# Presentation: 944005

## RPMS POS – Introduction to Point of Sale Billing

- Christina Harris
- Administrative Pharmacy Technician
- Claremore Comprehensive Health Center
- April 2007

## Key Components to Using RPMS POS

- Coordinated effort: Business Office, IT, Pharmacy
- Best – “hire or assign pharmacy biller”
- Having the necessary menus/keys
- Network participating agreements
- Staying current with software patches
- Drug file clean-up
- Patient registration

## POS Basics

- References: _[ftp://](ftp://ftp.ihs.gov/rpms/POS/)__[ftp.ihs.gov/rpms/POS](ftp://ftp.ihs.gov/rpms/POS/)__[/](ftp://ftp.ihs.gov/rpms/POS/)_
- Current patches:
- POS v1 patch 19
- Patch 20 which includes the NPI’s is currently in the internal testing phase and should release prior to the May 23rd deadline.
- Patient Reg v7.1 patch 1
- RPMS Support Desk: _[rpmshelp@ihs.gov](mailto:rpmshelp@ihs.gov)_

## ftp://ftp.ihs.gov/rpms/POS/

## POS DAILY TASKS

- Stranded claim report
- Rejection report
- Working on rejections
- Update patient registration information
- Obtain new insurance contracts

## Stranded Claim Report

- POS/RPT/CLA/STR
- START WITH START TIME: FIRST//
- If there are stranded claims; resubmit via POS Claims Data Entry Screen (User Screen)

**Select Claim results and status Option: str  List possibly stranded claims**
**    ****START WITH START TIME: FIRST//**
**DEVICE:   Virtual**
**CLAIMS WHICH MIGHT BE STRANDED                 JAN 16,2007  08:20    PAGE 1**
**        ****NUMBER  PATIENT               INSURER               LAST UPDATE**
**--------------------------------------------------------------------------------**
**          ******* NO RECORDS TO PRINT *****
**Press ENTER to continue:**

## Rejected Claim Report

- POS/RPT/CLA/REJ
- Enter selected date range
- START WITH RELEASED DATE:
- GO TO RELEASED DATE:

- POS REJECTED claims for prescriptions RELEASED on JAN 7,2007        01/16@08:40
- CLAREMORE   NCPDP (NABP) #3711062   Medicaid #100231960I
- LINCS RX ELECTRONIC/BCBS   Help Desk:(918)560-3388
- Trans. Date/Time    Claim ID              Presc/Fill            NDC Number
- Cardholder ID       Group Number         Qty  $billed
-                     **** DEMO PATIENT
- JAN  7,2007  14:50  P07-610435-100082     `2566404/3            49884059410
-   880431705           1400                90   123.51  ENALAPRIL 20MG TAB
-          EXCEEDED 0034 DAYS SUPPLY.
-          76:Plan Limitations Exceeded

## Working on Rejections

- It is recommended to work rejections on a daily basis.
- A majority of insurers only accept claims for 30 days which limits the time to obtain the necessary information in order to fix certain rejections.
- Once you have cleaned up the rejection report based on your facilities load of rejections you may be able to work on these on a weekly basis in order to allow time for other POS matters.

## Obtaining Insurance Contracts	

- In order to continue to collect you will need to obtain or renew contracts with insurers.
- This should be done after the current insurers have been worked and are billing appropriately.
- IHS facilities will obtain contracts directly from the insurer and then forward to area office for signatures and finalization.
- Tribal facilities can obtain their own contracts for their particular site without the help of area office.

## Claremore Experience - Organizing the Pharmacy Billing Program	

- Background
- Implemented RPMS POS in August 2001
- 80% of claims were rejected
- Hired a support assistant to do billing in August 2004
- In a matter of months we were able to increase pharmacy billing collections from $22,000/mo to $48,000/mo
- We are now collecting approximately $60,000/mo

## Items Needed

- Prepare a folder/binder with information that you will use frequently.
- Payer Formats
- NCPDP Reject Codes
- DUR Reject Codes
- DAW codes – for over-rides
- NCPDP fields – for over-rides
- Insurance Setup
- SUMI Report – POS report
- Survey of Insurers – POS report
- Processor User Manuals

## RPMS Menus used for Pharmacy Billing

- POS-Pharmacy Point of Sale
- BILL-Rx Point of Sale Billing Menu
- U – Pharmacy POS User Menu
- RPT-Pharmacy Electronic Claims Report
- Patient Registration – eligibility information
- Third Party Billing – used to enter new insurers and adding group numbers
- Accounts Receivable (A/R) – posting claims
- Outpatient Pharmacy package – prescriptions are entered and edited in this package.  VIEW RX is useful to view the prescription.

## Become Familiar with Insurers

- Know the plan limitations for POS insurers.
- Make a spreadsheet of the electronic claim insurers which include:
- Quantity/Day Supply limits
- Drugs that require a prior authorization
- Work with the pharmacy to dispense the appropriate amount in order to maximize collections.
- Medicaid patients it’s also important to know your high cost drugs.
- Ex: Advair, Singulair, etc.

## POS REPORTS

- These reports should be available when linking an insurer to POS format
- Know the RPMS Insurers that are set to transmit via POS
- POS / RPT / SET / SUMI
- Review Rx Priority Points

## SUMI Report

- PHARMACY ELECTRONIC CLAIMS INSURERS            MAY 17,2006  01:17    PAGE 1
-                                                                  Grace    Ins.
-                                                       Disp Fee     Per    Sel.
- Insurer                         Pricing Formula       Override  Override  Pts.
- --------------------------------------------------------------------------------
-         =====   DIAL OUT to: ENVOY DIRECT VIA T1 LINE
-            ----- Using electronic FORMAT: ADVANCE RX MGT SILVERSCRPT 5.1
-                                                BIN: 004336
- D-SILVERSCRIPT                  STANDARD                                          650.00
-  ----- Using electronic FORMAT: EXPRESS SCRIPTS 5.1
-                                        BIN: 003858
- BENEFIT PLANNERS, INC.      STANDARD                                            5.00
- EXPRESS SCRIPTS,INC.          STANDARD                                           20.00
- EXPRESS SCRIPTS                  STANDARD                                            20.00
-            ----- Using electronic FORMAT: GEHA 5.1
-                                                BIN: 610014
- GEHA/RX                               STANDARD                                               20.00
-  ----- Using electronic FORMAT: PAID 5.1
-                                      BIN: 610014
- PAID PRESCRIPTIONS, L.L.C.      STANDARD                                       20.00
- PAID PRESCRIPTIONS, INC.        STANDARD                                        20.00

## Linking the Insurer to POS format

- Need the following:
- Name of insurer (from Business office or SURVEY by INSURER report
- POS Format Name – to determine, need to know:
- BIN & PCN
- Look up on POS Master list
- If not found, look on Emdeon web site

## Survey by Insurer

## Three Steps to Link POS format

**POS / MGR / SET / INS / **
-                  *       PHARMACY POINT OF SALE V1.0        *
-                   *                                          *
-                   *  Edit Pharmacy POS Insurance settings    *
-                   ********************************************
-    SYS    Insurance selection parameters (system-wide)
-   1.  **INS    Quick setup of insurer**
-   2. **ADV    Advanced setup of insurer**
**   ****3. RPMS   Enter/edit RPMS Insurance file RX settings**
-    SUMI   POS Setup - Summary of Insurers

## POS selection of Insurance

- Not affected by Patient Registration package sequencing
- Selection criteria:
- Base points
- Rules among private insurers
- Points for particular insurers (POS / MGR / SET / INS / ADV)
- Insurer added most recently to patient registration record

## Calculate Points

- Assume base points have not been adjusted.  However, it would be good to verify.
- INS BASE PRVT: 900//
- INS BASE CAID: 600//
- INS BASE CARE: 300//
- INS BASE RR: 300//
- INS BASE SELF: 100//

## Insurer Points

- Extra points for specific insurers
- POS / MGR / SET / INS / ADV
- Rx Priority Points
- Insurer name used for Medical and Pharmacy Claims – 5 points
- Insurer name used only for Pharmacy claims – 20 points
- Medicare Part D insurer - >600 points; recommend 650 points if Medicare Part D is primary

## Calculate Points

- Select INS RULE ORDER: 20//
-   INS RULE ORDER: 20//
-   INS RULE NAME: POLICY HOLDER IS SELF//
-   INS RULE POINTS PLUS: **10//**
-   INS RULE POINTS MINUS:

## Calculate Points

- ----- Using electronic FORMAT: MEDICARE PARTD RXSOLUTIONS 5.1
-                                      BIN: 610097
- D-PACIFICARE SAVER              STANDARD                                  650.00
-            ----- Using electronic FORMAT: NATIONAL PHARM SVCS 5.1
-                                      BIN: 004758
- NATIONAL PHARMACEUTICAL SER     STANDARD
-            ----- Using electronic FORMAT: PAID 5.1
-                                      BIN: 610014
- GOVERNMENT EMPLOYEES HOSP ASSN  STANDARD                                  5.00
- MERCK-MEDCO RX SERVICES         STANDARD                                  20.00
- MEDCOHEALTH                     STANDARD                                  20.00

## POS Format - Definition

- Built into the POS software
- Designed from Payer Sheet
- Includes: BIN, PCN, help desk phone number, the type of provider number that will be transmitted (DEA versus Medicaid), the number of claims per transaction.
- Group number
- Format name is usually the same as the Emdeon Plan name.

## Emdeon Web Site

## Example of Payer Sheet

## Example of Insurance Card

## Slide 28

## Medicare Part D – Getting Started

- 1. Enter Insurers (use recommended naming convention, i.e. D-PLAN NAME) in 3PB Table Maintenance Insurer File.
- 2. Tie Medicare Part D POS format to appropriate Insurer
- 3. Enter patient with Medicare Part D in Patient Registration
- Determine duel-eligible members
- Can Run E1 to determine BIN, PCN & Group number which correlates to a Plan Name.
- 4. Backbill 180 days

## Using the Eligibility Check (E1)

-                   ********************************************
-                   *       PHARMACY POINT OF SALE V1.0     *
-                   *           Pharmacy electronic claims reports       *
-                   ********************************************
-    CLA    Claim results and status ...
-    SET    Setup (Configuration) reports ...
-    SURV   Surveys of RPMS database ...
-    **ELIG   Medicare Part D Eligibility Check**
-    OTH    Other reports ...

## Eligibility Check (E1)

- Generate eligibility chk (Med Part D) for which patient? DEMO PATIENT
-                                         M 04-20-1940 154459999   WE 59999
**On: **
**Patient Name:     DEMO PATIENT**
**Status:           A**
**Authorization #:**
**Insurance Level:  PRIMARY**
**BIN:           012304**
**PCN:           MPD**
**GROUP:      PDA23  **
**CARDHOLDER ID: 123456789**
**PERSON CODE:   1**
**PHONE NUMBER:  8005551212**

## Medicare Part D formats sorted by Plan

## POS Medicare Part D formats – sorted by BIN

## Entering Information on Page 4 of Patient Registration

## Adding Medicare Part D Plan on page 4

## Completed Patient Reg page 4

## Medicare Part D insurers set up to POS format

- POS / RPT / CLA / MPD
- MPD  TOTALS – MEDICARE PART D INSURERS
- Any insurers/plans listed on this report are tied to a format that is “tagged” as Medicare Part D.
-      PAYABLE      ADJUSTED      PAPER       REJECTED    RX CNT
- -------------------------------------------------------------------------------
- -------------------------------------------------------------------------------
- D-PACIFICARE SAVER
-            283.10        77.87         0.00                0.00         6
- -------------------------------------------------------------------------------
- D-PRESCRIPTION PATHWAY
-             15.54         5.01           0.00               10.75         2

## Medicare Part D - KEY HANDOUTS ON FTP SITE

- General Instructions for Billing Medicare Part D Using RPMS POS
- Patient Registration Instructions (Addendum) for patch 1 – PDF file
- POS Formats SORT BY PLAN
- POS Medicare Part D Formats – SORTED BY BIN
- Setting up POS Format – Medicare Part D

## Medicare Part D – Helpful Suggestions

- Use Plan Names as Insurer Names
- Eg. D-Silverscript versus Caremark
- Do NOT enter Person Code on page 4 of Patient Registration
- ALWAYS tie a Medicare Part D format to the insurer.
- Medicare Part D formats have been altered to send 1 claim for each transaction, as required.  Commercial formats send 4 claims at a time.
- POS Medicare Part D report only works if the Medicare Part D formats are used.

## Medicare Part D – Helpful Suggestions

- ALWAYS add Priority Points – recommend at least 605; 650 preferred.
- To verify Part D plans are set up correctly:
- Send a copy of SUMI report (POS / RPT / SET / SUMI) to OIT help desk at _[support@ihs.gov](mailto:support@ihs.gov)_
- It will be reviewed and feedback will be provided.
- Use the E1 – a good tool verify what plan the patient is enrolled in.

## SUMI Report

**PHARMACY ELECTRONIC CLAIMS INSURERS            MAY 17,2006  01:17    PAGE 1**
**                                                                 ****Grace    Ins.**
**                                                      ****Disp Fee     Per    Sel.**
**Insurer                         Pricing Formula       Override  Override  Pts.**
**--------------------------------------------------------------------------------**
**        ****=====   DIAL OUT to: ENVOY DIRECT VIA T1 LINE**
**           ****----- Using electronic FORMAT: ADVANCE RX MGT SILVERSCRPT 5.1**
**                                               ****BIN: 004336**
**D-SILVERSCRIPT                  STANDARD                                          650.00**
** ****----- Using electronic FORMAT: EXPRESS SCRIPTS 5.1**
**                                       ****BIN: 003858**
**BENEFIT PLANNERS, INC.      STANDARD                                            5.00**
**EXPRESS SCRIPTS,INC.          STANDARD                                           20.00**
**EXPRESS SCRIPTS                  STANDARD                                            20.00**
**           ****----- Using electronic FORMAT: GEHA 5.1  **
**                                               ****BIN: 610014**
**GEHA/RX                               STANDARD                                               20.00**
** ****----- Using electronic FORMAT: PAID 5.1**
**                                     ****BIN: 610014**
**PAID PRESCRIPTIONS, L.L.C.      STANDARD                                       20.00**
**PAID PRESCRIPTIONS, INC.        STANDARD                                        20.00**

## Common Rejections and how to Correct Them

## POS Rejections

- Before printing your rejections report it is always important to run the URM Report (update report master file).
- If you are running the report for the first time I would suggest going back for 365 days.
- POS/RPT/CLA/URM

## Rejection Codes

- Rejection codes are NCPDP standard codes used by processors.
- Complete list of rejection codes is located on the ftp site (NCPDP folder)
- M/I = Means Missing/Invalid
- All the rejection codes can by found on the ftp site

## Rejection codes

## Rejection codes – Header Segment

- Ø1  M/I Bin
- Ø2  M/I Version Number
- Ø3  M/I Transaction Code
- Ø4  M/I Processor Control Number
- Problem: the wrong format is being used.
- To correct: contact the insurer to determine the correct BIN/PCN.  Use the POS Format Master List on ftp site or Emdeon web site.

## Rejection Code – Patient Segment

- Ø8  M/I Person Code
- Ø9  M/I Birth Date
- 1Ø  M/I Patient Gender Code
- 11  M/I Patient Relationship Code
- 53  Non-Matched Person Code
- Problem: information in insurer’s system is different than what is on page 4 of Patient Registration.
- To correct: call processor pharmacy help desk to determine where discrepancy is.

## Rejection codes – Insurance Segment

- Ø6  M/I Group Number
- Ø7  M/I Cardholder ID Number
- 51  Non-Matched Group ID
- 52  Non-Matched Cardholder ID
- Problem: there is information missing or there is an eligibility issue.
- To correct: check a current card or call the pharmacy help desk.  The phone number is usually on the rejection report.  Once correct in Patient Registration (page 4), the claim can be resubmitted in POS.

## Rejection codes – Claim Segment

- 21  M/I Product/Service ID
- 22  M/I Dispense As Written (DAW)/Product Selection Code
- 28  M/I Date Prescription Written
- 54  Non-Matched Product/Service ID Number
- 55  Non-Matched Product Package Size
- 77 Discontinued Product/Service ID Number
- 78 Cost Exceeds Maximum
- Problem: Pharmacy issue
- To correct: have pharmacy verify the drug is entered correctly in drug file.

## Rejection codes – Claim Segment

- 7Ø Product/Service Not Covered
- 81  Claim Too Old
- Usually uncorrectable

## Rejection codes – Prescriber Segment

- 25  M/I Prescriber ID
- 56  Non-Matched Prescriber ID
- 71 Prescriber Is Not Covered
- Problem: Provider number needs to be verified or format is not submitting correct provider number.
- To solve: If provider number is correct; refer to RPMS Help desk to verify format is correct.

## Rejection Codes - Processing

- 85 Claim Not Processed
- 87 Reversal Not Processed
- 91 Host Response Error
- Problem: claims were not processed
- To correct: try resubmitting claim.  If still not working for several claims, notify RPMS Help Desk.

## Over-rides/Prior Auth

- Prior Authorization Required
- 79 Refill Too Soon
- 76Plan Limitations Exceeded
- 8E M/I DUR/PPS Level Of Effort
- 8Ø Drug-Diagnosis Mismatch
- 88 DUR Reject Error

## Medicare Part D- Rejections

## Rejection – M/I  BIN PCN GroupREJECTION:

- MAR 28,2006  10:20  P06-610468-100173 `1050039/0   12345123412
- 123456789                                    150   185.80 CARBAMAZEPINE
-       04:M/I Processor Control Number
-          06:M/I Group Number
-          01:M/I Bin
- To Correct:
- If commercial plan – contact processor help desk to verify BIN/PCN and group number.
- For Medicare part D plan – try E1

## Rejection – M/I BIN PCN Group

- Patient Name:     DEMO PATIENT
- Status:           A
- Authorization #:
- Insurance Level:  PRIMARY
- BIN:           610468
- PCN:           UAFC
- GROUP:         8310000
- CARDHOLDER ID: 123456789
- PERSON CODE:   1
- PHONE NUMBER:  8006988394

## Rejection – M/I BIN PCN Group

## Rejection – M/I Transaction Code

- Ø3: M/I Transaction Code
- If this is a Medicare Part D insurer, this usually means that a non-Medicare Part D format is being used.  Refer to Part D plans by BIN to find a different POS format.

## Rejection – 85: Claim not processed

- MAR 23,2006  10:00  P06-610459-108961  `104700/1  00093067005
-   0123456                            60    75.74  GEMFIBROZIL 600MG TAB
-          85:Claim Not Processed
-          NN:Transaction Rejected At Switch Or Intermediary
-          98:Connection To Payer Is Down
- These type of rejections are more common with some of the processors with the implementation of Medicare Part D.
- Try Resubmitting the claim – POS / U / EV / 3 – Single Patient / RES

## Rejection – M/I Birth Date

- 09:M/I Birth Date
- Contact processor to determine which birthdate they have in their system.
- For Medicare Part D patients – enter birthdate information on page 4 of Medicare Part D page.
- To over-ride birth date field:
- POS / N / Override / Field 304
- Enter birthdate as: YYYYMMDD

## Helpful Reports

- Reports to run on a daily basis include:
- REJ- which includes all of the rejections. It is good to run this report everyday to stay current with your rejections and prevent a rejection for claim too old.
- POS/RPT/CLA/REJ
- PAP- which includes all claims that were not transmitted electronically. You will use this report to determine which insurers you need a contract for.
- POS/RPT/CLA/PAP

- URM- Once you are finished working on your rejections it is imperative to run the urm to update the dollar figures in your day/ins reports.
- POS/RPT/CLA/URM
- STR-this report will give you a list of all claims that did not complete transmission. If they are within 365 days you can resubmit these on your own if they are over 365 days you will need to contact the RPMS help desk.
- POS/RPT/CLA/STR

## Management Reports

- DAY- totals by release date
- MCD- totals by Medicare Part D insurer
- It is good to run these report on a monthly basis after you have run the URM report.
- They will provide you with the payable, adjusted, and rejected totals for administrative reports.
- If you keep this information in a spreadsheet you can compare the previous months to show your progress at resubmitting rejected claims and backbilling.

## REJ - Rejected claims report

**POS REJECTED claims for prescriptions RELEASED on FEB 9,2001        02/10@04:06**
**SAN FELIPE   NCPDP (NABP) #3209219   Medicaid #B3713**
**MEDICAID EXEMPT   Help Desk:(505)246-9988 opt 3 opt 1**
**Trans. Date/Time    Claim ID              Presc/Fill            NDC Number**
**Cardholder ID       Group Number         Qty  $billed**
**                    ******** DUCK,RONALD**
**FEB  9,2001  11:22  P01-610084-104611     `947794/0             51111048893**
**  ****525340572                               24     4.11  ACETAMINOPHEN 325 MG  TAB**
**70:NDC NOT COVERED**

## REJ - Rejected claims report

**POS REJECTED claims for prescriptions RELEASED on FEB 9,2001        02/10@04:06**
**SAN FELIPE   NCPDP (NABP) #3209219   Medicaid #B3713**
**MEDICAID EXEMPT   Help Desk:(505)246-9988 opt 3 opt 1**
**Trans. Date/Time    Claim ID              Presc/Fill            NDC Number**
**Cardholder ID       Group Number         Qty  $billed**
**                    ******** DUCK,RONALD**
**FEB  9,2001  11:22  P01-610084-104611     `947794/0             51111048893**
**  ****525340572                               24     4.11  ACETAMINOPHEN 325 MG  TAB**
**70:NDC NOT COVERED**

## Rejection Report

- It is recommended to run the rejection report on a daily basis.
- POS/RPT/CLA/REJ
- Enter date range
- Report includes the following:
- NCPDP #, Insurer name, help desk #
- Trans. Date/Time, Clailm ID, Presc/Fill, NDC #
- Cardholder ID, Group #, Qty, $ billed, Patient name
- Reason the claim was not paid

## QUESTIONS?