| DESCRIPTION OF ENHANCEMENTS |
This project involves six different applications that have been significantly
OUTPATIENT PHARMACY (OP) V. 7.0 PSO*7*148
CMOP and remains in the queue to be transmitted in the next CMOP
transmission. The prescription will not be transmitted to CMOP until the
reject is resolved by the user through the Outpatient Pharmacy V. 7.0
application. No message is generated for prescriptions in this category.
INTEGRATED BILLING (IB) V. 2.0 IB*2*276
PHARMACY DATA MANAGEMENT (PDM) V. 1.0 PSS*1*90
CONSOLIDATED MAIL OUTPATIENT PHARMACY (CMOP) V. 2.0 PSX*2*48
ACCOUNTS RECEIVABLE (AR) V. 4.5 PRCA*4.5*230
ELECTRONIC CLAIMS MANAGEMENT ENGINE (ECME) V. 1.0 BPS*1*1
Veterans Health Information Systems and Technology Architecture (VistA)
software applications and infrastructure were enhanced, in order to allow the
electronic transmission of outpatient pharmacy prescription claims (WINDOW and
changed to enable VA Medical Centers to perform third party electronic billing
MAIL fills) to third party payers via the network connections available
through the Austin Automation Center (AAC). VistA will be enhanced to receive
electronic adjudicated responses from the third party payers, which include
real-time processing for Drug Review Utilization and Refill Too Soon rejects.
Reject information will be displayed to the pharmacist as the prescription is
being processed. The pharmacist will have the capability to take the
appropriate action to ensure patient safety or to override the reject and
resubmit the claim to the payer for payment. When a status of "PAYABLE" is
returned by the payer for a released prescription, VistA will automatically
create the bill in IB, authorize it and immediately create the receivable in
for prescriptions.
the AR application. Since the exact amount being paid by the payer is known,
a decrease adjustment will be automatically generated and applied so that the
receivable is equal to the net amount due from the payer.
The system also provides electronic payment matching capability (for
electronically billable outpatient pharmacy prescriptions) using the existing
Electronic Data Interchange (EDI) Lockbox functionality which processes other
electronic payments from third party payers. This real-time electronic claims
processing capability will be provided in accordance with the Healthcare
Insurance Portability and Accountability Act (HIPAA), EDI transactions and
the National Council for Prescription Drug Programs (NCPDP) mandated format
standards, specifically NCPDP Telecommunication Standard V. 5.1. Additional
functionality delivered with this project includes:
. Auto-Release/Outpatient Pharmacy Automation Interface (OPAI) Integration.
. Back-billing capability to allow electronic billing of claims from within
the IB application.
. Capability to MOVE a group of subscribers from one insurance plan to
another while automatically "expiring" the old plan, which is a major
time saver.
Below is a list of all the applications involved in this project along with
. Pharmacy Dispensed As Written (DAW) prescription processing.
Overview of the Process:
When a prescription is about to be filled and dispensed by the pharmacy, the
OP application submits the prescription to the new ECME application. ECME then
contacts IB to verify whether or not the prescription is electronically
billable. If so, ECME gathers the information necessary to generate a NCPDP
claim. The claim information is passed to the VistA Health Level Seven (HL7)
package. The HL7 package then sends the billing information to the AAC, where
their patch number:
it is routed to the corresponding third party insurance via Emdeon (formerly
WebMD).
Once the payer processes the information, the response coming back from the
payer is passed back to the site that made the request, and the information
is stored in the ECME package. If the third party payer accepted the claim,
the adjudicated information is passed along to IB. If the claim was rejected
the problem can be worked on and a new claim can be submitted to the payer.
For electronically billable CMOP prescription processing, the third party
claim is sent before the prescription information is transmitted to the
CMOP facility to be filled. Once the adjudicating response is electronically
received from the third party payer, if there are no Drug Utilization Review
or Refill Too Soon rejects, the prescription is then transmitted to the CMOP
facility. When the CMOP center sends the dispensing information back to VistA,
the National Drug Code (NDC) information is checked against the NDC sent to
the third party payer and, if different, a new claim is generated in the
background and is sent to the third party payer. In case the CMOP facility
indicates that it is unable to fill a "PAYABLE prescription fill, a reversal
is automatically submitted to the third party payer for the corresponding
APPLICATION/VERSION PATCH
fill.
This patch modifies the CMOP application to submit electronic claims for
prescriptions that are transmitted to CMOP centers to be filled and dispensed
remotely. All the prescriptions ready to be included on the batch to be
transmitted to CMOP are first transmitted to the third party insurance. Once
this step is completed, the system waits 60 seconds before the actual
transmission to CMOP starts. This process will affect the existing CMOP
functionality in two ways:
-----------------------------------------------------------------
1) If a response from the third party payer is not received by the time the
prescription is ready to be transmitted to CMOP, the prescription is
skipped and remains in the queue for the next CMOP transmission. A Mailman
message containing all the prescriptions in this category is generated at
the end of the process and it is transmitted to all the holders of the
PSXMAIL security key. If no users on the system have this key, the Mailman
message is sent to all the users holding the PSXCMOPMGR security key.
2) If the third party payer rejects the claim due to a DUR (Drug Utilization
Review) or a 'REFILL TOO SOON' reject, the prescription is not sent to
|
