| $$STORESP(DFN,.ARRAY) |
The Integrated Billing function $$STORESP^IBNCPDP is
used by Outpatient Pharmacy and ECME to pass the third party payer's billing
response information to Integrated Billing.
|
| VARIABLES |
TYPE |
VARIABLES DESCRIPTION |
.ARRAY |
Input |
The following elements will be passed to IB:
ARRAY("AUTH #")=
Authorization number returned by Insurance
ARRAY("BILLED")=
Amount billed to the insurance
ARRAY("CLAIMID")=
Reference Number to ECME (ECME #)
ARRAY("CLOSE COMMENT")=
Optional, if the close reason is defined
then the Close Comment parameter may be
sent to IB.
ARRAY("CLOSE REASON")=
Optional, Pointer to the IB CLAIMS TRACKING
NON-BILLABLE REASONS file (#356.8)
ARRAY("COPAY")=
Patient Copay Amount per the Insurance
ARRAY("DAYS SUPPLY")=
Days Supply
ARRAY("DISP FEE PAID")=
Dispensing Fee Paid by the Insurance
ARRAY("DOS")=
Date of Service in FileMan format
ARRAY("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.
ARRAY("DRUG")=
IEN of DRUG file (#50)
ARRAY("ING COST PAID")=
Ingredient Cost Paid by the Insurance
ARRAY("FILL NUMBER")=
Fill or refill number
ARRAY("NCPDP QTY")=
Quantity converted according to the NCPDP
Unit of Measure
ARRAY("NCPDP UNITS")=
Unit of Measure per the NCPCP standard
ARRAY("NDC")=
NDC
ARRAY("PAID")=
Amount paid by the Insurance
ARRAY("PAT RESP")=
Patient Responsibility per the Insurance
ARRAY("PLAN")=
IEN of the entry in the GROUP INSURANCE
PLAN file (#355.3), which was captured
from the $$RX^IBNCPDP call
ARRAY("POLICY")=
IEN of the INSURANCE TYPE multiple
(#.3121) of the PATIENT file (#2)
ARRAY("PRESCRIPTION")=
IEN from the Prescription file (#52)
ARRAY("PRIOR PAYMENT")=
Used for secondary claims to pass in
The amount paid by the primary
insurance. Required for secondary
claims on PAID event.
ARRAY("PRIMARY BILL")=
Bill IEN from BILL/CLAIMS file (#399).
Used for secondary claims to pass in
the Primary bill #. Required for
secondary claims on PAID event.
ARRAY("QTY")=
Quantity Dispensed
ARRAY("RELEASE COPAY")=
Optional, if the claim is being closed,
setting this parameter to 1 (TRUE)
indicates that the patients copay should
be released off hold.
ARRAY("RELEASE DATE")=
Release date/time in FileMan format
ARRAY("RESPIEN")=
IEN of the BPS RESPONSE file (#9002313.03)
ARRAY("RTYPE")=
IEN of record in RATE TYPE file (#399.3).
Required for secondary claims on PAID
event.
ARRAY("RXCOB")=
The payer sequence for the claim:
1-Primary, 2-secondary. VA doesn't bill
other insurances so it can be only
these two values. If null then the payer
sequence = Primary is assumed. Required
for secondary claims on PAID and
REVERSED events.
ARRAY("RX NO")=
RX Number from PRESCRIPTION file (#52)
ARRAY("STATUS")=
Bill status which will be assigned
one of the following values: "PAID",
"REVERSED", "CLOSED", "RELEASED",
"ELIG", or "SUBMITTED"
ARRAY("UNITS")=
Prescription Units
|
DFN |
Input |
Patient IEN for the prescription.
|
$$STORESP |
Output |
Bill number = success, 1 = not billable, 0^reason =
not successful
|
|
$$RX(DFN,.ARRAY) |
This function returns to the subscribing application
whether or not a prescription is third party billable. The subscribing
application shall pass an array of variables to IB. IB will use the array
elements during the billing determination logic. IB will return to the
subscribing application Payer information and a message notifying what billing
action should be taken on the prescription.
|
| VARIABLES |
TYPE |
VARIABLES DESCRIPTION |
DFN |
Input |
Patient IEN for the prescription.
|
.ARRAY |
Both |
**The following elements will be passed to IB:
ARRAY("COST")=
Price per Dispense Unit
ARRAY("DEA")=
DEA special handling code
ARRAY("DOS")=
Date of Service in Fileman format
ARRAY("FILL NUMBER")=
Fill number
ARRAY("IEN")=
IEN from Prescription file (#52)
ARRAY("NDC")=
NDC (ex: 55953-0344-80)
ARRAY("NCPDP QTY")=
Quantity converted according to the
NCPCP Unit of Measure
ARRAY("NCPDP UNITS")=
Unit of Measure per the NCPCP standard
ARRAY("PLAN")=
IEN of the entry in the GROUP
INSURANCE PLAN file (#355.3). Required
for secondary billing.
ARRAY("QTY")=
Quantity Dispensed
ARRAY("RELEASE DATE")=
Rx release date/time in Fileman format
ARRAY("RXCOB")=
Payer sequence for the claim (1-Primary,
2-Secondary). If null, then payer
sequence Primary (1) is assumed.
ARRAY("RX ACTION")=
RX Action making the call
Example: "ELIG" for eligibility
ARRAY("RTYPE")=
IEN of record in RATE TYPE file (#399.3).
Required for secondary claims.
ARRAY("SC/EI OVR")=
SC/EI Override (0 or 1) where:
0 - Do not ignore Service
Connection/Environmental Indicators
and answers to respective questions.
If the RX was connected to at least
one of patient's SC/EI conditions
then RX will be considered as
non-ECME billable and the API will
return 0 in the first piece and a
respective indicator in the second
piece. Example: 0^AGENT ORANGE.
If at least one of the questions
wasn't answered, the RX will be
considered as non-ECME billable and
the API will return 0 in the first
piece and NEEDS SC DETERMINATION in
the second piece
(0^NEEDS SC DETERMINATION).
1 - Ignore Service Connection/Environmental
Indicators and bill the payer. The API
will return 1 unless there is a
different reason the RX is not billable.
ARRAY("UNITS")=
Prescription Units
**The following elements will be returned from IB:
ARRAY("BILL")=
Bill Flag (0 OR 1)
ARRAY("INS",Sequence,1)=
Piece 1: IEN of record in the GROUP INSURANCE
PLAN file (#355.3)
Piece 2: BIN
Piece 3: PCN
Piece 4: Billing Payer Sheet Name (B1)
Piece 5: Group ID
Piece 6: Cardholder ID
Piece 7: Patient Relationship Code
Piece 8: Cardholder First Name
Piece 9: Cardholder Last Name
Piece 10: Home Plan State
Piece 11: Reversal Payer Sheet Name (B2)
Piece 12: Rebill Payer Sheet Name (B3)
Piece 13: Software/Vendor Certification ID
Piece 14: Insurance Co Name from Insurance
file (#36)
Piece 15: Eligibility Payer Sheet Name (E1)
Piece 16: Billing Payer Sheet IEN (B1)
Piece 17: Reversal Payer Sheet IEN (B2)
Piece 18: Rebill Payer Sheet IEN (B3)
Piece 19: Eligibility Payer Sheet IEN (E1)
Piece 20: Person Code
where:
The IEN of file 355.3 shall be recorded in
the subscribing application's database
so that it can be retrieved and passed in
as input to the function $$STORESP^IBNCPDP
Home Plan State = State IEN for State
file (#5)
ARRAY("INS",Sequence,2)=
Piece 1: Dispensing Fee Submitted
Piece 2: Basis of Cost Determination
Piece 3: Base Price
Piece 4: Gross Amount Due
Piece 5: Administrative Fee
Piece 6: Ingredient Cost
Piece 7: Usual and Customary Amount
where:
Basis of Cost Determination=
01 for AWP
05 for Cost
07 for Usual & Customary
Base Price=
AWP = Gross Amount Due less Dispensing Fee
and Administrative Fee
Cost = Ingredient Cost plus Dispensing Fee
U&C = Gross Amount Due
Gross Amount Due=
Ingredient Cost plus Dispense fee plus
Administrative fee
ARRAY("INS",Sequence,3)=
Piece 1: Group name
Piece 2: Insurance Company Phone Number
Piece 3: Plan ID
Piece 4: Plan Type
Piece 5: Insurance Company IEN (#36)
Piece 6: COB Indicator
Piece 7: Policy Number
Piece 8: Maximum Transaction Count
where:
Plan Type=
"C" for CHAMPVA
"T" for TRICARE
"V" for Veteran Insurance
COB Indicator=
COB field (#.2) of the INSURANCE
TYPE multiple (#.3121) of the
PATIENT file (#2)
Policy Number=
IEN of the INSURANCE TYPE multiple
(#.3121) of the PATIENT file (#2)
ARRAY("SC/EI NO ANSW")= IB returns the list of
SC and environmental indicators for
which SC/EI connected question(s)
has not been answered, example:
"AO,SWA,CV"
Set of the following Service Connection/
Environmental Indicator related nodes:
ARRAY("AO")=null,0 or 1 Agent Orange
ARRAY("EC")=null,0 or 1 Environmental
Contaminants
ARRAY("SWA")=null,0 or 1 SouthWest Asia
ARRAY("SC")=null,0 or 1 Service Connected
ARRAY("IR")=null,0 or 1 Ionizing
Radiation
ARRAY("HNC")=null,0 or 1 Head/Neck Cancer
ARRAY("MST")=null,0 or 1 Military Sexual
Trauma
ARRAY("CV")=null,0 or 1 Combat Veteran
ARRAY("SHAD")=null,0 or 1 Project 112/SHAD
ARRAY("CLV")=null,0 or 1 Camp Lejeune
where:
null - the question has not been answered
(and therefore requires service connection
determination if the patient has such a
condition in file
0 - user answered "No" (Not connected)
1 - user answered "Yes" (Connected)
|
$$RX |
Output |
Result ^ Reason ^ Primary Eligibility Type
where
Result:
1 = the transaction is billable
0 = not billable
Reason: reason not billable text (only
if Result=0)
Primary Eligibility Type:
C - CHAMPVA
T - TRICARE or Sharing
V - Veteran
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