| DESCRIPTION OF ENHANCEMENTS |
The National Council for Prescription Drug Programs (NCPDP) standard was
the payer's response and move on with the filling process; override
the reject by resubmitting the claim or postpone the processing of the
prescription by taking no action when the reject is received. For
prescriptions that have been electronically submitted to the third
party payer, an indicator is displayed on the Patient Prescription
Processing screen. This indicator will take the form of "e" next to
the prescription number (e.g.,"2090303$e").
A new section called REFILL TOO SOON/DUR REJECTS (Third Party) has
been created in the Medication Profile screen to single out
APPLICATION/VERSION PATCH
prescription that had an electronic claim rejected by third party
payers for REFILL TOO SOON or DUR reasons. Prescriptions under this
section have certain restrictions. Basically, they cannot be renewed,
refilled, reprinted, copied or released until the REJECT is resolved.
When an individual prescription is selected, the user will have a new
hidden option called REJ - View Reject, which will allow them to
resolve the REJECT and remove it from the REFILL TOO SOON/DUR REJECTS
(Third Party) section.
The prescription release option was modified to perform NDC (National
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Drug Code) validation for electronically billable prescriptions. When
the user selects a new NDC a new claim is submitted to the payer
before the prescription is released.
In the OP Medications screen, a new DAW CODE field (#81) of the
PRESCRIPTION file (#52) was created for electronically billable
prescriptions and can be edited by selecting '21' at the 'Select
Action' prompt. For non-electronically billable prescriptions this
field is not displayed at all.
OUTPATIENT PHARMACY (OP) V. 7.0 PSO*7*148
When the electronically billable prescription is released, this option
will allow the user to edit the NDC code for the prescription. In the
OP Medications screen the NDC field is listed under the Drug field
and can be edited by selecting '2' to edit the drug at the 'Select
Action' prompt. For sites that do not allow Drug editing, the option
'2' will allow editing of the NDC only.
2. Return Medication to Stock [PSO RETURNED STOCK] option
The Return Medication to Stock function was modified to notify the
INTEGRATED BILLING (IB) V. 2.0 IB*2*276
third party payer that a previously billed prescription was not
actually filled. If the prescription was previously billed to a third
party payer and a payable response was received, the claim will be
reversed, and the pharmacy user will see messaging stating that the
third party claim was submitted for reversal. If a claim for the
prescription was previously rejected by the third party payer, the
user will see a message indicating that no reversal was required. If
the prescription was not previously billed to a third party payer, no
message regarding electronic billing will be displayed.
PHARMACY DATA MANAGEMENT (PDM) V. 1.0 PSS*1*90
3. Delete a Prescription [PSO RXDL] option
The message for Delete a Prescription was modified to perform in the
same manner as the Return Medication to Stock function described
above.
4. Pull Early from Suspense [PSO PNDRX] option
The Pull Early from Suspense function was modified to submit a third
party claim for the prescription. A message will display to notify the
CONSOLIDATED MAIL OUTPATIENT PHARMACY (CMOP) V. 2.0 PSX*2*48
user of the status of the claim as it is going through the submission
process.
5. Print from Suspense File [PSO PNDLBL] option
This option was modified to submit third party claims in the same
manner as stated above except the Print from Suspense File function
will be performed in the background. No user interaction will occur.
6. ePharmacy Menu [PSO EPHARMACY MENU] menu
ACCOUNTS RECEIVABLE (AR) V. 4.5 PRCA*4.5*230
This new menu was created for electronic billing related options. It
is being placed under the Rx (Prescriptions) [PSO RX] menu. Two new
options are being added under this new menu:
6.1 Third Party Payer Rejects - Worklist [PSO REJECTS WORKLIST] option
This option is used to process third party payer rejects that have
clinical significance. For now, only DUR (Drug Utilization Review)
and REFILL TOO SOON rejects are being considered as having
ELECTRONIC CLAIMS MANAGEMENT ENGINE (ECME) V. 1.0 BPS*1*1
clinical significance.
6.2 Third Party Payer Rejects - View/Process [PSO REJECTS
VIEW/PROCESS] option
This option performs the same functionality as the option above.
However, the user has more filtering capabilities through this
option. In addition, closed/resolved rejects can only be viewed by
using this option.
7. Release Medication [PSO RELEASE] option
The prescription release process was modified to perform NDC (National
Drug Code) validation for electronically billable prescriptions. When
the user selects a new NDC, a new claim is submitted to the payer
before the prescription is released. Besides this option, the
prescription can be released from the Medication Profile screen and
from the Outpatient Rx's [PSD OUTPATIENT] option in the Controlled
Substances application.
adopted under the Healthcare Insurance Portability and Accountability Act
Veterans Health Information Systems and Technology Architecture (VistA)
8. View Prescriptions [PSO VIEW] option
This option was changed to include two new sections: ECME Log and ECME
REJECT Log. Information about third party payer submission and rejects
will be displayed under these sections.
9. Edit Prescriptions [PSO RXEDIT] option
The new DAW CODE field (#81) of the PRESCRIPTION file (#52) was
created for electronically billable prescriptions and can be edited
software applications and infrastructure were enhanced, in order to allow the
through this option. For non-electronically billable prescriptions,
the field is not displayed at all.
Once an electronically billable prescription is released, this option
will allow the user to edit the NDC code. The NDC code is displayed on
the screen just below the Drug field, and can be edited by selecting
field '2' to edit the Drug. For sites that do not allow Drug editing,
the field '2' can be used to edit the NDC code only.
10. The NDC field (#4) under the CMOP EVENT multiple (#52.01) of the
electronic transmission of outpatient pharmacy prescription claims (WINDOW
PRESCRIPTION file (#52) has been renamed to NDC RECEIVED. This field
holds the NDC that was received from the CMOP facility with the
dispensing message. The renaming was necessary due to the addition of
the NDC SENT field (#12) under the same multiple that is being created
by this project (see below item 11).
11. A new NDC SENT field (#12) is being created under the CMOP EVENT
multiple (#52.01) of the PRESCRIPTION file (#52), to store the NDC
that was transmission to CMOP. This field is used for electronic
billing purposes to analyze the difference between the NDC sent to
and MAIL fills) to third party payers via the network connections available
CMOP and the actual dispensed NDC by the CMOP facility.
12. A new DAW CODE field (#81) is being created on the PRESCRIPTION
file (#52) and also under the REFILL multiple (#52.1) of the
PRESCRIPTION file (#52). This field contains the NCPDP DAW used in the
electronic claims submission to third party payers (insurance
companies).
13. A new RE-TRANSMIT FLAG field (#82) is being created on the
PRESCRIPTION file (#52) and also under the REFILL multiple (#52.1) of
through the Austin Automation Center (AAC). VistA will be enhanced to receive
the PRESCRIPTION file (#52). This field is used to indicate that a
claim should be electronically re-transmitted to the 3rd party payer
(insurance company). It will be primarily used by CMOP and local mail
prescriptions.
14. A new multiple REJECT INFO field (#52.25) has been created on the
PRESCRIPTION file (#52) to store information about DUR and Refill Too
Soon Rejects returned by 3rd party payers.
The following fields are part of this multiple:
electronic adjudicated responses from the third party payers, which include
.01 NCPDP REJECT CODE
1 DATE/TIME DETECTED
2 PAYER MESSAGE
3 REASON
4 PHARMACIST
5 FILL NUMBER
6 GROUP NAME
7 PLAN CONTACT
8 PLAN PREVIOUS FILL DATE
9 STATUS
real-time processing for Drug Review Utilization and Refill Too Soon rejects.
10 CLOSED DATE/TIME
11 CLOSED BY
12 CLOSE REASON
13 CLOSE COMMENTS
14 REASON FOR SERVICE CODE
15 PROFESSIONAL SERVICE CODE
16 RESPONSE ID
17 OTHER REJECTS
18 DUR TEXT
19 RESULT OF SERVICE CODE
Reject information will be displayed to the pharmacist as the prescription is
20 INSURANCE NAME
21 GROUP NUMBER
22 CARDHOLDER ID
23 RE-OPENED
Two new cross-references named "REJDAT" and "REJSTS" were created for
this multiple in the PRESCRIPTION file (#52). The "REJDAT" uses the
DATE/TIME DETECTED field (#1) and the "REJSTS" uses the STATUS field
(#9).
being processed. The pharmacist will have the capability to take the
appropriate action to ensure patient safety or to override the reject and
(HIPAA) for pharmacy claims. The HIPAA NCPDP - GLOBAL project involves six
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
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
different applications that have been significantly changed to enable VA
electronic payments from third party payers. This real-time electronic claims
processing capability will be provided in accordance with the HIPAA, EDI
and the 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
Medical Centers to perform third party electronic billing for prescriptions
another while automatically "expiring" the old plan, which is a major
time saver.
. 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
using the NCPDP standard.
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
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
Below is a list of all the applications involved in this project along with
indicates that it is unable to fill a "PAYABLE" prescription fill, a reversal
is automatically submitted to the third party payer for the corresponding
fill.
This patch modifies the OP application to perform real-time electronic claim
submission to third party payers. It will also enable OP users to see and act
on third party payer rejects such as Drug Utilization Review (DUR) and Refill
Too Soon rejects along with their daily normal prescription processing
activities. The following areas of OP have been changed:
their patch number:
1. Patient Prescription Processing [PSO LM BACKDOOR ORDERS] option
At the point that the prescription is verified, the New Order, Edit,
Renew, Refill, and Pull Early from Suspense functions will begin the
third party billing evaluations. If IB determines that the
prescription is third party billable, a message will be displayed on
the user's screen stating that the claim is being submitted to ECME
and it will also show the progress of the claim. If the payer rejects
the claim for DUR or Refill Too Soon, the payer's information will be
displayed, and the user will be given the opportunity to either ignore
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