Important Provider Notice: Information Regarding 2015 Medicare Part D Plan Claims Processing
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Catamaran
1600 McConnor Parkway
Schaumburg, IL 60173
Important Provider Notice: Information Regarding 2015
Medicare Part D Plan Claims Processing
Dear Pharmacy Provider:
This notice is provided as a general reference regarding new processing
requirements and program changes for the Part D benefit for 2015. It also
seeks to reinforce already established practices. While C a t a m a r a n s e e k s
t o i n c l u d e a s m u c h a s possible in these notices, it is important to always
refer to the online claims system response at Point of Sale:
Hospice Reminder:
Beneficiaries in Hospice may receive a prior authorization rejection for Analgesics,
Antianxiety, Antiemetics, and Laxatives to determine if the claim should be covered
under the Hospice benefit, Medicare Part D benefit, or fall under the beneficiary’s
liability. Rejected claims return codes A3, 75, 569, and include a custom message with
the phone number to begin the A3 Rejection Override review process.
Pharmacies should to work with hospice providers or prescribers to obtain written
documentation of drugs that are medically necessary but unrelated to the terminal
illness or related conditions. This written documentation should then be sent to the Plan
Sponsor (or Catamaran if review has been delegated) for A3 Rejection Override
review. If the prescriber determines the drug is covered under the hospice benefit, the
pharmacy should submit the claim to the hospice provider identified by the prescriber. If
the prescriber is unable to make that determination, the pharmacy should provide the
standardized pharmacy notice, and advise the beneficiary or prescriber to contact the
Part D sponsor at the telephone number in the secondary message to initiate the
coverage determination request. Pharmacies may also initiate an A3 Rejection override
for members who are no longer in hospice by submitting written documentation to the
Plan Sponsor (or Catamaran if review has been delegated).
Concurrent DUR Medicare Part D Therapeutic Dose Limits Edit Expansion
The Catamaran Therapeutic Dose Limits (THERDOSE) screening within the concurrent
DUR program applies safety edits that minimize the risk of medication
overutilization. The rules monitor for total daily medication use above the FDA approved
maximum dosing across multiple claims at the ingredient level. Currently the
CC061_2015 Call Letter_TeamPlaces/MedicarePartD/ProductLibrary/2014ClientCommunications 1Catamaran standard includes Soft Rejects when a member exceeds the acetaminophen
maximum daily dose, and returns messaging only for several other therapeutic
categories. Effective January 1, 2015, Catamaran will also start rejecting oral diabetes
products (single ingredient and multiple ingredients) that exceed the FDA approved
maximum dosing in order to align with CMS’ Patient Safety Monitoring program for these
products. Pharmacies can override the soft reject to expedite successful adjudication of
THERDOSE rejections (DUR Reject 88) at POS (point-of-sale).
DUR/PPS Codes: (Reason, Professional, and Result Codes)
Pharmacists should use their professional judgment to review and override a THERDOSE
Soft Reject. The pharmacist will need to identify and enter the appropriate DUR/PPS
Reason, Professional, and Result codes for each component. This information is then
collected and used to respond to CMS’ Acetaminophen Overutilization Monitoring
Program cases, and will also be used to review CMS Diabetes Medication Dosage Patient
Safety Reports. If a pharmacist receives this specific type of error (DUR Reject 88), the
following steps should be followed.
1. Review the patient profile to identify why the patient is filling greater than the FDA
approved maximum dose.
2. Consult with the appropriate clinicians and/or the member as needed
3. Based on your clinical judgment, determine if the drug should be dispensed
4. If determined appropriate, override the rejection by identifying and entering the
appropriate Reason, Professional, and Result code for each component.
a. The Reason code below should auto-populate. If not, then use the Reason
Code below of HD (High Dose Alert).
b. Select the appropriate Professional and Result codes from the list provided
under item 2 below.
5. Each component is only allowed to have one code.
The pharmacist will need to identify and enter the appropriate DUR/PPS Reason,
Professional, and Result codes for each component. Appropriate code options are listed
below in sections 1 and 2.
1. Reason for Service Code:
HD High Dose Alert
2. Professional Code Values and Result Code Values:
Professional Description Result Codes Description
Codes
CC061_2015 Call Letter_TeamPlaces/MedicarePartD/ProductLibrary/2014ClientCommunications 2Professional Description Result Codes Description
Codes
M0 Prescriber Consulted 1A Filled As Is,False Positv
M0 Prescriber Consulted 1B Filled Prescription As Is
M0 Prescriber Consulted 1C Filled,Different Dose
M0 Prescriber Consulted 1D Filled,Different Directns
M0 Prescriber Consulted 1F Filled,Different Quantity
M0 Prescriber Consulted 2A Prescription Not Filled
M0 Prescriber Consulted 3C Discontinued Drug
M0 Prescriber Consulted 3D Regimen
Changed
M0 Prescriber Consulted 3E Therapy
Changed
P0 Patient 1A Filled As Is,False Positv
Consulted
P0 Patient 3K Instructions
Consulted Understood
R0 Pharmacist Consulted 1A Filled As Is,False Positv
Othr
R0 Pharmacist Consulted 1B Filled Prescription As Is
Othr
R0 Pharmacist Consulted 1C Filled,Different Dose
Othr
R0 Pharmacist Consulted 1D Filled,Different Directns
Othr
R0 Pharmacist Consulted 1F Filled,Different Quantity
Othr
R0 Pharmacist Consulted 2A Prescription Not Filled
Othr
R0 Pharmacist Consulted 3C Discontinued Drug
Othr
R0 Pharmacist Consulted 3D Regimen
Othr Changed
R0 Pharmacist Consulted 3E Therapy
Othr Changed
CC061_2015 Call Letter_TeamPlaces/MedicarePartD/ProductLibrary/2014ClientCommunications 3The following example illustrates the use of the DUR/PPS codes related to a
THERDOSE edit reject:
• A member presents a prescription for hydrocodone/APAP (10/325mg) with a
quantity = 100 and day supply = 10.
• The pharmacist attempts to process the claim and receives a ‘DUR Reject 88’
(THERDOSE).
• The pharmacist reviews the patient profile and discovers the member recently
filled an oxycodone/APAP (5/325mg) prescription with quantity = 60 and day
supply = 15.
• The overlap of the 2 prescriptions caused the THERDOSE edit to be triggered.
• The pharmacist consults with the prescriber and determines that the
oxycodone/APAP product is being discontinued.
• The pharmacist then enters the appropriate Reason, Professional, and Result codes
and then re-submits the claim.
• In this scenario, an appropriate combination would be as follows:
o HD (High Dose Alert)
o M0 (Prescriber Consulted)
o 3C (Discontinued Drug)
The entering of the above codes resolves the DUR Reject 88 for THERDOSE
NPI/Prescriber Identifier: As a reminder, pharmacies are required to process
prescription claims using the prescriber’s National Provider Identifier (NPI). Prescribers
need to be identified by an individual (Type I) NPI. If a Type I NPI is not used to identify
the prescriber, the claim will reject. To assist pharmacies in complying with this
requirement, if a non-NPI identifier such as a DEA is submitted the claims processing
system will attempt to match that identifier with a Type I NPI. If the submitted
prescriber identifier is inactive or invalid, the claim will reject with the NCPDP reject code
56 or 619. If your pharmacy can document that the NPI is correct and active, please
resubmit the claim with the Submission Clarification Code (SCC) of 42- (Prescriber ID
Submitted has been validated, is active). Every attempt should be made to obtain a
correct prescriber identifier without impacting a beneficiary’s access to drugs. Claims
submitted with SCC 42 will undergo post adjudication review by Catamaran. Claims for
which a prescriber identifier is not found to be valid in a national database source may
result in notifications or warnings, or require claims corrections or reversals. It is required
that all network pharmacy providers utilize and maintain internal processes for the
validation of prescriber information for NPI active status and DEA confirmation of the
schedule levels when applicable to a dispensed product along with appropriate
confirmation of the prescriber’s prescriptive authority for the medication being dispensed.
DEA/Prescriber Identifier for Scheduled II Controlled Substances:
Scheduled II Controlled Substances require a validated DEA number.
CC061_2015 Call Letter_TeamPlaces/MedicarePartD/ProductLibrary/2014ClientCommunications 4Once you submit a valid NPI, Catamaran will attempt to cross walk the submitted NPI to
the DEA number on file.
As DEA numbers can be for an individual or a hospital/institute we will verify the
prescriber’s DEA license category is valid, and appropriate for the drug being prescribed,
especially for narcotic prescriptions. For example, prescribers with a 2N or 3N DEA
license cannot prescribe narcotics. If you receive a reject and believe the prescriber’s
DEA schedule is appropriate for the drug prescribed, you may resubmit the claim using
one of the following NCPDP SCCs in field 420-DK
SCC Description
Code
43 For prescriber ID submitted, associated prescriber DEA Renewed, or
In Progress, DEA Authorized Prescriptive Right
44 For prescriber ID submitted, associated prescriber DEA recently
licensed or re-activated
45 For prescriber ID submitted, associated DEA is a valid Hospital DEA
with Suffix
46 For prescriber ID submitted, and associated prescriber DEA, the DEA
has authorized prescriptive right for this drug DEA Class
Similar to claims submitted with an SCC of 42, claims submitted with SCC 45 will
undergo post adjudication review by Catamaran. Claims for which a prescriber identifier
is not found to be valid in a national database source may result in notifications or
warnings, or require claims corrections or reversals. It is recommended that all network
pharmacy providers utilize and maintain validation of prescriber information for NPI
validation and DEA confirmation of the schedule levels.
Required submission of the Pharmacy Service Type Code & required submission
of the Patient Residence Code:
This Began in 2014 and continues to be enforced in 2015, CMS is requiring valid Patient
Residence and Pharmacy Service Type values. Therefore, claims with a missing or invalid
code will reject at point-of-sale.
Pharmacies must include a valid Patient Residence code on all Part D claims
transactions; however if the patient residence is unknown, these pharmacies may
default to a Patient Residence of 01 (Home). CMS expects that LTC pharmacies, home
infusion pharmacies and specialty pharmacies, since they deliver to the patient
residence, know the patient residence code.
Valid Pharmacy Service Type codes currently include the following values:
CC061_2015 Call Letter_TeamPlaces/MedicarePartD/ProductLibrary/2014ClientCommunications 51- Community/Retail Pharmacy Services;
2- Compounding Pharmacy Services;
3- Home Infusion Therapy Provider Services;
4- Institutional Pharmacy Services;
5- Long Term Care Pharmacy Services;
6- Mail Order Pharmacy Services;
7- Managed Care Organization Pharmacy Services;
8- Specialty Care Pharmacy Services; and
99- Other
Valid Patient Residence codes at this time include:
0- Not specified, other patient residence not identified below;
1- Retail; Home Infusion;
3- Nursing Facility;
4- Assisted Living Facility;
6- Group Home;
9- LTC: Intermediate Care Facility/Mentally Retarded; and
11- Hospice
General Guidance:
Please ensure that your pharmacy:
• Provides the required written appeals notice (CMS 10147) to the Part D member when
prompted by the online transaction response.
• Provides a transition fill, as required when prompted by the online transaction
response. The purpose of a transition fill is to ensure there is no disruption in therapy,
• Routinely screens all new employees against both the OIG and GSA exclusion lists and
again monthly. In addition you must remove all employees, contractors or any party
involved in the delivery of the drug benefit from administering the Medicare Part D
prescription drug benefit if found on this listing.
• Completes the required annual Fraud, Waste and Abuse and Compliance training and
ensures that all new employees, contractors or any party involved in the delivery of
the drug benefit complete this training within ninety (90) days of hire
If you suspect potential Fraud, Waste or Abuse (FWA) is occurring please contact the
Plan Sponsor for the claims transaction or Catamaran at 1-888-625-5685 or email us
at SIU@catamaranrx.com .
Should you have any further questions, please call the Catamaran helpdesk at:
1-800-880-1188.
Thank you,
Catamaran Provider Relations
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