Point of Sale Pharmacy Billing Basics

1. Point of Sale Pharmacy Billing Basics Christina Brady POS User Support Specialist Office of Information Technology CNI Technology - Contractor Albuquerque, New Mexico

2. Objectives • POS Billing Process • RPMS packages used with POS billing • POS Tips • Current patches • Emdeon • POS Master Format List

4. RPMS Packages Used with POS • Patient Registration – Eligibility Information • Third Party Billing – Enter/Edit insurers and group numbers • Accounts Receivable (A/R) – Posting of Remittance Advice/Explanation of Benefit • Outpatient Pharmacy Package – Enter prescription to process electronically

5. Patient Registration • Patient Registration allows users to add, edit, view, delete, or print information related to their facility’s patient. • Page 1 - Allows the viewing of the patient’s demographic information which is required when calling the processor/insurer. For POS purposes you will need the ability to view this page. • Page 4 - Allows you to add/edit insurers that have been created in table maintenance of TPB to patient’s profile. For POS purposes you will need the ability to view/edit this page.

6. Third Party Billing • The Table Maintenance Menu in TPB allows you to add/edit the Insurer File Menu and the Group Insurance Plans Menu • Adding an insurer in table maintenance • ABM – TMTP – INTM – EDIN – 2 Add New Insurer • Enter the name of your new insurer • Enter the mailing address and phone number of insurer • Insurer Status – “BILLABLE” • Type of Insurer – “PRIVATE” for commercial plans and “MD” for Medicare Part D plans • RX Billing Status – “P” to bill POS, “U” to make unbillable, and “O” for outpatient drugs only

7. Third Party Billing Cont. • Add/Edit a group number in table maintenance • ABM – TMTP – GRTM – EDGR • Enter group name • Do Group Numbers vary – Leave as default of “NO” • Enter Group Number located on card (recommendation to have the group name and number the same) • Example: Group Name: XYZ-RX Group Number: XYZ-RX (the group number is what crosses over on the claim not the group name)

8. Accounts Receivable (A/R) • Payable POS claims and reversals will create a charge automatically in the A/R package through the POS interface to Third Party Billing. • Charges are automatically posted to A/R when: • An electronic claim transaction completes • The insurer indicates that the claim is payable • The insurer indicates that the claim has been “Captured” • Charges that are not automatically posted to A/R are: • Charges for patients without insurance • Charges for patients with insurance, but the insurance can’t be billed electronically • Charges for patients with insurance, but the drug is unbillable • Unsuccessful electronic claims (rejected by the insurance)

9. Outpatient Pharmacy Package • Enter prescription details under patient’s pharmacy profile • Print prescription label to screen or to label printer to start the process of sending the claim to the insurer • Maintain/Update the drug file on a monthly basis

10. Pharmacy Tips • When entering a NEW prescription, a REFILL, or RENEWING a prescription, a “call to bill the claim” is made to the POS package when the label is printed. • The reprinting of a label (REPRINT AN OUTPATIENT LABEL) does not affect the POS software. • CANCELLING a prescription is used when a patient has a drug discontinued for some reason or if the prescription is replaced by another drug of a different dosage or strength. If a prescription is canceled NO call is made to the POS software because the patient received the prescription.

11. Pharmacy Tips • To DELETE a prescription means the prescription is to be marked as not given to this patient. It is used when a prescription was given to a patient by mistake and caught before the patient got it. Using this option causes the POS software to automatically reverse the claim. • RETURN MEDICATION TO STOCK option is to be used when a patient does not pick up a prescription. This process will automatically make a call to the POS to reverse the claim. • You cannot dispense a 90 day supply for a 30. The dispensed amount is to equal the billed amount.

12. Tips for Contacting the Help Desk • Research the claim first it will save time for you and the Help Desk if all the information required to solve the problem is available during the call • Have the pharmacy’s NCPDP or NPI number available. This is normally the first question they ask • The insurer recognizes claims by the internal rx number the one with the ` sign prior to the number displayed on the rejection report or at the end of the claim on the POS user screen

13. Design a Process for Working Rejections • Review rejection report daily • Run URM (POS / RPT / CLA / URM) to clear rejections from report before and after working rejections or running reports • If time is limited, focus on high cost drugs • To maximize collections, involve pharmacists. • The business office and the pharmacy at each facility should decide on a plan of action to optimize the amount of collections received from the rejected claims. This is a joint effort and will take involvement from both departments as well as IT.

14. Current Patch Information • Patient Registration – Version 7.1 patch 3 released nationally 4/17/2007 • Third Party Billing – Version 2.5 patch 15 released nationally 9/25/2008 • Accounts Receivable – Version 1.8 patch 7 released nationally 9/26/2008 • Outpatient Pharmacy – Version 7.0 patch 6 released nationally 6/25/2008 • Point of Sale – Version 1.0 patch 27 released nationally 9/8/2008

15. Master Format List • Nationally used list for all POS Formats • List updated with each patch and sent out on the POS Listserv • Verify bin/pcn combination on master format list to determine the POS Format Name • Sorting Excel sheet by bin, pcn, or format name makes it easier to locate correct plan • Pay attention to comments when selecting a plan

16. Emdeon • When to use Emdeon? • After viewing the Master Format List and not able to find the bin/pcn combination that you need. • Log into website and enter bin or pcn to identify plan needed • Copy and paste plan into an email and send to support@ihs.gov requesting a new format be added to the Master Format Sheet • Login: indianhealth • Password: admin280

17. Q&A