DC PBM Compound Training

1. DC PBM Compound Training June 24, 2009 and June 30, 2009

2. Overview • Introductions • DC Compound Coverage • DC DHCF Payer Specifications • Multi-Line Compound Claim Guidelines • IV and TPN Compound Submission • Paper Claim Compound Submission • Compound Reimbursement • Questions?

3. Introductions • ACS Atlanta Staff • Karen Crowley • Louise Gustafson • Daniel Shackelford, PharmD • ACS DC Staff • Wallene Bullard, PharmD • Patricia Sims, PharmD

4. DC Compound Coverage • Provider Manual • http://www.dcpbm.com • Section 5 - Compounds • 5.1 Multi-Line Compound Claim Submission • 5.2 IV Compound Submission and Dispensing Fee • Section 6 - Paper Claim (Note: Pharmacies have 181 days from the first Date of Service (DOS) to submit an original claim. The timely filing rules apply to both POS andpaper claims.) • Universal Claim Form

5. DC DHCF Payer Specifications • 7.1 - NCPDP Version 5.1 Payer Sheet • Claim Segment (Ø7) • Field 4Ø6-D6 - Compound Code • Ø = Not specified • 1 = Not a compound • 2 = Compound • 42Ø-DK - Submission Clarification Code • Ø8 = Process compound for Approved Ingredients • This allows payment for covered ingredients and ignores non-covered ingredients

6. DC DHCF Payer Specifications (cont.) • 7.1 - NCPDP Version 5.1 Payer Sheet • Compound Segment (1Ø) • Field 45Ø-EF - Compound Dosage Form Description Code * • Ø3 = Cream • Ø4 = Suppository • 11 = Solution • 12 = Suspension • 451-EG - Compound Dispensing Unit Form Indicator • 1 = Each • 2 = Grams • 3 = Milliliters * Some examples only - not inclusive of all valid values

7. DC DHCF Payer Specifications (cont.) • 7.1 - NCPDP Version 5.1 Payer Sheet • Compound Segment (1Ø) • Field 452-EH - Compound Route of Administration * • 4 = Injection • 7 = Mouth/Throat • 11 = Oral • 17 = Topical • Field 447-EC - Compound Ingredient Component Count • Field 488-RE - Compound Product ID Qualifier Ø3 = National Drug Code (NDC) • Field 489-TE - Compound Product ID (NDC) • Field 448-ED - Compound Ingredient Quantity * Some examples only - not inclusive of all valid values

8. Multi-Line Compound Claim Guidelines • Compounds submitted with compound code = 2 must contain more than one ingredient • Multi-line compounds are adjudicated line by line • If one or more ingredients are denied, the entire compound will deny • Submit “Submission Clarification Code” = “Ø8” to allow processing of covered ingredients • To request PA of non-covered ingredients, contact Help Desk at (800) 273-4962 or fax PA form to (866) 535-7622 • Compounds exceeding $125.00 require UCF submission

9. IV and TPN Compound Submission • IV compound claims are determined by submitting a medication with an IV route of administration • All IV compounds require prior authorization for submission (POS and Paper) • Without PA claims will reject with NCPDP Reject Code 70 – Product/Service Not Covered • Compounds containing an ingredient in Therapeutic Class C5B are classified as TPN claims

10. Compound Reimbursement

11. Paper Claim Compound Submission • When submitting paper claim forms, DC DHCF requires the use of the NCPDP Standard Universal Claim form. • Paper claims are required for compound claims over $125.00. • Paper Claims should be sent to the ACS Call Center at the address below: ACS P.O. Box 967 Henderson, NC 27536 Attn: Paper Claims Processing

12. Sample Compound Claims

13. Sample Compound Claims

14. Sample Compound Claims

18. Questions?