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Maryland Medicaid Pharmacy Programs Claims Processing Training

Maryland Medicaid Pharmacy Programs Claims Processing Training . January 2007. Affiliated Computer Services (ACS). Agenda Implementation Information Call Center Information Operational Information (All Programs) Operational Information (By Program) Clinical Information (By Program)

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Maryland Medicaid Pharmacy Programs Claims Processing Training

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  1. Maryland Medicaid Pharmacy Programs Claims Processing Training January 2007

  2. Affiliated Computer Services (ACS) Agenda • Implementation Information • Call Center Information • Operational Information (All Programs) • Operational Information (By Program) • Clinical Information (By Program) • Coordinated ProDUR – MCO/PBM Information • Conclusion

  3. Program Learning Objectives • Understand and explain how the POS system works. • To know the differences between the old and new POS processing system • Be able to operate the system at Provider level and educate Providers Staff • Understand processing procedures on PDL, Mental Health drugs, HIV, and drugs requiring PA

  4. ACSPrescriptions Benefit Management (PBM) • Serves 32 programs nationwide– including Medicaid, senior programs, and workers’ compensation programs • Process more than 200 million pharmacy claims annually. • Manage states’ drug spend of more than $14 Billion. • Manages 14 million covered lives, or 1 in every 3 Medicaid eligibles nationwide.

  5. ACSPrescriptions Benefit Management (PBM) • Processes over 2 million calls and faxes in our call centers annually • Processes an average of 100,000 prior authorizations each month. • Manages a retail pharmacy network of 56,000 providers, approximately 80% of all pharmacies nationwide. • Administers federal and supplemental rebate programs and collects over $100 Million in manufacturer rebates

  6. ACSPrescriptions Benefit Management (PBM) • Call Center • Our call center is open 24/7 and includes multi-lingual support services. • (800) 932-3918 • Aetna • Humana

  7. Implementation Information • February 4, 2007 is the official implementation date. • Down time – FH will cease processing at 11PM February 3, 2007. • ACS will be processing no later than noon on February 4, 2007. • Follow internal downtime procedures during this outage

  8. Implementation Information • BIN 610084 • PCN • OOEP DRMDPROD • MDKDP DRKDPROD • MDBCCDT DRDTPROD • MDMADAP DRMAPROD

  9. Implementation Information • Group IDs • OOEP MDMEDICAID • MDKDP MARYLANDKDP • MDBCCDT MDBCCDT • MDMADAP MADAP

  10. MCO /PBM Implementation Information • BIN 610084 • Use current PCN for Coordinated ProDUR. (see previous slides)

  11. ACS Call Center All Programs • Call Center • PA Call Center number • Phone: 1-800-932-3918 • Fax: 1-866-490-1901 • Technical Call Center number • Phone: 1-800-932-3918 • Fax: 1-866-490-1901 • Hours of Operation: 24/7/36

  12. ACS Call Center Technical Call Center • Program Inquiries • General Inquiries

  13. ACS Call Center • Staffed by Customer Service Representatives and Pharmacy Technicians • Pharmacist on site 8:30 am to 5:00 pm and on call 24 hours per day • Staffed 24/7/365 Will Handle: • Claims inquiries • Clinical inquiries • Program specific and general inquiries • Prior Authorizations

  14. ACS Call Center • Henderson facility handles overflow and after hours • PAC Eligibility Services Call Center information • Call Center Number – (800) 226-2142 • Maryland residents who have applied but no decision has been made – questioning status of application • Applicant questioning a determination decision

  15. Operational Program Changes General Information • Claims will only be accepted in the NCPDP Version 5.1 Claim Format via POS • Paper Claims will be accepted for special circumstances • There is no Batch claim submissions accepted

  16. Maryland Medicaid (OOEP)

  17. Medicaid Program Specific Information BIN 610084 PCN DRMAPROD Group ID MDMEDICAID Provider ID NCPDP Number Prescriber ID DEA Number Recipient ID Medicaid ID Number

  18. Copays • Fee for Service = $1.00 / 3.00 PAC copays = $2.50 / 7.50 NH = NO copays; • Pregnancy =NO copays (PA type = 4) • Family Planning medications = no copay MMI State Funded Foster copay = $1.00 / 3.00 (no exceptions) (Coverage Code = 110.) • MCO/ HMO copay = $1.00 / 3.00

  19. Copay Exceptions • Patient is pregnant • Patient Drug is a Family Planning drug. • LTC claims, with the exception of groups S16, S17, and S18. • Group S12 and drug is family planning. • PDL – 3 day emergency supply

  20. Dispensing Fees • Brand not on PDL: $2.69 • PDL and generic: $3.69 • LTC/Hospice/LTC and Hospice Brand not on PDL = $3.69; PDL and generic: $4.69 • Partial Fills: • ½ dispensing fee at initial fill • ½ dispensing fee at completion fill • Copay paid on initial fill.

  21. Age Limitations Maryland Medicaid will enforce the following Age Restrictions: • Non-legend chewable tablets of any ferrous salt when combined with vitamin C, multivitamins, multivitamins and minerals, or other minerals in the formulation • Topical Vitamin A Derivatives, HIC3 = L9B; and Route = Topical • Ferrous sulfate covered for recipients < 12 years

  22. Generic Mandatory • The system will deny brand drugs when a generic is available • Edit 22 (M/I /DAW code) and the message text: “Generic Available – Call State at 410-767-1755, Med Watch form required” • When submitted as Brand Medically Necessary (DAW = 1) with the exception of the following (pay at EAC): • Levothyroxine HICL seq Num = 002849 • Brimonidine eye drops GSN = 48333 and 27882

  23. Generic Mandatory • The system will cover brand drugs billed as generic with DAW=5 without preauthorization • Brand drugs will be rejected with NCPDP edit 22 (M/I DAW code) and the message text: “Generic Available – Call State at 410-767-1755, Med Watch form • The system will accept the following Dispense as Written (DAW) values (NCPDP field 408-D8): 0 - default, no product selection 1 - Physician request 5 - Brand used as generic 6 – Override

  24. Partial Fill Claim Submission Guidelines: • Dispensing status = P or C • Qty Intended to be dispensed • Days Supply Intended to be Dispensed • Quantity Dispensed Cannot submit a P and C transaction the same day. Cannot submit a C transaction before a P transaction.

  25. Coordination of Benefits (COB) ACS will process a claim for TPL when: • There is presence of COB on the recipient Eligibility file • There is presence of COB submitted on a claim with an Other Payer Amt. Paid. • Claims that are submitted without COB information when there is presence of COB on the eligibility file will deny with NCPDP reject 41 – Submit claim to other payer. • Claims submitted with an Other Coverage Code 8 – Copay Only – are not accepted by Maryland Medicaid.

  26. Coordination of Benefits Qualified Medicare Beneficiary (QMB) • Medicare B • Medicare D • Claims processing rules and drug coverage

  27. LTC / Hospice The system will determine LTC claims by the following conditions: • Claim contains Patient Location code = ‘04’ (NCPDP field 307-C7) • Facility ID (NCPDP field # 336-8C) is on list of institutions • Pharmacy Provider ID is on the list of LTC providers • Note: Existing "NH" provider numbers = LTC providers / institutions

  28. LTC / Hospice The system will determine Hospice-Only claims by the following conditions: • Claim contains Patient Location code = ‘11’ (NCPDP field 307-C7) • Client Specific Reporting field on Recipient Eligibility file = "HI" • The Date of Service is within an active coverage span on the Recipient Eligibility file • Facility ID (NCPDP field # 336-8C) is on list of institutions (see appendix) • Note: The system will deny Hospice claims that do not have both a Patient Location code = ‘11’ and a Client Specific Reporting field on Recipient Eligibility file = "HI”

  29. LTC / Hospice ACS will determine RECIPIENTS with BOTH LTC/HOSPICE LTC/Hospice claims will be determined by the following distinct conditions: • Client SPECIFIC REPORTING field = "HI" on the recipient's enrollment record with a date span that includes DOS, AND • PATIENT LOCATION (NCPDP field # 307-C7) = "11", AND • FACILITY ID (NCPDP field # 336-8C) any value on the list of institutions, AND

  30. LTC / Hospice ACS will determine RECIPIENTS with BOTH LTC/HOSPICE LTC/Hospice claims will be determined by the following distinct conditions: (continued from previous slide) • Designated LTC providers in the SERVICE PROVIDER ID (NCPDP field # 201-B1) • The system will deny non-LTC claims for unit dose medications with certain exceptions; claims will deny with error 70 (drug not covered) and message text: “Unit Dose Package Size

  31. Prior Authorizations • Methods to obtain a Prior Authorization • Call specified Call Center • Complete and fax a Prior Authorization request form • Smart PA

  32. Prior Authorizations • Maryland Medicaid Staff • All Days Supply • Growth Hormones • Synagis (Palivizumab) • Female Hormones for a male and vice versa • Nutritional supplements (see MD PA form for clinical criteria) • Recipient Lock-In • Price (long-term PAs only) • Oxycontin Quantity (during business hours) • Antihemophilic Drugs (claim pended in X2 and evaluated manually by State) -Duragesic Patch Quantity (during business hours)

  33. Prior Authorizations • Maryland Medicaid Staff (continued) • Topical Vitamin A Derivatives • Opiate Agonists for Hospice and Hospice/LTC • Antiemetic • Serostim • Botox • Orfadin • Revlimid • Revatio • Brand Medically Necessary

  34. Prior Authorizations • ACS ProDUR Call Center Prior Authorizations • Quantity (Note Oxycontin, Duragesic Patch exceptions) • CNS Stimulants • Actiq • Anti-Migraine • Anti-Psychotics • Oxycontin, Duragesic Patch Qty for after hours/weekends

  35. Prior Authorizations • ACS Technical Call Center • PDL - Non-Preferred drugs • Early Refill • Maximum dollar limit per claim = $2500. • Age Restrictions • Maximum Quantity overrides

  36. Prior Authorizations • Maryland CAMP Office • Depo Provera • Lupron Depot

  37. SmartPA SmartPA New Clinical PA rules engine • ACS Stores both medical and Pharmacy claims history. • Claim is submitted, looks at both while reading the rule. Smart PA will issue a PA if claim and history meet criteria without pharmacy or physician intervention.

  38. SmartPA • Prior Authorizations handled by SmartPA • CNS Stimulants • Actiq • Anti-Migraine • Atypical Antipsychotics • Serostim • Botox • Synagis • Growth Hormones

  39. SmartPA • Prior Authorizations handled by SmartPA • Antiemetic • Topical Vitamin A • Orfadin • Revlamid • Revatio • Nutritional Supplements • Oxycodone

  40. Contact Numbers Maryland Medicaid: (410) 767-1755 Eligibility Services: (800) 226-2142

  41. Breast and Cervical Cancer Diagnosis and Treatment (BCCDT)

  42. BCCDT Program Specific Information BIN 610084 PCN DRDTPROD Group ID MDBCCDT Provider ID NCPDP ID Number Federal Tax ID Prescriber ID DEA Number Recipient ID BCCDT Recipient ID

  43. Copays / Dispensing Fee BCCDT Recipients do not have copays Dispensing fee structure: • BRAND products = $2.69 • Generic Products = $3.69 • Partial Fill dispensing fee will be paid ½ at the initial fill and ½ at the completion fill

  44. Generic Mandatory • BCCDT has a generic mandatory program in place. • The system will deny brand drugs when a generic is available with NCPDP Reject 22 (M/I Dispense As Written/DAW code) when submitted as Brand Medically Necessary (DAW = 1). • The system will accept the following Dispense as Written (DAW) values (NCPDP field 408-D8): • 0 - default, no product selection • 1 - Physician request • 5 - Brand used as generic

  45. Coordination of Benefits / Medicare D • BCCDT will cost avoid for Medicare D recipients • Providers are required to ensure COB claims for Medicare D to contain “77777” in the Other Payer ID (NCPDP field 340-7C). • The Other Payer ID is not required for non-Medicare D carriers

  46. Coordination of Benefits / Copay Only Rules for copay only claim submission: • $60.00 maximum on all copay only claims. Amounts greater than $60.00 will have to be approved by BCCDT • BCCDT will pay copays for PAC (plan 930 - formerly MPAP) recipients only if claims contain an "8" in NCPDP field 308-C8, Other Coverage Code. • The system will reject PAC claims (plan 930) where the Other Coverage Code is not equal to ‘8’ (Copay Only) with reject code edit 70 (Drug Not Covered) and the message text “BCCDT Only Reimburses Co-payments – Please bill PAC

  47. Coordination of Benefits / Copay Only The following fields must be populatedwhen submitting a copay only claim: • Other Coverage Code (308-C8) = 8 • Other Amount Claimed Submitted Count = 1 • Other Amount Claimed Submitted Qualifier = 99 • Other Amount Claimed Submitted = copay amount and must equal the amount in Gross Amount Due • Gross Amount Due = copay amount and must equal the amount in the Other Amount Claimed Submitted • **No COB Segment is submitted with a Copay only claim.

  48. Coordination of Benefits / QMB • BCCDT will pay coinsurance for QMB recipients (plan 910) if claims contain an other coverage code of 3 or 4 for Med-B covered drugs only. • QMB recipients (plan 910) have pharmacy coverage except for drugs covered by Medicare B such as Xeloda- then BCCDT pays only denied claims. Pharmacies then must bill Medicare and then Medicaid and BCCDT will be the payer of last resort for coinsurance. • The system will reject QMB claims (plan 910) where the Other Coverage Code is not equal to ‘3-4’; the response will contain reject code edit 70 (Drug Not Covered) and the message text “BCCDT Only Reimburses Non-Covered Medicare B covered drugs"

  49. Coordination of Benefits / Medicare B ACS will deny COB claims for Medicare B recipients (plan 980) if the Other Coverage Code is not equal to ‘2’ with edit 41 (bill other insurance) and the message text: “Bill Medicare B“.

  50. Drug Coverage OTC drugs are generally not covered except for the drug listed in the grid in your pharmacy provider Manual.

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