB file #356.8

 ;                      "CLAIMS TRACKING NON-BILLABLE REASONS"

 ;    ("CLOSE COMMENT")= Optional, if the close reason is defined

 ;                       then the Close Comment parameter may be

 ;                       sent to IB

 ;    ("DROP TO PAPER")= Optional, this parameter may be set to 1(TRUE)

 ;                       for certain Close Claim Reasons, indicating

 ;                       that that the closed episode still may be

 ;                       "dropped to paper" - passed to the Autobiller

 ;    ("RELEASE COPAY")= Optional, if the claim is being closed, setting

 ;                       this parameter to 1 (TRUE) indicates that the

 ;                       patients copay should be released off hold

 ;    ("DIVISION")     = Pointer to the MC DIVISION file (#40.8)

 ;    ("AUTH #")       = ECME approval/authorization number

 ;    ("CLAIMID")      = Reference Number to ECME

 ;    ("EPHARM")       = Optional, #9002313.56 ien (E-PHARMACY division)

 ;    ("RTYPE")        = Optional, rate type specified by user during

 ;                       manual ePharmacy processing

 ;    ("PRIMARY BILL") = Optional, if this is to be a secondary bill,

 ;                       this is the primary bill the secondary relates

 ;    ("PRIOR PAYMENT")= Optional, on secondary bills this is the offset

 ;                       to be applied from the primary payment.

 ;    ("RXCOB")        = Optional, COB indicator (secondary = 2)

 ;

 ;

 ; Return is the bill number for success or 1 if not billable.

 ; "0^reason" indicates not success

 ;

 ;

 Q $$ECME^IBNCPDP2(DFN,.IBD)

 ;

 ;

UPAWP(IBNDC,IBAWP,IBADT) ; used to update AWPs.  This is an API that

 ; pharmacy will call.

 ;

 ;  IBNDC = NDC number to update with the price.

 ;  IBAWP = average wholesale price of the NDC

 ;  IBADT  = effective date of change (optional, default it today)

 ;

 ;  return will be a positive number indicating success.

 ;  if it is unsuccessful, then "0^reason" will be returned.

 ;

 Q $$UPAWP^IBNCPDP3(IBNDC,IBAWP,$G(IBADT,DT))

 ;

BILLABLE(DRUG,ELIG,IBRMARK,IBBDAR) ; used to pass the ePharmacy Billable Status 

 ;

 ;Input:

 ;  DRUG = PRESCRIPTION File #52 IEN (required)

 ;  ELIG = BILLING ELIGIBILITY INDICATOR (T,C,V) field #85 of file 52 or 52.1. If not defined, assume "V".

 ;

 ;Output:

 ;  IBRMARK = "DRUG NOT BILLABLE" - only set if drug not billable (pass by reference)

 ;   IBBDAR = (optional) array values returned regarding drug file billable fields (pass by reference)

 ;  Function Value:   1 if drug is billable, 0 if drug is not billable

 ;

 N IBRES,EPHNODE

 S IBRES=0,IBRMARK="DRUG NOT BILLABLE"    ; assume not billable as default

 ;

 I '$G(DRUG) G BILLQ

 I $G(ELIG)="" S ELIG="V"

 ;

 S EPHNODE=$$PSSBILSD^PSS50(DRUG)        ;using PSS API to obtain this information IA# 6245

 ;

 ; set the values into the array 

 S IBBDAR("DRUG-BILLABLE")=$P(EPHNODE,U,1)

 S IBBDAR("DRUG-BILLABLE TRICARE")=$P(EPHNODE,U,2)

 S IBBDAR("DRUG-BILLABLE CHAMPVA")=$P(EPHNODE,U,3)

 ;

 ; If Elig is VET:

 ;  and ePharmacy Billable field is YES, then drug is billable.

 ;  Otherwise, drug is non-billable.

 I ELIG="V" D  G BILLQ

 . I $P(EPHNODE,U,1) S IBRES=1 K IBRMARK Q

 . Q

 ;

 ;If Elig is TRICARE:

 ; And ePharmacy Billable TRICARE field is YES, then drug is billable

 ; And ePharmacy Billable TRICARE field is NO, then drug is non-billable

 ; And ePharmacy Billable field is YES and ePharmacy Billable TRICARE field is unanswered, then drug is billable

 ; Otherwise, drug is non-billable

 ;

 I ELIG="T" D  G BILLQ

 . I $P(EPHNODE,U,2) S IBRES=1 K IBRMARK Q                         ; TRICARE billable true

 . I $P(EPHNODE,U,1),$P(EPHNODE,U,2)="" S IBRES=1 K IBRMARK Q      ; TRICARE billable unanswered + ePharm billable true

 . Q

 ;

 ;If Elig is CHAMPVA:

 ;  And ePharmacy Billable CHAMPVA field is YES, then drug is billable

 ;  And ePharmacy Billable CHAMPVA field is NO, then drug is non-billable

 ;  And ePharmacy Billable field is YES and ePharmacy Billable CHAMPVA is unanswered, then drug is billable

 ;  Otherwise, drug is non-billable

 ;

 I ELIG="C" D  G BILLQ

 . I $P(EPHNODE,U,3) S IBRES=1 K IBRMARK Q                         ; CHAMPVA billable true

 . I $P(EPHNODE,U,1),$P(EPHNODE,U,3)="" S IBRES=1 K IBRMARK Q      ; CHAMPVA billable unanswered + ePharm billable true

 . Q

 ;

BILLQ ;

 Q IBRES

 ;