# Presentation: 547706

## ePharmacy - Advanced 

- ePharmacy - Advanced
- (Million Dollar Baby)
- VEHU 2007

## ePharmacy Faculty

- Greg Laird
- Judy Petersen
- Janet Graham

## ePharmacy Objectives

- By the end of today’s session you’ll be able to...
- Understand how ePharmacy processes CMOP and Local Mail Out transactions
- Realize the importance of ePharmacy messages
- Be aware of the OPECC ECME User Screen
- Recognize the significance of the ePharmacy parameters and reports
- Know how to find ePharmacy resources

**Notes:**
Here is the list of topics we will be discussing
We will provide an overview of the current ePharmacy menu, and how to identify ePharmacy prescriptions.
We will go over the resolution of e-Pharmacy Rejects
Then discuss the Date of Service issue and CMOP Functionality
We will go over important aspects of Electronic Claims Management Engine Set-up
We will have a brief review of the ECME User Screen
We will provide an Update on how automation systems interface with ePharmacy and
List some current Challenges and Enhancements

## Overview

## e-Pharmacy Overview

- e-Pharmacy is the **real-time** processing of electronic prescription claims from VistA to Third Party Payers
- Electronic processing of third party claims is a HIPAA requirement
- ePharmacy transactions only take place when Veteran has Prescription Insurance **and** Rx is billable
- Payers provide an immediate adjudicated response
- Claim is marked payable or rejected
- Average response time ~18 seconds

**Notes:**
1. e-Pharmacy is one of the new e-business initiative enabling real-time electronic claims processing.  As many as 10% of the veterans we treat nationwide have third party Rx coverage and we can get back some of our pharmacy expenses by billing their third parties
2. HIPAA established national standards for electronic claims processing through the National Council for Prescription Drug Programs (NCPDP).  Since these rules went into effect many third parties will no longer accept paper claims
3. With ePharmacy we send real-time electronic claims messages to third parties via VISTA, and
4. The process shortens the time it takes to get reimbursed
5. Another benefit is we receive immediate feedback on a veteran’s Pharmacy insurance coverage but
6. Keep in mind that the insurance and billing sections will be responsible for entering and updating cardholder information

## e-Pharmacy Overview

- Staff Pharmacists resolve Drug Utilization Review (DUR) or Refill Too Soon (RTS) rejects
- ePharmacy claims for CMOP and Local Mail Outs processed as part of background job
- DUR & RTS rejects from this process are sent to *Third Party Payer Rejects - Worklist* for resolution by ePharmacy Site Manager
- Revenue Staff responsible for resolving **all other** rejects
- Insurance Verifiers responsible for maintaining Veteran insurance information

**Notes:**
1. e-Pharmacy is one of the new e-business initiative enabling real-time electronic claims processing.  As many as 10% of the veterans we treat nationwide have third party Rx coverage and we can get back some of our pharmacy expenses by billing their third parties
2. HIPAA established national standards for electronic claims processing through the National Council for Prescription Drug Programs (NCPDP).  Since these rules went into effect many third parties will no longer accept paper claims
3. With ePharmacy we send real-time electronic claims messages to third parties via VISTA, and
4. The process shortens the time it takes to get reimbursed
5. Another benefit is we receive immediate feedback on a veteran’s Pharmacy insurance coverage but
6. Keep in mind that the insurance and billing sections will be responsible for entering and updating cardholder information

## ePharmacy - Under the Hood

- Processing Window Fills

## Processing Window Fills

**Notes:**
The processing of Window fills takes place in real time.
Each Rx is evaluated by the ePharmacy software to see if they can be processed by e-Pharmacy and sent to the appropriate Third Party Payer. (Rx is billable, Patient has insurance with pharmacy coverage, Insurance matched & activated for e-Pharmacy)

## Window Fill - Payable

**Notes:**
The third party payer adjudicates the claim and provides a real-time response that tells whether the claim is PAYABLE or REJECTED.

## Window Fill - PayableRx Label Prints

**Notes:**
An Rx Label prints when a claim comes back as payable.

## Window Fills Transmission

**Notes:**
The process repeats for the next ePharmacy billable prescription.  The claim goes to the third party payer.

## Window Fill – RejectedReason – Invalid Ins, NDC, Days Supply, etc.

**Notes:**
In this example the claim rejected.  It could be because the patient’s Insurance ID is invalid or the payer considers the NDC to be invalid, or the plan will not reimburse for 90-day fills.

## Window Fill – RejectedReject to OPECC / Rx Label Prints

**Notes:**
These rejects are placed on the OPECC’s ECME User Screen for resolution.  There is no reason to hold up the prescription, so the Rx label prints.

## Window Fills Transmission

**Notes:**
The process repeats for the next ePharmacy billable prescription.  The claim goes to the third party payer.

## Window Fill – RejectedReason – Refill Too soon or DUR

**Notes:**
In this example the claim rejects for reason that has to be resolved by the Pharmacy.  The rejects will be for a DUR or a Refill Too Soon.

## Window Fill – Rejected Reject to User’s screen / NO Rx Label Prints

**Notes:**
Since these rejects may impact patient safety, the Rx label will NOT print.
Since this is a real-time window fill, the reject is sent to the Pharmacist’s screen to be resolved.

## Window Fill – Rejected Reject resolved / Rx Label Prints

**Notes:**
Once the reject is resolved, in most cases, the claim is automatically resubmitted and returned as payable.
The Rx label prints.

## ePharmacy - Under the Hood

- Processing CMOP Fills

## CMOP Transmissions

- Before e-Pharmacy Activated

**Notes:**
We’ll start be showing the CMOP Transmission process BEFORE ePharmacy is activated.

## CMOP Transmission Processbefore e-Pharmacy

**Notes:**
The CMOP application gathers the prescriptions that are ready to be transmitted.

## Prescriptions transmitted to CMOP

**Notes:**
Then they transmit.  

## CMOP Transmissions

- After e-Pharmacy Activated

**Notes:**
Now we’ll show the CMOP Transmission process AFTER ePharmacy is activated.
It’s a tad more complicated.

## e-Pharmacy Steps added to CMOP Transmission process

**Notes:**
The CMOP application gathers the prescriptions that are ready to be transmitted.

## e-Pharmacy evaluation occurs on Prescriptions

**Notes:**
Then the Rx’s get evaluated by the ePharmacy software to see if they can be processed by e-Pharmacy and sent to the appropriate Third Party Payer. (Rx is billable, Patient has insurance with pharmacy coverage, Insurance matched & activated for e-Pharmacy)

## Payers adjudicate e-Pharmacy claims

**Notes:**
Only ePharmacy billable prescriptions are sent to payers.
Statistics from sites who are actively using ePharmacy show approximately 3% of all prescriptions are billable through ePharmacy.

## Wait Time built in to process

**Notes:**
The CMOP software now has a wait-time built in to allow for payer responses to come back before the transmission to CMOP.
The wait time consists of 15 seconds per Rx  (In this example we have 4 e-Pharmacy claims so we multiply 4 times 15 for 60 seconds.  Then we add an additional 60 seconds (this is a fixed value).  
In this example the software waits 120 seconds for a response from the payer.  This is necessary because of the volume of CMOP claims being processed.

## Prescription #1 is Non-BillableRx sent to CMOP

**Notes:**
In order to show the various ways an Rx could be evaluated – we will discuss 6 different prescriptions.  2 will be not be billable through e-Pharmacy, the other 4 will be e-Pharmacy billable.

Let’s look at how each Rx is processed.

Rx #1 is non billable – either the patient isn’t insured or the insurance is not active for e=Pharmacy.  It gets transmitted to CMOP.

## Prescription #2 is PayableRx sent to CMOP

**Notes:**
Rx #2 is adjudicated as a payable claim. The prescription is transmitted to CMOP.

## Prescription #3 Non-Billable (Null DEA)Rx sent to CMOP

**Notes:**
Rx #3 the Drug’s DEA Special Hdlg field was null (empty).  This  Rx is not billable so the system transmits the Rx to CMOP.

## Prescription #4 No Payer Responsee-mail sent to Key holders / Rx kept in CMOP queue

**Notes:**
For Rx #4 there is no payer response - even after waiting 120 seconds.  It could be because the network or payer system is busy.  An e-mail message is sent to the holders of the PSXMAIL security key and the Rx goes back into the CMOP queue. 

## Prescription #5 Rejected – Invalid NDCReject sent to OPECC / Rx sent to CMOP

**Notes:**
Rx #5 the Rx is rejected for an invalid NDC.  The reject goes on the ECME User Screen for the OPECC to resolve.  The Rx gets transmitted to CMOP.  We don’t hold up Rx’s because of invalid NDCs or any other reject that is processed by the OPECC.

## Prescription #6 Rejected – Refill Too SoonReject sent to Third Party Reject Worklist

**Notes:**
For Rx #6 the Payer sends back a Refill Too Soon reject.  The reject goes on to the Pharmacy Third Party Payer Reject Worklist to be resolved by the e-Pharmacy Site Manager.  

## Recap – Status of Six Prescriptions

**Notes:**
Now do a quick recap on each Rx processed.

Rx #1 is non billable – either the patient isn’t insured or the insurance is not active for ePharmacy.  It was transmitted to CMOP.
Rx #2 is payable. The Rx transmitted to CMOP
Rx #3 the Drug’s DEA Special Hdlg field was null (empty).  This  Rx is not billable.  The Rx transmited to CMOP.
Rx #4 there was no payer response. Since we don’t know if there could be a DUR for this Rx, the Rx goes back into the CMOP queue. 
Rx #5 the Rx is rejected for an invalid NDC.  The reject goes on the ECME User Screen for the OPECC to resolve.  The Rx gets transmitted to CMOP. 
Rx #6 generated a Refill Too Soon reject.  The reject goes on to the Pharmacy Third Party Payer Worklist to be resolved by the e-Pharmacy Site Manager.  The Rx will not be sent to CMOP until the reject is resolved.

4 Rx’s got transmitted to CMOP – one’s in the CMOP queue and one’s on the Worklist. 

## CMOP Transmission Today +1

**Notes:**
It’s the next morning. We finally got a response from the payer for Rx #4 that says the claim is payable.  The Rx remains in the CMOP queue.
When the CMOP transmission runs later today, Rx #4 gets transmitted to CMOP.

## CMOP Transmission Today +1

**Notes:**
The Rx/reject on the worklist gets processed.  The e-Pharmacy Site Manager determines the resolution is the Change the Suspense Date to the date specified in the Payer Message.  It’s CMOP Transmission date +3.

## CMOP Transmission Today +2

**Notes:**
Today is CMOP Transmission date +2.
Rx #6 remains in the CMOP queue because it cannot be processed until T+3.

## CMOP Transmission Today +3

**Notes:**
Today is CMOP Transmission date +3.
Rx #6 gets processed out of the CMOP queue.  The Payer adjudicates the claim as payable.  The Rx gets transmitted to CMOP.

## NDC Change - CMOP

- Rx Activity Log        Jul 26, 2007@12:54:19          Page:    4 of    6 ECME, Patient One  PID: ###-##-####               Ht(cm): 175.26 (03/14/2007)  DOB:                                Wt(kg): 67.91
- ECME Log:                                                                       #   Date/Time           Rx Ref          Initiator Of Activity                   ========================================================================1   6/25/07@19:18:06    REFILL 3        RPH,ONE P                          Comments: Submitted to ECME:CMOP TRANSMISSION(NDC:00006-0072-31)                2   6/25/07@22:21:34    REFILL 3        POSTMASTER                              Comments: Submitted to ECME:CMOP RELEASE(NDC:00378-3151-93)
- Enter ?? for more actions                                             Select Action:Next Screen//

**Notes:**
Sometimes the NDC chosen when the prescription is transmitted to CMOP changes as the result of the CMOP fill.
Checking the ECME Activity Log when viewing a prescription will display this information  

## Final Recap – Six Prescriptions

**Notes:**
Now do a final recap on how each Rx processed.

Rx #1 is non billable – either the patient isn’t insured or the insurance is not active for ePharmacy.  It was transmitted to CMOP.
Rx #2 is payable. The Rx transmitted to CMOP
Rx #3 the Drug’s DEA Special Hdlg field was null (empty).  This  Rx is not billable.  The Rx transmitted to CMOP.
Rx #4 the payer response was payable. The Rx transmitted to CMOP.
Rx #5 the Rx is rejected for an invalid NDC.  The reject goes on the ECME User Screen for the OPECC to resolve.  The Rx gets transmitted to CMOP. 
Rx #6 The reject was resolved when the e-Pharmacy Site Manager changed the suspense date.  On T+3, the claim was resubmitted to the payer, came back payable and the Rx transmitted to CMOP.

## Local Mail Label Print before ePharmacy
Local Mail Label Print after ePharmacy
 1st Step
 Wait Time
 2nd Step

- Local Mail Label Print after ePharmacy
-  1st Step
-  Wait Time
-  2nd Step

- Local Mail

**Notes:**
Now lets look at how Local mail outs get processed.

## Local Mail Label Printbefore e-Pharmacy

**Notes:**
The Outpatient Pharmacy application gathers the prescriptions that are ready for labels to be printed.
Then they print.

## Local Mail Label Printafter e-Pharmacy – 1st step

**Notes:**
After ePharmacy is activated, The Outpatient Pharmacy application gathers the prescriptions that are ready for their labels to print.
Then the Rx’s get evaluated by the ECME & IB software to see if they can be processed by e-Pharmacy and sent to the appropriate Third Party Payer.
As with the CMOP this example shows the various ways an Rx could be evaluated – we will discuss 6 different prescriptions.  2 will be not be billable through e-Pharmacy, the other 4 will be e-Pharmacy billable Rxs.

## Local Mail Label Print - Wait Time

**Notes:**
Just like the CMOP processing, Outpatient Pharmacy software has a wait-time built in to allow for payer responses to come back before the label prints.
The wait time consists of 15 seconds per Rx  (n this example we have 4 e-Pharmacy claims so we multiply 4 times 15 for 60 seconds.  Then we add an additional 60 seconds (this is a fixed value).  
In this example the software waits 120 seconds for a response from the payer.  This is necessary because of the volume of claims being processed.

## Prescription #1 is Non-BillableRx sent to Label Printer

**Notes:**
Now let’s look at how each Rx is processed.

Rx #1 is non billable – either the patient isn’t insured or the insurance is not active for ePharmacy.  The label prints.

## Prescription #2 is PayableRx sent to Label Printer

**Notes:**
Rx #2 is payable. The label prints.

## Prescription #3 Non-Billable (Null DEA)Rx sent to Label Printer

**Notes:**
Rx #3 the Drug’s DEA Special Hdlg field was null (empty).  This  Rx is not billable and the label prints.
Do I detect a pattern here?

## Prescription #4 No Payer ResponseNo e-mail sent / Rx kept in Suspense queue

**Notes:**
Rx #4 there is no payer response - even after waiting 120 seconds.  It could be because the network or payer system is busy. the Rx goes back into the Suspense queue. 

## Prescription #5 Rejected – Invalid NDCReject sent to OPECC / Rx Label prints

**Notes:**
Rx #5 the Rx is rejected for an invalid NDC.  The reject goes on the ECME User Screen for the OPECC to resolve. The label prints.
We don’t hold up Rx’s because of invalid NDCs.

## Prescription #6 Rejected – Refill Too SoonReject sent to Third Party Reject Worklist

**Notes:**
Rx #6 Payer sends back a Refill Too Soon reject.  The Rx/reject goes on to the Pharmacy Third Party Payer Worklist to be resolved by the e-Pharmacy Site Manager.  

## Recap – Six Local Mail Prescriptions

**Notes:**
Labels printed for 4 Rx’s– one’s in the suspense queue and one’s on the Worklist.  

## Pull from Suspense Today +1

**Notes:**
We finally get a response from the payer for Rx #4 that says the claim rejected for a DUR.  The Rx remains in the CMOP queue and the reject goes to the Third Party Payer Reject Worklist.

## Process RTS Reject Today +1

**Notes:**

The Rx/reject on the worklist gets processed.  The e-Pharmacy Site Manager processes the Refill Too Soon reject first.  
The resolution is to change the Suspense date to the date provided by the Payer.  The Rx is placed in the Suspense queue. 

## Process DUR Reject Today +1

**Notes:**

The e-Pharmacy Site Manager processes the DUR reject next.  It is determined this patient is now taking a medication prescribed by an outside physician that could cause a Drug-Drug Interaction.  The VA physician is consulted and a decision is made to discontinue the VA med.  The Rx is DC’d.  

## Pull from Suspense Today +2

**Notes:**
On Suspense Today +2  Rx #6 – the Refill Too Soon reject – remains in the suspense queue.  It cannot be processed until the new suspense date T+3.

## Pull from Suspense Today +3

**Notes:**
On T+3, Rx #6 gets processed out of the Suspense queue.  The Payer adjudicates the claim as payable.  The Rx Label prints.

## Final Recap – Six Local Mail Rxs

**Notes:**
One final recap.
One Rx was DC’d and a patient safety issue handled thanks to a DUR returned by a payer.
The labels printed for the remaining 6 prescriptions.

## ECME User Screen

## ECME User Screen

- Select ECME Option:
-    U      ECME User Screen
-    MGR    Pharmacy ECME Manager Menu ...
-    RPT    Pharmacy Electronic Claims Reports ...
- Select ECME Option: **U**  **ECME User Screen**
- Please wait...

**Notes:**
The ECME User Screen is normally used by the OPEC to resolve rejects.  ePharmacy Site Managers may have access to the option to do research.
The ECME User Screen contains more information about each individual claim and provides information on all rejects for all reasons.
Sometimes prescriptions reject for Invalid Days Supply and other reasons in addition to RTS or DUR reasons.  The ECME user screen can reveal information about the specific sequence and timing of the rejects, and how they may have impacted a prescription fill.
It can also be used to determine if there are overall claims transmission problems and whether they a related to a specific payer etc.

## PHARMACY ECME               Jun 05, 2007@14:15:12         Page:    1 of    6 
SELECTED DIVISION(S): ALL
Transmitted by ALL users       Activity Date Range: within the past 7 day(s)   
                                                        Sorted by: Insurance
#  PATIENT/DRUG/COMMENTS     INSURANCE/NDC/RX#/ECME#          LOC/TYP RXINF
1  ONE,ECME PATIENT (XXXX)   AETNA PH/800 238-6279   *Done* Pb:0 Rj:6 AcRv:0 RjRv:0 
  1.1   HYDROCHLOROTHIAZIDE 50  65243-0040-09  51413205C$  3/9631034 C RT ACT/RL
      Rejected                                                                  
      54:Non-Matched Product/Service ID Number                                  
      To dispute this claim, call 1-800-238-6279 for forms and instructions     
  1.2   OMEPRAZOLE 20MG SA CAP  62175-0118-43  51513913A$  3/9631038 C RT ACT/RL
      Rejected                                                                  
      70:Product/Service Not Covered                                            
      RX not covered- consider Prilosec OTC. To dispute this claim, call 1-800-2
      38-6279 for forms and instructions                                        
  1.3   SIMVASTATIN 40MG TAB    00006-0749-82  51399898C$  3/9631040 C RT ACT/RL
      Rejected                                                                  
      76:Plan Limitations Exceeded                                              
+         Enter ?? for more actions
CU  Continuous Update   REV Reverse Payable Claim    	FR  Further Research
UD  Display Update      RES Resubmit Claim        	PD  Print Data
CV  Change View         CLO Close Rejected Claim  	LOG Print Claim Log
SO  Sort List           CMT Add/View Comments     	EX  Exit
Select Action: Next Screen//

- SELECTED DIVISION(S): ALL
- Transmitted by ALL users       Activity Date Range: within the past 7 day(s)
-                                                         Sorted by: Insurance
- _#  PATIENT/DRUG/COMMENTS     INSURANCE/NDC/RX#/ECME#          LOC/TYP RXINF_
- 1  ONE,ECME PATIENT (XXXX)   AETNA PH/800 238-6279   *Done* Pb:0 Rj:6 AcRv:0 RjRv:0
-   1.1   HYDROCHLOROTHIAZIDE 50  65243-0040-09  51413205C$  3/9631034 C RT ACT/RL
-       Rejected
-       54:Non-Matched Product/Service ID Number
-       To dispute this claim, call 1-800-238-6279 for forms and instructions
-   1.2   OMEPRAZOLE 20MG SA CAP  62175-0118-43  51513913A$  3/9631038 C RT ACT/RL
-       Rejected
-       70:Product/Service Not Covered
-       RX not covered- consider Prilosec OTC. To dispute this claim, call 1-800-2
-       38-6279 for forms and instructions
-   1.3   SIMVASTATIN 40MG TAB    00006-0749-82  51399898C$  3/9631040 C RT ACT/RL
-       Rejected
-       76:Plan Limitations Exceeded
**+         Enter ?? for more actions**
- CU  Continuous Update   REV Reverse Payable Claim    	FR  Further Research
- UD  Display Update      RES Resubmit Claim        	PD  Print Data
- CV  Change View         CLO Close Rejected Claim  	LOG Print Claim Log
- SO  Sort List           CMT Add/View Comments     	EX  Exit
- Select Action: Next Screen//

- ECME User Screen

**Notes:**
The User Screen contains a lot of information. You can reference the ECME User Manual, Section 5 starting on page 11, in the future.
Starting at the top:  This section is the Header and outlines the Current View of the User Screen.  It displays the date/time of when the screen was built, page status, selected division(s), user and activity date range. 	
	Division:  All divisions are being viewed on this screen.  If one particular division is being viewed, that name willed be displayed.
	Transmitted by:  Currently All users will be displayed.  

The middle section displays information about the patient and prescription.  

The first line is the Patient Summary Information which displays the patient’s name, patient last four, insurance company and phone, claim progress status and a summary status of all claims submitted for this patient.  

This example the patient name is ONE,ECME PATIENT and the last four are (XXXX).  Aetna is the insurance company.  The claim progress status is “Done”. The claim progress is displayed in increments from 0% to 100%, at which time the system displays “done” as the status.
	For a complete listing of progress statuses refer to the ECME User Manual on page 16.  

The summary status codes are next: 
		Pb = Payable  - There are 0 payable listed.
		Rj = Rejected – There are 6 rejects
		AcRv = Reversal Accepted – There are 0 accepted reversals.
		RjRv = Reversal Rejected – There are 0 rejected reversals.

The next line after the patient information is the Prescription lines.  An ECME transaction is sent to the payer for each billable refill.  Each billable refill will be displayed as a separate line in the User Screen.  Each line gives:
	drug name – This example is Hydrochlorothiazide
	NDC – Which is 65243-0040-09
	Rx# - Which is 51413205C
	refill# - This is the 3rd refill for this drug.
	ECME # - 9631034
	Fill location – C = CMOP
			 M = Local Mail
			W = Window Fill
		This Rx was filled at CMOP.  
	Bill Type – BB = Backbill
			RT = Real Time Fill – Notice this claim was submitted real time.
	Rx Status – ACT = Active Rx – This example is an active Rx.  Other abbreviations you may see are:
			DIS = Discontinued Rx
			SUS = Suspended Rx
	Release Status – NR = Rx NOT Released
			RL = Rx Released.  This Rx is released.

The next line on this sample is the response returned by the payer.  The payer returned Rx 1.1 with a reject code of 54.  Another common response is Payable.  For the complete list of responses refer to the ECME User Manual on page 17.

The bottom section lists the options available in the ECME User Screen.  In addition to the options listed, other List Manager options are available (i.e. search, first screen, last screen, etc.)

## ECME User Screen – Sort List

- CU  Continuous Update   REV Reverse Payable Claim    	FR  Further Research
- UD  Display Update      RES Resubmit Claim        	PD  Print Data
- CV  Change View         CLO Close Rejected Claim  	LOG Print Claim Log
**SO  Sort List**           CMT Add/View Comments     	EX  Exit
- Select Action: Next Screen//**SO Sort List**
- Select one of the following:
-           T         TRANSACTION DATE
-           D         DIVISION
-           I         INSURANCE
**          **C         REJECT CODE
-           P         PATIENT NAME
-           N         DRUG NAME
-           B         BILL TYPE (BB/RT)
-           L         FILL LOCATION
-           R         RELEASED/NON-RELEASED
-           A         ACTIVE/DISCONTINUED
- ENTER SORT TYPE: I// **C ** **REJECT CODE**
-      Select one of the following:
-           Y         YES
-           N         NO
- DO YOU WANT TO SAVE THIS VIEW AS YOUR PREFERRED VIEW (Y/N)?: N
- Updating screen...

**Notes:**
These are the different sort options.  The list will be sorted with the same like items listed together.  (i.e. If you sort by Reject Code, it will group the rejects together by reject code (i.e. all Reject 19’s will be listed together before going to the next reject.)  One thing to keep in mind is if multiple rejects are listed for the same Rx, it will sort by the first reject listed. If you sort by patient name, all Rx’s for the same patient will be listed together. 

## ECME User Screen 

- _PHARMACY ECME                 Jun 05, 2007@15:06:36          Page:    1 of   7 _
- SELECTED DIVISION(S): ECME DIVISION
- Transmitted by ALL users        Activity Date Range: within the past 5 day(s)
-                                                           Sorted by: **Reject Code**
-  _#  PATIENT/DRUG/COMMENTS       INSURANCE/NDC/RX#/ECME#            LOC/TYP RXINF_
- ---- Reject code: **19:M/I Days Supply** ------------------------------------------
**1**   ECME, PATIENT ONE (YYYY) CAREMARK/800 345-5413   *Done* Pb:0 Rj:2 AcRv:0 RjRv:0
-   **1.1**   MINOCYCLINE HCL 50MG C  00093-3165-01  51293352C$  3/9555018 C RT EXP/RL
-       Rejected
-       76:Plan Limitations Exceeded
-       **19:M/I Days Supply**
-       Maximum Days Supply of 60               RX IS OVER ONE YEAR OLD
**  ****1.2**   LEVOTHYROXINE NA (SYNT  00074-9296-19  51293349C$  3/9558187 C RT ACT/RL
-       Rejected
-       76:Plan Limitations Exceeded
-       **19:M/I Days Supply**
-       Maximum Days Supply of 60
**2**   ECME, PATIENT TWO  (ZZZZ) AETNA PH/800 238-6279   *Done* Pb:0 Rj:4 AcRv:0 RjRv:0
**+         Enter ?? for more actions**
- CU  Continuous Update     	REV Reverse Payable Claim 		FR  Further Research
- UD  Display Update        	RES Resubmit Claim        		PD  Print Data
- CV  Change View           	CLO Close Rejected Claim  		LOG Print Claim Log
- SO  Sort List             	CMT Add/View Comments     		EX  Exit
- Select Action: Next Screen//

**Notes:**
The number on the left is patient line item.  The 1.1 and 1.2 indicates patient one and prescription one and two.

The Reverse Payable Claim menu option sends a claim reversal request to the insurer for a claim that was returned as “Payable”, “Reversal Rejected” and “Reversal Stranded”.

The next option is Resubmit Claim.  This option sends new or updated data to the insurer for a prescription that was previously submitted.  If the claim was previously “payable” it will send a reversal and then resubmit.  If the claim was previously “rejected” it will send the updated claim without sending a reversal.

The Close Rejected Claim option will be used if a resolution is not available for a rejected claim.  For instance, a carrier does not accept 90 day fills.  The claim rejects as “76: Plan Limitations Exceeded”.  The OPECC cannot resolve this reject and will close the claim to remove it from the User Screen.

## Parameters, Bulletins and Reports

**Notes:**
The next few slides will deal with some ePharmacy related parameters and the processes they control, as well as some important e-mail messages and reports.

## Auto Reversal Process

- It is **critical** to release all billable prescriptions filled in a timely manner
- Otherwise VA may receive payments for prescriptions never filled
- ECME Auto Reverse Parameter defines the number of days the system will wait before the ePharmacy sends a reversal transaction to the payer
- Exceptions
- Prescriptions filled as “given in clinic” should **not be released**.
- The ECME Auto reversal should occur on these Rx’s since we should not bill the third party for these medications.
- ECME Auto Reverse process reverses claims for outpatient prescriptions processed for inpatients
- (example: self-medication programs)

**Notes:**
The ePharmacy software assumes unreleased prescriptions were never filled, so the software Automatically reverses claims for prescriptions that have not been released
This is important from a payment received perspective – if not auto-reversed in a timely manner payment can be received for prescriptions never filled
For this reason it is important to release all billable prescriptions filled
Prescriptions filled to be given in clinic should not be released – since we should not bill the third party for them.  These are billed as part of their clinic visit.
The software Uses the ECME Auto Reverse Parameter setting to determine how many days will elapse before claims will be reversed
The background job will Also reverses claims for outpatient prescriptions processed for inpatients, for example prescriptions filled as part of a self medication programs
Timing for reversal of Inpatient Rxs is not related to Auto reverse parameter – is hard coded at 5 days.  It runs with the nightly background job and looks at Rxs filled 5 days ago.  If the patient has a discharge status the day the program is running, it will not auto-reverse.  If the patient has an inpatient status as of that date, it will reverse he claim.  The inpatient reversal functionality is not fool-proof, but is correct the majority of time and we are provided notices for auto-reversed prescriptions.

## ECME Parameters
Auto-reverse parameter
Can be set for 0-30 days
Most sites set at 4 days
Work with OPECC and Accounts Receivable staff to determine best setting

ECME Timeout
Has to do with the number of seconds transmissions will go on before user is allowed to go to next task
Can be set for 0-30 seconds
Most sites set at 30 seconds

- Auto-reverse parameter
- Can be set for 0-30 days
- Most sites set at 4 days
- Work with OPECC and Accounts Receivable staff to determine best setting
- ECME Timeout
- Has to do with the number of seconds transmissions will go on before user is allowed to go to next task
- Can be set for 0-30 seconds
- Most sites set at 30 seconds

- ECME Parameters

**Notes:**
As mentioned earlier The Auto reverse parameter controls the number days that will elapse before claims are reversed for prescriptions that have not been released.  It can be set for 0-30 days, and most sites have it set at 4 or 5 days.  Get guidance from your OPECC and AR staff to set this to the most appropriate number of days for your facility.
The ECME Timeout has to do with the length of time prescriptions are going to remain in transmission before the user is allowed to proceed to the next VISTA task.  Most Beta sites have this set at 30 seconds.
If the setting is too short, the DUR and RTS rejects will end up for the Releasing RPh to take care of.  Most sites have this set at 30 seconds

## Through Days and Pull Ahead Settings

- Pharmacy parameters control when Rx’s sent to CMOP
- CMOP Thru Days CS Transmission
- CMOP Thru Days Non-CS Transmission
- Days to Pull Suspended CS CMOP
- Days to Pull from Suspense

**Notes:**
The Pharmacy process parameters listed in this slide control when prescriptions are sent to CMOP
The first two are from the CMOP System file (File 550).  They are:
CMOP Thru Days for Controlled Substance prescriptions Transmission
CMOP Thru Days Non-CS Transmission
The next two are from the Outpatient Site file (File 59).  They are:
Days to Pull Suspended CMOP Controlled Substance prescriptions and
Days to Pull from Suspense

## CMOP Thru Days Parameters

- CMOP Thru Days CS Transmission
- CMOP Thru Days Non-CS Transmission
- Daily process identifies all Prescriptions in the Suspense file with Fill dates that fall within X days in the future for transmission to CMOP.
- Parameters allow time for prescriptions to be transmitted, processed and mailed to a patient.
- Each can be set for 0 to 10 days

**Notes:**
Taking the CMOP Thru Days parameters first:
These control the daily process that identifies prescriptions for transmission to CMOP.  All Prescriptions in the Suspense file with fill dates that fall within the selected number of days in the future will transmit. These parameters allow time for prescriptions to be transmitted, processed and mailed to a patient.  
Note that the number of days entered in these parameters apply to all divisions.  (Individual sites cannot set thru days for their divisions.)

## Outpatient Days to Pull Parameters 

- Days to Pull Suspended CS CMOP
- Days to Pull from Suspense
- Used to find additional prescriptions for the patients identified by the CMOP Thru Days process. The purpose is to help minimize mailing costs.
- Each can be set for 0-10 days

**Example:**
- Patient One has 3 prescriptions identified by the CMOP Thru Days process.  The system now looks to see if Patient One has additional prescription will Fill Dates X days in the future to add to the CMOP Transmission.  (X = the division’s Days to Pull number)

**Notes:**
The two Outpatient site parameters control the days for a process that finds additional prescriptions for the patients identified by the CMOP Thru Days process. 
It goes back through the patients from the list created from the CMOP pull, and pulls any additional prescriptions within the time frame specified.
Of course the purpose is to help minimize mailing costs. 
These parameters are different from the CMOP file parameters in that each division can specify the Days to Pull Parameters for their division.

## Why are these parameters important?

- The pull ahead parameters have an impact on the Date of Service used on an e-Pharmacy claim.
- We don’t recommend changing your parameters initially
- Remember, e-Pharmacy prescriptions will be a small percentage of your total suspended prescription volume.
- Changing parameter sessions can be *considered* if you see a **significant** number of RTS rejects

**Notes:**
The reason why we mention this is pull-ahead settings that go way into the future can possibly create more Refill too Soon rejects
However We don’t recommend changing your parameters initially
Remember, e-Pharmacy prescriptions will be a small percentage of your total suspended prescription volume.  
Changing these parameter sessions can be considered if you see a significant number of RTS rejects.
We have also found that there is a tendency for VA fill dates to align with 3rd party fill dates over time so this may help diminish the impact of pull ahead. 

## Pull Ahead Settings at Six ePharmacy Sites

**Notes:**
As you can see from this slide there is a Wide variation in settings but all these sites are making things work.

## ePharmacy Bulletins

## CMOP Not Transmitted Message

- Subj: ePharmacy - CMOP Not TRANSMITTED Rx List  [#55657173] 07/24/07@18:44
- 15 lines
- From: POSTMASTER  In 'IN' basket.   Page 1  *New*
- --------------------------------------------------------------------------
- The prescriptions listed below are third party electronically billable.
- They have not been transmitted to CMOP because they have been submitted to
- third party payer but we have not received a response regarding these
- prescriptions yet. The prescriptions will remain in the CMOP queue to be
- transmitted in the next transmission if the response from the third party
- payer has been received.
- Division: ECME TEST
- -------------------------------------------------------------------------------
- RX#/Fill      PATIENT(LAST4SSN)        DRUG                      FILL DATE
- -------------------------------------------------------------------------------
- 52593020A/0   ECMEpatient,One(0000) FORMOTEROL FUMARATE 12MCG Jul 29, 2007
- Total ECME TEST: 1 Patients and 1 Prescriptions.
- Enter message action (in IN basket): Delete//

- Bulletin sent to users who hold the PSXMAIL security key.

**Notes:**
We get these messages when the claims transmissions time out when the prescriptions are pulled to be sent to CMOP
They go to anyone who holds the PSXMAIL key
They usually are nothing to be concerned about unless you see the same ones recurring, or get 10 or more of them in one day.  
If you get many more than normal it could be a sign of a problem in the CMOP claims transmission process.

## Auto-Reversal e-Mail Message

- Subj: ECME AUTO-REVERSAL PROCESS  [#55682790] 07/09/07@01:00  12 lines
- From: BPS PACKAGE  In 'IN' basket.   Page 1  *New*
- ---------------------------------------------------------------------------
- The ECME Nightly Process completed auto-reversals for the following e-Pharmacy prescriptions.
- TOTAL AUTO-REVERSED CLAIMS: 3
- Claims Auto-Reversed on 07/09/06:
-  #    RX     FILL  STATUS FILL DATE PATIENT                   BPS PHARMACY
- ---------------------------------------------------------------------------
-  1 987654321   1   W/RL  07/03/07   TEST,PATIENT ONE           ECME 2 TEST
-  2 123456789C  2   C/NR  07/14/07   TEST,PATIENT TWO           ECME TEST
-  3 787878787   1   M/RL  07/03/07   TEST,PATIENT THREE         ECME 2 TEST
- ---------------------------------------------------------------------------
- Enter message action (in IN basket): Delete//

- Bulletin sent to members of the G.BPS OPECC mail group

**Notes:**
This slide shows the first of three auto-generated VISTA e-mail messages that can be helpful.
This informs you of any ePharmacy prescriptions that have been auto-reversed, either because they were not released, or they were found to be inpatients.
The message information provides the Rx#, the fill# for the Rx, the routing, fill date, patient name and Pharmacy.
A user must be enrolled in the G.BPS OPECC mail group to get these messages
It is important for ePharmacy site managers to get these, since the action that needs to be taken, e.g. Medication Release, will be Pharmacy’s.
You sometimes find prescriptions that were filled and are billable but were never released.
You also find prescriptions reversed for inpatient reasons that were really not the case.
The majority of the prescriptions on the list are sent back because of delays in CMOP filling, and you usually do not take any action on these.
Your focus here will be on the window and local mail fills.

## RX Not Processed

- Subj: RX not processed for site ECME TEST VAMC  [#4757272] 07/01/07@12:53
- 11 lines
- From: BPS PACKAGE  In 'ECME' basket.  Automatic Deletion Date: Aug 30, 2007
- Page 1  *New*
- ------------------------------------------------------------------------------
- Prescription 4150294 and fill number 0 could not be processed because the
- previous request was in progress.  There may have been a delay in processing
- of the previous claim or the previous claim may be stranded.
- For more information on this prescription's activity, please view the
- ECME log within the View Prescription (VP) option on the Further Research (FR)
- menu of the ECME user screen.
- Patient Name: ECMEpatient,One
- Last four digits of SSN: 0000

- Bulletin sent to members of the G.BPS OPECC mail group

**Notes:**
Users usually get the Rx Not Processed message when the HL7 link is down or the third party processor is not receiving transmissions.
These go to the G.BPS OPECC group, as well as to the initiator of the activity that prompted the message, e.g. the prescription finisher, so you may get inquiries from staff about these.

## ePharmacy Reports

## Claims Submitted, Not Yet Released Report

-                *************************************************
-                *Electronic Claims Management Engine (ECME) V1.0*
-                *                ECME TEST DIV                  *
-                *           Claim Results and Status            *
-                *************************************************
-    PAY    Payable Claims Report
-    REJ    Rejected Claims Report
-    ECMP   CMOP/ECME Activity Report
-    REV    Reversal Claims Report
-    **NYR    Claims Submitted, Not Yet Released**
-    REC    Recent Transactions
-    DAY    Totals by Date
-    CLO    Closed Claims Report
- Select Claim Results and Status Option: **NYR**

**Notes:**
This slide just shows the location of the unreleased report just discussed.  
It is found in the Claims Results and Status section of the ECME reports module.

## Results of Not Yet Released Rx Report

- _DIVISION__	__PATIENT NAME__	__RX#__	__DATE__	__DRUG__	__	__FILL LOCATION_
- ECME TE  ECME,ONE PATI   564477   6/30/07  CITALAPRAM 20MG     M
- ECME TE  ECME,TWO PATI   564544   7/01/07  OXYCODONE 10MG      W
- ECME TE  ECME,THREE PA   564621   7/02/07  DIGOXIN 0.2MG       C
**Other fields, including insurance and reimbursement information, can be printed on this report.**

**Notes:**
This screen shows a report that can be helpful.
The report lists ePharmacy prescriptions that have not yet been released.
It is good for the ePharmacy site manager or designee to look at this report once or twice a week.  
It will forewarn them of Rxs about to be auto reversed because they have not been released.
This report can be automatically queued to run everday.
It is not to be confused with the Outpatient VISTA unreleased report - Released and Unreleased Prescription Report  [PSO RELEASE REPORT] 
The report can help a user identify prescriptions that need to be released

## ePharmacy & Automation

## Automation/OPAI Lessons

- HL7 Complete Message
- Does it exist for the Rx?
- Is the RXD segment correct?
- NDC
- Does the vendor system return the actual NDC?
- Is it an 11-digit number?
- File #52
- Rx released (auto or manual) vs unreleased
- Field 27 (for Original)
- Field 52, Subfield 11 (for Refills)
- Vendor Dispensing Reports

**Notes:**
Sites need to understand how OPAI functions at their respective sites. Don't assume that it works the same way at your site as it does for another site even though you're using the same vendor system.

In some instances, a vendor system may not return an HL7 Complete Message to VistA. This means the Rx has to be manually released. 

Is the information returned in the HL7 Complete Message correct for the various dispensing scenarios encountered at your site? We discovered that the RXD segment was not correct when an Rx or tote was cancelled (i.e., not filled thru Optifill). Consequently, VistA was showing these Rx's as being filled and released when in fact they were not. Additionally, erroneous NDC info was being used to populate/update File 50, Field 32 data (i.e., LAST LOCAL NDC).

As our Phase 1 sites implemented e-Pharmacy an issue with the ScriptPro system was identified. Although the system recorded the actual 11-digit NDC used to fill the Rx, it did not return this NDC in the HL7 Complete Message sent back to VistA. In place of the actual 2-digit segment found at the end of the NDC number, ScriptPro was replacing it with '00' in the last segment and sending that back in the NDC information. ScriptPro is working with sites to correct the issue.

You must look in File #52 to view certain pieces of data returned to VistA via OPAI. It's extremely important to understand that the NDC data reflected in these fields is from the vendor side ONLY if the Rx is auto-released. If the Rx wasn't released thru OPAI, and if you are going to manually release it, you'll have to refer to the actual HL7 Complete Message, a Vendor Report, etc. to obtain the correct NDC info.

## McKesson/Parata Automation

- Working with test sites
- Testing OPAI with McKesson/Parata
- Test ePharmacy with McKesson/Parata + OPAI

**Notes:**
We wanted provide an update on the McKesson/Parata software functionality with regard to ePharmacy.
As you may know implementation has been on hold for these sites because of software issues.
Do the work of Palo Alto the McKesson/Parata software is now functioning with OPAI.
We are currently looking for a McKesson/Parata site that can test ePharmacy

## ePharmacy Challenges & Resources

## Challenges

- Days Supply Rejects
- 90 day fills main issue
- More payers are accepting now
- Invalid NDC rejects
- Main problem is with **re-packager’s NDCs** not being recognized by third parties
- Problems getting Data Management company (First Databank & Medispan etc.) files updated for NDC
- Much progress has been made
- Dispensing units a problem
- Third parties want insulin quantities expressed in ml and inhalers in gms  - VA uses unit of ‘each’
- Temporary fix currently being tested

**Notes:**
One of the big challenges we have had is with days supply rejects.  The days supply problem is mainly a 90 day fill issue but can reject for any days supply over what the third party will reimburse for.  We are not to change our prescription days supplies just to get a claim to go through.
We have had problems with NDC rejects but we are making headway with regard this issue. Main problem is with re-packager’s NDCs not being recognized by third parties.
The dispensing units problem happens when the units of issue we use do not match the NCPDP standard.  For example third parties want insulin quantities expressed in ml and inhalers in gms or ml and we use a unit of ‘each’.  We will be fixing that in the next iteration of the software.

## Challenges (continued)

- Billing Tricare and ChampVA
- These claims use a cost plus fee billing structure
- VA will not dispense Rx if claim not payable
- Working on requirements for a future enhancement
- Patient inquiries and concerns
- Patients know their copays are reduced by monies collected from third party
- Third Parties send EOBs to the patient providing the status of the claim, e.g., Invalid NDC
- Patient may have to make a VA copayment  when they previously did not have to when a paper claim was submitted for the same drug
- Patients sometimes call Pharmacy about third party processing questions

**Notes:**
Point one here affects the sites that bill Tricare and ChampVA for prescription fills.  We currently cannot do this, but it is on the list of enhancements to be discussed.
New patient inquiries to the Pharmacy have developed with ePharmacy.   This is because  Patients know their copays are reduced by monies collected from third party. Third Parties also send Explanation Of Benefits to the patient providing the status of the claim, e.g., Invalid NDC.  Patient may have to make a VA copayment  when they previously did not have to when a paper claim was submitted for the same drug, for example if the claim rejected because of days supply or NDC reasons.

## Educational Resources

- ePharmacy User Support Calls – VANTS  82429
- 2nd & 4th Monday of each month @ 11 am Eastern
- VistA University – ePharmacy Training Page
- _[http://vaww.vistau.med.va.gov/VistaU/e-bp/e-pharmacy.htm](http://vaww.vistau.med.va.gov/VistaU/e-bp/e-pharmacy.htm)_
- Live Meeting Sessions
- e-Pharmacy Checklists
- Show-Me videos
- ePharmacy Simulation Training located on VA Employee Education System On-Line Learning Website
- _[https://](https://vaww.ees.aac.va.gov/librix/loginhtml.asp?v=librix)__[vaww.ees.aac.va.gov/librix/loginhtml.asp?v](https://vaww.ees.aac.va.gov/librix/loginhtml.asp?v=librix)__[=](https://vaww.ees.aac.va.gov/librix/loginhtml.asp?v=librix)__[librix](https://vaww.ees.aac.va.gov/librix/loginhtml.asp?v=librix)_
- OI&T Project Website
- _[http://](http://tspr.vista.med.va.gov/warboard/anotebk.asp?proj=699&Type=Active)__[tspr.vista.med.va.gov/warboard/anotebk.asp?proj](http://tspr.vista.med.va.gov/warboard/anotebk.asp?proj=699&Type=Active)__[=699&Type=Active](http://tspr.vista.med.va.gov/warboard/anotebk.asp?proj=699&Type=Active)_
- VISN POCs

**Notes:**
1. We have listed some web sites and contact information here for reference purpose. We encourage to access these and learn as much as you can.
2. Send a message to the VHA ePharmacy Implementation Team if you need to know your VISN POC
3. Call me as well – Greg Laird 785 350 4540

##     Questions?