| DESCRIPTION OF ENHANCEMENTS |
This patch is one of four patches that enhance the ePharmacy software to
3. (Dormant except for item C.) - The Third Party Payer Rejects -
Worklist [PSO REJECTS WORKLIST] option and the Third Party Payer Rejects -
View/Process [PSO REJECTS VIEW/PROCESS] options have been modified in the
following manner:
A. Non-DUR/RTS Tricare rejections will be segregated at the end of
the displayed information. They will be denoted with a "TRICARE -
Non-DUR/RTS" header. This header will remain regardless of
APPLICATION/VERSION PATCH
whether the GI - Group by Insurance action is toggled on or off.
The Tricare section will sort in the same manner as the main sort
for non-Tricare prescriptions (i.e. by Rx, drug, patient, etc.).
B. Tricare DUR/RTS rejects will be displayed with all other DUR/RTS
rejects. When GI - Group by Insurance action is toggled on, the
header "TRICARE" will be displayed, and this "TRICARE" section
will sort alphabetically within the other insurances. This
Tricare section is separate from the Non-DUR/RTS section that
displays at the end of the listing. When GI is toggled off, these
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rejects will sorted in the same section as all other DUR/RTS
rejects.
C. (Not dormant) - The new TRI - Show/Hide Tricare toggle action has
been added to the hidden menu on the Insurance Rejects screen.
When toggled to Show, Tricare Non-DUR/RTS reject will be
automatically displayed at the end of the listing. Toggling the
TRI action to Hide will remove them from the screen.
D. The Reject Information screen has been modified to display TRICARE
1. CONSOLIDATED MAIL OUTPATIENT PHARMCY (CMOP) V. 2.0 PSX*2*66
in the header for the Reject Information section. For DUR/RTS
Tricare rejects, the IGN - Ignore Reject action will be shown but
will not be selectable. For Non-DUR/RTS Tricare rejects, the FIL -
Fill Rx action will be displayed. If the prescription is payable,
the user will be allowed to fill the prescription and print the
label. If not payable, a message will be displayed stating that
the prescription must have a payable status to be filled.
E. For rejects that remain in suspense, the user will be allowed to
process the rejection as indicated above, however no labels will
2. OUTPATIENT PHARMACY (OP) V. 7.0 PSO*7*287
be printed until the prescription is pulled early or printed from
suspense. Upon resolving the reject, the user will be notified
of this information. CMOP prescriptions will function in the same
manner.
4. In preparation for a future ePharmacy patch the following fields are
being added to PRESCRIPTION file (#52) for original fills and refills:
DATE NDC VALIDATED field (#83) and NDC VALIDATED BY field (#84).
5. For ePharmacy prescriptions, the price per dispense unit for the
3. ELECTRONIC CLAIMS MANAGEMENT ENGINE (ECME) V. 1.0 BPS*1*6
NDC will be saved in PRESCRIPTION file (#52). For original fills, the
UNIT PRICE OF DRUG field (#17) will be updated. For refills, the CURRENT
UNIT PRICE OF DRUG field (#1.2) of REFILL multiple (#52.1) will be
updated. If the NDC chosen is the default NDC, the value stored will be
taken from PRICE PER DISPENSE UNIT field (#16) of DRUG file (#50). If the
NDC selected is a synonym, the PRICE PER DISPENSE UNIT field (#404) of
SYNONYM multiple (#9) of DRUG file (#50) will be saved. In the case of
CMOP fills, only the default NDC price will be stored which is taken from
PRICE PER DISPENSE UNIT field (#16) of DRUG file (#50).
4. INTEGRATED BILLING (IB) V. 2.0 IB*2*383
6. (Dormant) - If ECME's status on the claim remains in an "In Progress"
state past the processing time out during finish of the prescription,
Tricare prescriptions will not be allowed to be filled and must be
discontinued.
7. (Dormant) - If the pharmacy is active for ePharmacy processing but the
insurance plan is not linked or not active, Tricare prescription will be
allowed to be filled normally. The phrase "Inactive ECME Tricare" will be
displayed during Finish.
All four patches are being released separately with a requirement that
they be installed in the order outlined above. There are no other
provide the framework to support Tricare and Active Duty outpatient
dependencies between these patches, except that Tricare/Active Duty
billing will not be supported by ePharmacy until all 4 patches are
installed.
All sites should install these patches regardless of whether or not they
have been activated for ePharmacy by the CBO or are providing outpatient
pharmacy services to Tricare or Active Duty patients. After the
installation of these patches, the activation status of the site will not
be impacted. As before, activation of the ePharmacy product will require
instructions provided by the CBO, and sites are not to activate ePharmacy
pharmacy billing. The Tricare/Active Duty portions of this software
unless instructed specifically by the CBO. Also, sites should not start
to provide outpatient pharmacy services to Tricare patients without
discussions with the CBO.
This patch modifies the Outpatient Pharmacy v7.0 application as described
below. The modifications labeled dormant in the software and will remain
inactive until the future Tricare patch is released.
1. (Dormant) - Prescriptions where the patient is Tricare eligible will
be submitted to ECME for third party insurance processing in the same
enhancement will not be active until a future patch is released. The
manner as all other insurance types. Tricare eligibility is determined by
Integrated Billing (IB). An indicator is returned to Outpatient Pharmacy
PRESCRIPTION file (#52) and REFILL multiple (#52.1) to be stored in the
new BILLING ELIGIBILITY INDICATOR field (#85). Because this is a set of
codes field, the internal value will be T, V or C. These values will be
displayed respectively to the user as TRICARE, VETERAN, or CHAMPVA. Note
that CHAMPVA will not be addressed in this patch. Prescriptions with only
a 'VETERAN' eligibility flag are what is currently processed through ECME.
2. (Dormant) - When a Tricare prescription has a third party rejection,
release of the additional patch is pending Central Business Office (CBO)
the same reject notification screen will be displayed to the user as is
currently done for the Veteran eligibility. Tricare Rejections will be
stored in the same manner as Drug Utilization Review (DUR) and
Refill-too-soon (RTS) prescription reject are currently stored.
The following exceptions will apply for Tricare prescriptions:
A. All Tricare rejections will be denoted as Tricare in the REJECT
Information header on the Reject Information screen.
contracting with the Tricare Fiscal Intermediary.
B. Where DUR or RTS are one of the reject codes, the user will be
able to select from (D)iscontinue the prescription, submit
(O)verride codes, or (Q)uit which sends the rejection to the Third
Party Payer Rejects - Worklist. Tricare rejection may not be
(I)gnored.
C. For prescription rejections that have non-DUR/RTS rejects, the
user will be able to select from (D)iscontinue the prescription or
(Q)uit which sends it to the Third Party Payer Rejects - Worklist.
D. For non-billable Tricare prescriptions, an abbreviated version of
the reject notification screen will be displayed. Because the
prescriptions is non-billable, the insurance and ECME information
that's currently provided for DUR/RTS rejects will not be
displayed (i.e. insurance, group name, group #, ECME #, contact,
cardholder ID). In this case, the user will only be able to
(D)iscontinue the prescription due to the business rule that OP
cannot fill Tricare prescriptions that are non-billable.
E. Labels will not print for discontinued Tricare prescriptions.
Below is a list of all the applications involved in this project along
Reprint labels will not be allowed to be printed for Tricare
rejected prescriptions. The reject notification screen will be
displayed during reprint in the same manner as non-Tricare
prescription currently are displayed with the exception of the
available actions listed above for Tricare prescriptions.
F. Suspended prescriptions will remain on suspense when a reject
occurs, when the Rx is non-billable, or when the third party claim
remains in an 'IN PROGRESS' status in ECME. Labels will not
print. Once the reject is resolved, the user may pull the Rx
with their associated patch number:
early from suspense or wait for the next scheduled print from
suspense runs at which time labels will print accordingly. This
includes CMOP and local suspense.
G. Rejected Tricare prescription may not have a partial fill ordered
until the reject is resolved.
H. When the Pull Early from Suspense [PSO PNDRX] option is used,
Tricare prescriptions will be processed in the foreground and
rejections will be displayed for user intervention.
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