# Presentation: 037890

## e-Pharmacy – Basic Training (Heartbreak Ridge)

- e-Pharmacy – Basic Training (Heartbreak Ridge)
- VEHU 2007

## ePharmacy Faculty

- Greg Laird
- Judy Petersen
- Janet Graham

## ePharmacy Objectives

- By the end of today’s session you’ll be able to...
- Explain why ePharmacy is important to VA
- Understand impact of ePharmacy on Staff Pharmacists
- List the two types of ePharmacy rejects processed by Pharmacy staff
- Comprehend importance of valid NDC data
- Know how to find ePharmacy resources

## Overview / Benefits / Statistics

## 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 (continued)

- 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

## Benefits of e-Pharmacy

- Pharmacy
- Patient Safety enhanced by having Drug Utilization Review (DUR) information on prescriptions filled outside of VA
- Revenue
- Payments received sooner
- Easy to track status of electronic claims
- VACO Program Offices
- Meets HIPAA Mandate for electronic claims processing
- National database of transactions available to analyze and resolve root cause of some rejects

**Notes:**
1. One advantage of the process is that we get back DUR information that can help us with patient safety 
2. We are not going deny a patient their prescription solely because it will not be paid for by his third party, so all prescriptions are filled as normal even if they reject, unless they reject for DUR or Refill Too Soon (RTS) reasons.  For DUR and RTS rejects, labels do not print until the rejects are resolved.
3. The software allows us to monitor the status of claims and
4.  We have been developing the product for over 4 years now.

## Impact on Pharmacy Staff

- Electronic claims are submitted automatically when **billable** prescriptions are filled by Pharmacy
- Pharmacists receive real-time Drug Utilization Review (DUR) and Refill-Too-Soon information from payers when processing _Window Fills_ (at Finish) or when editing certain fields on an Rx.  This allows patient safety issues to be resolved **prior** to Rx release

## Impact on Pharmacy Staff (continued)

- Pharmacists must validate NDCs for manually filled Local prescriptions at Medication Release
- Most automated systems using OPAI validate NDCs in the background
- Rejects from CMOP and those not handled immediately are sent to the ‘*Third Party Payer Rejects - Worklist*‘.  Rejects on the worklist need to be resolved DAILY.
- No active sites have added additional staff to handle e-Pharmacy workload

## e-Pharmacy Workload

**e-Pharmacy  Data from 11 Sites – ****October 2005 – March 2007**

**Notes:**
1.  This chart is from FY2006 data from 11 e-Pharmacy sites.  About 3.4% of all prescriptions filled at those sites were billable through e-Pharmacy.  (Include time period in slide)

## e-Pharmacy Reject Statistics

**e-Pharmacy  Data from 11 Sites – ****October 2005 – March 2007**

**Note: One e-Pharmacy Claim may generate multiple rejects**

**Notes:**
Looking at the total number of rejected claims we see that Refill Too Soon rejects at 4% and and DUR rejects at 1%, are a small percentage of overall e-Pharmacy rejects.

## ePharmacy Statistics – 11 Active Sites Oct 05-Mar 07

- Analysis of the last 18 months for 11 sites
- Number of ePharmacy claims averaged 3.3% of Rx volume
- Combined totals of Refill Too Soon and Drug Utilization Review rejects averaged about 0.2% of total Rx volume
- RTS and DUR rejects for each site averaged 6 per day
- Number of Prescriptions processed averaged 1,122,991 for the 18 month period

**Notes:**
This slide contains data from the 11 sites that processed ePharmacy claims for the entire year of FY2006.  One of these sites were not processing ePharmacy Rxs through CMOP, so that accounts for the lower figures in the ranges
 As was mentioned earlier ePharmacy claims averaged about 3.4% of total prescriptions, and it ranged from 0.3% to 7.4%. 
 When you look at Pharmacy rejects as a percent of total Rx volume, it averages only 0.23%, with the range being 0.03% to 0.7%.
4. The average number of RTS and DUR rejects was 6 per day, with the range from 1 per day up to 12 per day.
5. The prescription volume averaged about 684,000 per year at these sites.
6. If you have not yet implemented you may be able to use these figures to predict how your site will be affected when all payers are activated.  The main variable is how many of your veterans have third party insurance. For example, the site above that averaged 7.2% of claims had the lowest Rx volume of the 11 sites.

## ePharmacy Statistics – 11 Active Sites Oct 05-Mar 07 (continued)

**Notes:**
This slide contains data from the 11 sites that processed ePharmacy claims for the entire year of FY2006.  One of these sites were not processing ePharmacy Rxs through CMOP, so that accounts for the lower figures in the ranges
 As was mentioned earlier ePharmacy claims averaged about 3.4% of total prescriptions, and it ranged from 0.3% to 7.4%. 
 When you look at Pharmacy rejects as a percent of total Rx volume, it averaged only 0.23%, with the range being 0.03% to 0.7%.
4. The average number of RTS and DUR rejects was 6 per day, with the range from 1 per day up to 12 per day.
5. The prescription volume averaged about 1,122,991 per year at these sites.
6. If you have not yet implemented you may be able to use these figures to predict how your site will be affected when all payers are activated.  The main variable is how many of your veterans have third party insurance. For example, the site above that averaged 7.2% of claims had the lowest Rx volume of the 11 sites.

## ePharmacy Time Study – 4 sites

- Average time spent for **all** ePharmacy-related tasks at these 4 facilities was about **30 minutes per day**
- ePharmacy activities include those tasks performed by the ePharmacy site manager & Staff Pharmacists
- ePharmacy site manager spent **20 minutes** per day on ePharmacy tasks
- The 4 sites from this study averaged 612,000 Prescriptions for FY 2006

**Notes:**
1. An ePharmacy time study was performed at the 4 sites listed.  It provided some data on the length of time it takes to perform the essential ePharmacy tasks.
2.  We asked sites to monitor the time spent by the ePharmacy Site Manager or designee.  This is the Pharmacy person that will spend the most time with ePharmacy.
The average time spent on ePharmacy functions by all pharmacy staff averaged about 30 minutes per day per facility.
 The sites in the study averaged about 600,000 total Rx fills per year
 This data will hopefully serve as a start for some DSS workload elements.

## ePharmacy Billing Criteria

## Third Party Billing Rules

- ePharmacy follows federal billing regulations
- The charge is $51/prescription
- Charge is independent of days supply
- Can bill for Rxs for NSC condition – even if patient has greater than 50% SC eligibility
- SC Rxs and Rxs related to Treatment Indicators, (e.g. AO/MST/IR, etc.) are **not** billed
- Patient’s VA Rx copayment is currently reduced by amounts collected from third party

**Notes:**
1. Looking at some billing criteria, we are currently using e-Pharmacy only for claims that follow federal billing regulations.  This means we are not currently transmitting claims for Champ VA or Tricare Rxs, which have a cost plus fee billing charge. 
2.  Federal billing rules currently charge is $51/prescription and
3. Charge is independent of days supply
4. We bill for prescriptions for Non Service Connected conditions, as long as patient’s eligibility status is less than 100% Service Connected.  So even patients with a status of Greater than 50% SC can have prescriptions billed to third parties as long as the prescription itself is not service connected
5. Prescriptions for SC Rxs and Rxs connected to Treatment Indicators such as Agent Orange, Military Sexual Trauma, Ionizing Radiation, are not billed
6. Currently, a patient’s VA copayment is reduced by amounts collected from third party 

## What Drug File Items are Covered

- Third parties generally cover Rx Only items
- OTC items are usually not covered
- Exceptions are OTC Insulins
- Supply Items are usually not covered
- Some plans will cover blood glucose testing strips and other diabetic supplies
- Some plans do **not** cover repackaged drugs
- Sometimes there is NDC specific acceptance of a drug
- e.g. some NDCs for a drug may be OTC and others Rx Only

**Notes:**
1. Third parties generally cover only prescription items
2. OTC items are usually not covered, with the big exception of OTC Insulins
3. Supply Items are also usually not covered, however some plans will cover blood glucose testing strips and other diabetic supplies.
4. We have found that some plans do not cover repackaged products. We are working with the third parties to get them to accept repackaged products, and we have made quite a bit of progress with regard to this.
5. Sometimes you will find NDC specific acceptance of a drug.  In other words some NDCs for a drug may be OTC and others Rx Only.  Examples of drugs that can be both RxOnly and OTC  are clotrimazole cream, diphenhydramines, omeprazole, meclizines.

## DEA, SPECIAL HDLG

- ePharmacy uses DEA, SPECIAL HDLG field values to flag the drug file items that claims will be transmitted for when used in prescriptions
- If this field is **null** for a drug file entry, claims will not transmit
- Entries with any field value **except** M, Ø, I, S, and 9, are transmitted
- If entries with I, S, or 9 also contain the “E” (electronically billable), those prescriptions will transmit
- Entries with an M or Ø will **never** transmit

**Notes:**
1. The DEA, Special Hdlg field in the Drug File (50), is used to control, at the drug file level, whether claims are transmitted.  Since updates are drug specific and not plan or insurance specific, they affect transmissions to all payers.
2. If the DEA, Special Hdlg field in the Drug File (50) is null for a drug file entry, claims will not transmit.  So there has to be a value in the field if you want a claim to transmit.
3.  Entries with any field value except M, Ø, I, S, and 9, are transmitted.  I have included a list of the field choices in the notes section of this slide
4. If entries with I, S, or 9 also contain the “E” (electronically billable), those prescriptions will transmit.
5. However entries with an M or Ø will never transmit.

M – Bulk Compound Items
0 – Mfg in Pharmacy
I - Investigational Drugs
S – Supply Items
9- Over The Counter
6 – Legend Item

## Sensitive Drugs

- US Code of Federal Regulations prevents VA from informing third parties that patients have AIDS, Sickle Cell Anemia, Drug Abuse, or Alcohol Abuse without the patients permission
- Information about this can be found in (VHA Handbook 1605.1, Subpart 14)
- Electronic claims submissions for medications exclusively used to treat those conditions may violate privacy regulations
- Release of Information permissions now obtained and maintained manually – no electronic process at this time

## Sensitive Drugs (continued)

- Interim fix is to place an Ø or M in the DEA, SPECIAL HDLG (3) in Drug File (50) of drugs like lamivudine, naltrexone etc.
- This prevents Rxs for those drugs from transmitting claims
- Software enhancement has been requested to better deal with issue

**Notes:**
The interim fix is to place an 0 or M in the DEA, SPECIAL HDLG (3) in Drug File (50) of drugs like lamivudine, naltrexone etc.
This will prevent Rxs for those drugs from transmitting claims
3. A more permanent software solution will be discussed for Iteration II of Phase 4.  I have attached a list of some of the drugs you might consider updating for this reason to the notes section of this slide.

A partial list of drugs is below:
ABACAVIR	
ABACAVIR300/LAMIVUDINE	
DELAVIRDINE MESYLATE	
DIDANOSINE 400MG	
DISULFIRAM (ANTABUSE)	
EFAVIRENZ	
INDINAVIR SULFATE	
INDINAVIR	
LAMIVUDINE	
LAMIVUDINE /ZIDOVUDINE 	
NALTREXONE	
NELFINAVIR MESYLATE	
RITONAVIR	
SAQUINAVIR (INVIRASE)	
STAVUDINE (d4T)	
TENOFOVIR DISOPROXIL	
ZALCITABINE (ddC)	
ZIDOVUDINE	

## ePharmacy in the Real World

## Greg, VA Pharmacist

- VA Pharmacist working in the Outpatient Area finishing prescriptions.

**Notes:**
Meet Greg. He’s a VA Pharmacist working in the Outpatient area today.

A patient came into my cube and says, “I just came from my doctor’s appointment and she told me she ordered prescriptions for me and to check with Pharmacy”. I signed into my VistA system and sure enough there they were, orders for an antibiotic and a pain pill and some renewals on his maintenance prescriptions.  
I finished the prescription for the antibiotic and counseled him about what he should avoid and how to take it. 
When he’s through I see these strange messages appear across the screen.  

## Clint, VA Patient

- VA Patient picking up meds following a clinic visit.

**Notes:**
Meet Greg. He’s a VA Pharmacist working in the Outpatient area today.

A patient came into my cube and says, “I just came from my doctor’s appointment and she told me she ordered prescriptions for me and to check with Pharmacy”. I signed into my VistA system and sure enough there they were, orders for an antibiotic and a pain pill and some renewals on his maintenance prescriptions.  
I finished the prescription for the antibiotic and counseled him about what he should avoid and how to take it. 
When he’s through I see these strange messages appear across the screen.  

## e-Pharmacy Claim Submission – Window Fill

- # of Refills: 0
-        SC Percent: 10%
-      Disabilities: NONE STATED
- Was treatment for a Service Connected condition? NO
- Is this correct? YES// YES
- Prescription 383404 successfully submitted to ECME for claim generation.
**Claim Status: **
**IN PROGRESS-Waiting to start**
**IN PROGRESS-Waiting for packet build**
**IN PROGRESS-Waiting for transmit**
**IN PROGRESS-Transmitting**
**E PAYABLE **

**Text appears only when finishing a Window fill and Rx is e-Pharmacy billable**

**Notes:**
The message says something about transmitting but they quickly leave the screen, so I go on to the next prescription.  

## Refill Too Soon Reject

**Notes:**
I bring up the next prescription and start to finish it.  I counsel him and right after I answer the last finish question in the computer I see that strange messaging again. This time though, this weird screen pops up.  I was surprised because I had never seen anything like this before.  The screen had all this information about the patient and his prescription and an insurance company and this frightening message in the middle that said... ‘Refill Too Soon’.

## Refill Too Soon Reject (continued)

- Now what do I do?

**Notes:**
Uh oh,  now what do I do?
Luckily I remembered that Judy, one of the other pharmacists, knew about this new thing they call ePharmacy.  Judy is our site manager for this.  I ask the patient to wait a minute while I gave Julie a call. 

Hi Judy, could you come over to my outpatient window.  I am finishing prescriptions for a patient and have a weird message on my computer screen.

## Judy, VA PharmacistePharmacy Site Manager

- Let’s look at the message from the payer...

**Notes:**
Let’s look at the message from the payer and figure out why they say it’s a refill too soon.

## Refill Too Soon Reject (continued)

**Notes:**
Judy:  In the center of the screen you can see reject type is 79 -Refill Too Soon and dated for today.  Right below that is the Payer message.  It says the next refill isn’t payable until a MONTH from now. 

Judy – to the patient:  “ Do you have insurance for prescriptions.”

Patient:  Yes, I have a job downtown with insurance coverage.  I use it for emergency coverage, and comes to the VA for everything else because I thinks the care I receive at the VA is the best.  

Judy:  “Greg – Can you bring up the patient’s medication profile on another VISTA session?  <pause>   “Just as I suspected, there is no indication we filled this prescription recently”.  

Judy – to the patient:  “Our system is telling us you just received this medicine recently, would you have gotten it from another pharmacy?”   
Patient:  “You know, last night when I started feeling bad I called my private doctor.  I think he may have phoned in a prescription for me at the Night Owl pharmacy downtown, but I started feeling better and I never picked it up”.  

Judy:  “I think I know what’s happening.  I’m going to call the Night Owl Pharmacy and asks them if they still have this prescription on the shelf.”   <pause>  “Sure enough they do.”
Patient:  Can you tell them to cancel that prescription? 
Judy: “I’ll tell Night Owl that we will fill our prescription and just cancel the one they have.  We just started billing third parties electronically for prescriptions so this process is new to us.  It should work out well for you though, since any money we get from your insurance will apply to your VA co-pay for this prescription.” 

## Reject Action - Quit

**E REJECTED**
**             ***** REJECT RECEIVED FROM THIRD PARTY PAYER ***
-  ---------------------------------------------------------------------
-  Division: ECME TEST                          NCPDP#:  1098981
-  Patient : 				Sex: M   DOB: (XX)
-  Prescription : 410444/0 AMOXICILLIN 500MG C   ECME#: 1106444
-  Reject Type  : 79 – REFILL TOO SOON on AUG 22,2007
-  Payer Message: Refill Payable on or after 09-19-07
-  Insurance    : CAREMARK                     Contact: 1-555-555-5555
-  Group Name   : XXXXX                   Group Number: XXXXX
-  Cardholder ID: XXXXXXXXX
-  ---------------------------------------------------------------------
**   ****Select one of the following:**
** **
**       ****I  (I)GNORE – FILL Rx WITHOUT CLAIM SUBMISSION**
**       ****Q  (Q)UIT – SEND TO WORKLIST (REQUIRES INTERVENTION)**
** **
**(I)gnore,(Q)uit: // ****Q  Quit**

**Notes:**
Judy to Greg:  Greg, choose the Quit option located at the bottom of the screen.  That sends the reject to the Worklist so I can work on it.  We need to give Night Owl a few minutes to cancel their prescription.  When they cancel their prescription it will reverse the claim to Harry’s third party so we can get our prescription claim to go through. 

## The REST of the story...

- Greg was able to finish processing the rest of the patient’s prescriptions.
- Since the remaining Rx’s were mail-out medications there were no ePharmacy messages on the screen
- Transmission messages display for the pharmacist for third party prescriptions filled locally (Window Fills)
- ePharmacy Transmissions for mail-out prescriptions are not sent to payers until the Rx is pulled from suspense
- Pharmacy has to deal with Refill Too Soon and DUR rejects because they could have **patient safety issues** and other implications

**Notes:**
Since the remaining Rx’s were mail-out medications there were no ePharmacy messages on the screen.
Transmission messages display for third party prescriptions filled locally, 
Pharmacy has to deal with two reject types
79 – Refill Too Soon (RTS)
88 – Drug Utilization Review (DUR)
These rejects could have patient safety issues and other implications.
All other rejects, like invalid Cardholder IDs, are handled on the Billing side by the OPECC  (Outpatient Pharmacy Electronic Claims Coordinator)

## Keep in mind...

- Prescriptions that reject for RTS or DUR will **not be filled/dispensed** until these rejects are resolved
- The label for the patient’s medication will **not print** until the RTS is resolved
- ePharmacy Site Manager must use the ***Third Party Payer Reject Worklist*** to resolve the reject

## Worklist Functionality

- Third Party Payer Rejects - Worklist Option

## e-Pharmacy Menu

- Patient Prescription Processing
-           Barcode Rx Menu ...
-           Complete Orders from OERR
-           Discontinue Prescription(s)
-           Edit Prescriptions
-           **ePharmacy Menu ...**
-           Manual Print of Multi-Rx Forms
-           Reprint an Outpatient Rx Label
-           Signature Log Reprint
-           View Prescriptions
- Select Rx (Prescriptions) Option: **EPharmacy Menu**
-    IR     Ignored Rejects Report
-    MP     ePharmacy Medication Profile (View Only)
-    PF     ePharmacy Medication Profile Division Preferences
-    VP     Third Party Payer Rejects - View/Process
-    **WL     Third Party Payer Rejects – Worklist**
- Select ePharmacy Menu Option: **WL  Third Party Payer Rejects - Worklist**
- You may select a single or multiple DIVISIONS,
- or enter ^ALL to select all DIVISIONS.
- DIVISION: **ECME TEST VA HSRO****     ****111X**    ECME TEST VA
- ANOTHER ONE:  ****** More than one division may be selected**
- Please wait...

**Notes:**
Go over each option of the ePharmacy menu and tell what they do

## Third Party Payer Rejects – Worklist

- _Rejects Processing Screen     Aug 22, 2007@12:07:20       Page:    1 of  2 _
- Divisions: ECME TEST VA
- Selection: ALL UNRESOLVED REJECTS
-   _**# Rx#          PATIENT(ID)[^]           DRUG                 REASON**_
**1  410444  ECMEPATIENT,FOUR (0000) AMOXICILLIN 500MG C 79 :REFILL TOO SO**
**    ****Payer Message: Refill Payable on or after 09-19-07 **
- 2  402269  TEST,PATIENT (0000) MODAFINIL 200MG TAB  79 :REFILL TOO SO
-     Payer Message: BSM:RTS BY 5 DAYS (FILL ON 08/27/07), FOR SIG/DOSING CHANG...
- 3  401296D TEST,PATIENT (0000) METFORMIN HCL 1000MG 79 :REFILL TOO SO
-     Payer Message: BSM:RTS BY 17 DAYS (FILL ON 09/08/07), FOR SIG/DOSING CHAN...
- 4  401268  TEST,PATIENT (0000) CITALOPRAM HYDROBROM 79 :REFILL TOO SO
-     Payer Message: BSM:RTS BY 5 DAYS (FILL ON 08/27/07), FOR SIG/DOSING CHANG...
- 5  401139A TEST,PATIENT (0000) SIMVASTATIN 80MG TAB DUR:DD (DRUG-DRUG
-     Payer Message: 1-LOVASTATIN,SIMVASTATIN/DILTI,DILTIAZEM HCL,DUR REJECT ER..
_**Select the entry # to view or ?? for more actions    **__                    __x_
- DR  Sort by Drug          RE  Sort by Reason       RX  Sort by Prescription
- PA  Sort by Patient       RF  Screen Refresh       GI  Group by Insurance
- Select: Quit//

**Notes:**
How do items get on this worklist
How to sort
How to read

## Expanded WL Entry

_**Reject Information(UNRESOLVED)**__  Aug 22, 2007@12:10:07         Page: 1 of  2 _
- Division : ECME TEST                                NCPDP#: 2354671
- Patient  : (000-00-0000)  Sex: M   DOB:             (XX)
- Rx#      : 410444/0          ECME#: 2628477         Fill Date: Aug 22, 2007
- Drug     : AMOXICILLIN 500MG CAPS                   NDC Code: 0000-0000-01
- _REJECT Information_
- Reject Type   : 79 - REFILL TOO SOON received on AUG 22, 2007@09:11:33
- Reject Status : OPEN/UNRESOLVED
- Payer Message : Refill Payable on or after 09-19-07
- Reason        :
- DUR Text      :
- _INSURANCE Information_
- Insurance     : CAREMARK
- Contact       : 1-555-555-5555
- Group Name    : XXXXX
- Group Number  : XXXXXXXXXX
_**+        Enter ?? for more actions                                        **__**x**_
- VW  View Rx               IGN Ignore Reject       OVR Submit Override Codes
- MP  Medication Profile    RES Resubmit Claim      CSD Change Suspense Date
- Select: Quit//

**Notes:**
Explain this is the expanded Worklist entry for this reject.

<Go to next screens to talk about each section>

## Expanded WL Entry

- _Reject Information__**(UNRESOLVED)**__  Aug 22, 2007@12:10:07         Page: 1 of  2 _
**Division : ECME TEST                                NCPDP#: 2354671**
**Patient  : (000-00-0000)  Sex: M   DOB:             Rx#      : 410444/0          ECME#: 2628477         Fill Date: Aug 22, 2007**
**Drug     : AMOXICILLIN 500MG CAPS                   NDC Code: 0000-0000-01**
- _REJECT Information_
- Reject Type   : 79 - REFILL TOO SOON received on AUG 22, 2007@09:11:33
- Reject Status : OPEN/UNRESOLVED
- Payer Message : Refill Payable on or after 09-19-07
- Reason        :
- DUR Text      :
- _INSURANCE Information_
- Insurance     : CAREMARK
- Contact       : 1-555-555-5555
- Group Name    : XXXXX
- Group Number  : XXXXXXXXXX
_**+        Enter ?? for more actions                                        **__**x**_
- VW  View Rx               IGN Ignore Reject       OVR Submit Override Codes
- MP  Medication Profile    RES Resubmit Claim      CSD Change Suspense Date
- Select: Quit//

**Notes:**
The top section contains the prescription claim information sent to the payer.
Division
Outpatient Pharmacy’s NCPDP or NPI 
Patient’s name, ssn, sex and date of birth
The VA prescription number
The ECME number sent to the payer.  
Fill Date
Drug and NDC

## Expanded WL Entry

- _Reject Information__**(UNRESOLVED)**__  Aug 22, 2007@12:10:07         Page: 1 of  2 _
- Division : ECME TEST                                NCPDP#: 2354671
- Patient  : (000-00-0000)  Sex: M   DOB: JAN 01,1900(XX)
- Rx#      : 410444/0          ECME#: 2628477         Fill Date: Aug 22, 2007
- Drug     : AMOXICILLIN 500MG CAPS                   NDC Code: 0000-0000-01
_**REJECT Information**_
**Reject Type   : 79 - REFILL TOO SOON received on AUG 22, 2007@09:11:33**
**Reject Status : OPEN/UNRESOLVED**
**Payer Message : Refill Payable on or after 09-19-07**
**Reason        :**
**DUR Text**      :
- _INSURANCE Information_
- Insurance     : CAREMARK
- Contact       : 1-555-555-5555
- Group Name    : XXXXX
- Group Number  : XXXXXXXXXX
_**+        Enter ?? for more actions                                        **__**x**_
- VW  View Rx               IGN Ignore Reject       OVR Submit Override Codes
- MP  Medication Profile    RES Resubmit Claim      CSD Change Suspense Date
- Select: Quit//

**Notes:**
The center section contains the reject information returned by the payer.
Reject Type
Reject Status
Payer Message
Reason
DUR Text

## Expanded WL Entry

- _Reject Information__**(UNRESOLVED)**__  Aug 22, 2007@12:10:07         Page: 1 of  2 _
- Division : ECME TEST                                NCPDP#: 2354671
- Patient  : 		(000-00-0000)  Sex: M   DOB:
- Rx#      : 410444/0          ECME#: 2628477         Fill Date: Aug 22, 2007
- Drug     : AMOXICILLIN 500MG CAPS                   NDC Code: 0000-0000-01
- _REJECT Information_
- Reject Type   : 79 - REFILL TOO SOON received on AUG 22, 2007@09:11:33
- Reject Status : OPEN/UNRESOLVED
- Payer Message : Refill Payable on or after 09-19-07
- Reason        :
- DUR Text      :
_**INSURANCE Information**_
**Insurance     : CAREMARK**
**Contact       : 1-555-555-5555**
**Group Name    : XXXXX**
**Group Number  : XXXXXXXXXX**
**Subscriber ID : NNNNNN**
_**+        Enter ?? for more actions                                        **__**x**_
- VW  View Rx               IGN Ignore Reject       OVR Submit Override Codes
- MP  Medication Profile    RES Resubmit Claim      CSD Change Suspense Date
- Select: Quit//

**Notes:**
The bottom section contains the insurance information for the patient.
Name of the Insurance company
Contact phone number
Group name
Group number 
Subscriber ID

## Expanded WL Entry

- _Reject Information__**(UNRESOLVED)**__  Aug 22, 2007@12:10:07         Page: 1 of  2 _
- Division : ECME TEST                                NCPDP#: 2354671
- Patient  : 		(000-00-0000)  Sex: M   DOB:
- Rx#      : 410444/0          ECME#: 2628477         Fill Date: Aug 22, 2007
- Drug     : AMOXICILLIN 500MG CAPS                   NDC Code: 0000-0000-01
- _REJECT Information_
- Reject Type   : 79 - REFILL TOO SOON received on AUG 22, 2007@09:11:33
- Reject Status : OPEN/UNRESOLVED
- Payer Message : Refill Payable on or after 09-19-07
- Reason        :
- DUR Text      :
_**INSURANCE Information**_
**Insurance     : CAREMARK**
**Contact       : 1-555-555-5555**
**Group Name    : XXXXX**
**Group Number  : XXXXXXXXXX**
**Subscriber ID : NNNNNN**
_**+        Enter ?? for more actions                                        **__**x**_
- VW  View Rx               IGN Ignore Reject       OVR Submit Override Codes
- MP  Medication Profile    RES Resubmit Claim      CSD Change Suspense Date
- Select: Quit//

**Notes:**
At the bottom of the screen are the actions that can be performed from this screen.
View Rx
Medication Profile
Ignore Reject
Resubmit claim
Submit Override Codes
Change Suspense Date

## Resubmit Claim

_**+        Enter ?? for more actions                                   **__**s**_
- VW  View Rx             IGN Ignore Reject   OVR Submit Override Codes MP  Medication Profile  **RES Resubmit Claim**  CSD Change Suspense Date
- Select: Next Screen// **RES Resubmit Claim**
- Claim Status:
- IN PROGRESS-Waiting to start
- IN PROGRESS-Waiting for packet build
- IN PROGRESS-Waiting for transmit
- IN PROGRESS-Transmitting
**E PAYABLE**

**Notes:**
The claim is resubmitted – returns as payable.
The label for this medication will print 

## RTS - Change Suspense Date

- Payer Message : BSM:RTS BY 4 DAYS (**FILL ON 08/26/07**), FOR SIG/DOSING CHANGES SUBMIT '05' IN DENIAL OVERRIDE/SUBMISSION CLARIFICATION, LAST FILLED 07/31/07
- Reason        :
- DUR Text      :
- INSURANCE Information
- Insurance     : MEDIMPACT INCORPORATED
- Contact       : 1-555-555-5555
- Group Name    : XXXXXXXX
- Group Number  : NNNNN
**+         Enter ?? for more actions**_**                                   **_
- VW  View Rx               IGN Ignore Reject       RES Resubmit Claim
- ED  Edit Rx               OVR Override Reject     **CSD Change Suspense** **Date**
- Select: Next Screen// **CSD   Change Suspense Date**
- SUSPENSE DATE: AUG 22, 2007// **08/26/2007****  **(AUG 26, 2007)
-      When you confirm, this REJECT will be marked resolved. A
-      new claim will be re-submitted to the 3rd party payer
-      when this prescription fill is transmitted to CMOP on
-      the next CMOP transmission.
-      Confirm? ? YES//

- Note, Changing the Suspense Date means the Rx will not be pulled for filling until the date specified.

## Expanded WL Entry – Hidden Options

- Payer Message : Refill Payable on or after 09-19-07
- Reason        :
- DUR Text      :
- _INSURANCE Information_
- Insurance     : CAREMARK
- Contact       : 1-555-555-5555
- Group Name    : XXXXX
_**+        Enter ?? for more actions                                   **__**s**_
- VW  View Rx               IGN Ignore Reject       OVR Submit Override Codes
- MP  Medication Profile    RES Resubmit Claim      CSD Change Suspense Date
- Select: Quit// **??**
**The following actions are also available:**
**COM  Add Comments****         DN   Down a Line        PS   Print Screen**
**CLA  Submit Clarif. Code****  UP   Up a Line          PL   Print List**
**ED   Edit Rx****              FS   First Screen       SL   Search List**
**PA   Submit Prior Auth.****   LS   Last Screen        ADPL Auto Display(On/Off)**
**+    Next Screen          GO   Go to Page         QU   Quit**
**-    Previous Screen      RD   Re Display Screen**
- Enter RETURN to continue or '^' to exit:

**Notes:**
Step through the major hidden options and what they are used for.

## Expanded WL Entry – Hidden Options

- Patient Medication Profile    Jul 26, 2007@15:12:38          Page:  1 of  1
- ECMEPATIENT,TEST (###-##-####)                 WEIGHT(kg): 96.36 (05/15/2007)
- DOB: JAN 1,1901(##)                            HEIGHT(cm): 180.34 (05/15/2007)
- SEX: MALE                            EXP/CANCEL CUTOFF: 120 DAYS
-                                                      ISSUE    LAST     REF DAY
- _# Rx#           DRUG [^]                      QTY ST DATE     FILL     REM SUP_
-             **REFILL TOO SOON/DUR REJECTS(Third Party) (1 order)**
- 1 52705082C$e   CLONAZEPAM 1MG TAB             30 S> 07-24-07 07-30-07   5  30
-                         **CURRENT ORDERS (10 orders)**
- 2 52773220$e    CITALOPRAM HYDROBROMIDE 40MG   30 DP>04-18-07 05-15-07  11  30
- 3 52781678$e    CLONAZEPAM 0.5MG TAB           10 E> 05-15-07 05-15-07   0   5
- 4 52705082B$e   CLONAZEPAM 1MG TAB             30 DC>01-18-07 07-10-07   3  30
- 5 52655281$e    GEMFIBROZIL 600MG TAB         180 DC>04-18-06 04-18-07   2  90
- 6 52655281A$e   GEMFIBROZIL 600MG TAB         180 A> 05-15-07 07-07-07   2  90
- 7 52714238$e    OMEPRAZOLE 20MG EC CAP        180 A> 10-18-06 01-10-07   3  90
- 8 52714241$e    RANITIDINE HCL 150MG TAB      180 A> 10-18-06 10-18-06   3  90
- 9 51264143F$e   SIMVASTATIN 80MG TAB           45 A> 05-15-07 05-24-07   3  90
- 10 52742810$e   TRAZODONE HCL 50MG TAB         60 A> 01-18-07 05-15-07  11  30
- 11 52803429$e   VENLAFAXINE HCL 37.5MG SA CAP  60 A> 07-24-07 07-24-07   1  30
_**x**__**          Select the entry # to view or ?? for more actions                   **__**x**__**  **_
- CV  Change View           ID  Sort by Issue Date    RX  Sort by Prescription
- DR  Sort by Drug          LF  Sort by Last Fill     SIG Show/Hide SIG
- GS  Group by Status       PI  Patient Information
- Select: Quit//

**Notes:**
This is a display of the medication profile that appears when chosen via the rejects Information screen
The display can be sorted in the ways listed below

## More Examples

- RTS & DUR Rejects
- ePharmacy Actions

## Example of messagingREJECTED for DUR

- *** REJECT RECEIVED FROM THIRD PARTY PAYER ***
-  ---------------------------------------------------------------------
-  Division: ECME TEST                          NCPDP#:  1098981
-  Patient : ECMEPATIENT,ONE                Sex: M DOB: JAN 1, 1901 (XX)
-  Prescription : **410223/0 HCTZ 50/TRIAMTERENE**   ECME#: 1106936
-  **Reject Type  : ****88 – DUR REJECT received on AUG 22,2007@13:14:34**
-  **Payer Message: ****LISINOPRIL/HCTZ, TRIAMTERINE, DUR REJECT ERROR**
-  Insurance    : HUMANA                       Contact: 1-555-555-5555
-  Group Name   : XXXXX                   Group Number: XXXXX
-  Cardholder ID: XXXXXXXXX
-  ---------------------------------------------------------------------
-    Select one of the following:
-        O  (O)VERRIDE – RESUBMIT WITH OVERRRIDE CODES
-        I  (I)GNORE – FILL Rx WITHOUT CLAIM SUBMISSION
-        Q  (Q)UIT – SEND TO WORKLIST (REQUIRES INTERVENTION)
- (O)verride, (I)gnore,(Q)uit: //

- This is an example of a DUR reject. The finishing Pharmacist needs to decide how to handle this reject.

**Notes:**
The prompts are the same until you answer YES to the ‘Is this Correct?’ question.
Here’s an example of a DUR Reject sent by a payer.  

## Types of DUR Rejects

**Drug-Drug interaction**
- The payer identified a potential Drug-Drug interaction.  Often the same order check can be found by looking at the order details in CPRS.  Other times the medication profile shows no indication of the patient taking the other medication.
**Patient Age exceeds Maximum Age**
- The payer has a maximum age limit for this drug.
**Max Dose Limitation**
- The payer has a limit of 1 dose per day.
**Ingredient Duplication**
- This is usually a Refill Too Soon reject sent as a DUR by the payer.
**Overuse Precaution**
- This is usually a Refill Too Soon reject sent as a DUR by the payer.

## Example of Actions Available for DUR

- *** REJECT RECEIVED FROM THIRD PARTY PAYER ***
-  ---------------------------------------------------------------------
-  Division: ECME TEST                          NCPDP#:  1098981
-  Patient : ECMEPATIENT,ONE                Sex: M DOB: JAN 1, 1901 (XX)
-  Prescription : 410223/0 HCTZ 50/TRIAMTERENE   ECME#: 1106936
-  Reject Type  : 88 – DUR REJECT received on AUG 22,2007@13:14:34
-  Payer Message: LISINOPRIL/HCTZ, TRIAMTERINE, DUR REJECT ERROR
-  Insurance    : HUMANA                       Contact: 1-555-555-5555
-  Group Name   : XXXXX                   Group Number: XXXXX
-  Cardholder ID: XXXXXXXXX
-  ---------------------------------------------------------------------
-    **Select one of the following:**
** **
**       ****O  (O)VERRIDE – RESUBMIT WITH OVERRRIDE CODES**
**       ****I  (I)GNORE – FILL Rx WITHOUT CLAIM SUBMISSION**
**       ****Q  (Q)UIT – SEND TO WORKLIST (REQUIRES INTERVENTION)**
** **
**(O)verride, (I)gnore, (Q)uit: //**

**Notes:**
The prompts are the same until you answer YES to the ‘Is this Correct?’ question.
Here’s an example of a DUR Reject sent by a payer.  

## Reject Actions

**Override** – Allows the user to enter codes needed to override this reject and get a payable 3rd party claim.
- This option is active for DUR rejects only.
**Ignore** – Allows the user to by-pass 3rd party processing. The label will print and the prescription can be filled.
- The VA will not be reimbursed for this prescription.
**Quit** – Allows the user to postpone the processing of this prescription until this 3rd party reject is resolved.
- A label will not be printed for this prescription and it cannot be filled/dispensed until this reject is resolved.
- Rejects are moved to the Third Party Payer Rejects – Worklist option under the e-Pharmacy menu

**Notes:**
Override – Allows the user to enter codes needed to override this reject and get a payable 3rd party claim.  
You may need to call the 3rd party payer to determine which code sets are needed to override a particular reject.  
Once the proper override is accepted, the label will print and the prescription can be filled.
This option is active for DUR rejects only. 
Ignore – Allows the user to by-pass 3rd party processing. The label will print and the prescription can be filled.  
You are ignoring the potential clinical safety issues suggested by the 3rd party payer. 
The VA will not be reimbursed for this prescription.
The user is required to enter his/her electronic signature and a free text comment explaining why the reject was ignored. 
Quit – Allows the user to postpone the processing of this prescription until this 3rd party reject is resolved.  
A label will not be printed for this prescription and it cannot be filled/dispensed until this reject is resolved.  
Rejects are moved to the Third Party Payer Rejects – Worklist option under the e-Pharmacy menu.

## How to know when Override is the right action:

- Select **Override** when you’ve
- Checked the patient’s history and consulted with the physician (if necessary).
- If you determine the patient has been on the medication without problems and the physician wants him to remain on it an override is appropriate.

## Override Action

- Contact the Payer to obtain the correct override codes. The Payer phone number is contained in Reject Message.
**Examples of Reason for Service Codes (part of DUR message)**
- DA	Drug-Allergy Ar – Adverse Drug Reaction
- DD 	Drug-Drug Interaction
- PA	Drug-Age
**Examples of Professional Service Codes**
- M0 	Prescriber Consulted
- R0	Pharmacist Consulted Other Source
- FE	Formulary Enforcement
**Examples of Result of Service Codes**
- 1B	Filled Prescription As Is
- 1G	Filled, With Prescriber Approval
- The payer may/or may not allow you to override the reject.

## How to know when Ignore is the right action:

- Select **Ignore** when...
- you know you **cannot get reimbursement** from payer
- there is an **immediate need** to fill the prescription for the patient
- Examples:
- Payer uses 88 DUR reject code for Days-Supply rejects (i.e., 90-Day Fill). This is usually obvious within payer message text.
- Payer won't allow an override.
- Backbilling triggered DUR for prior authorization – Payer date is *after* DOS (fill/refill date or release date) – if already dispensed to patient no other option.
*Once you get accustomed to how certain payers process claims, you’ll know how to interpret the true meaning of payer messages.*
- Remember, you must enter your electronic signature and a free text comment explaining why the reject was ignored.

## How to know when Quit is the right action:

- Select **Quit** when...
-  more information is needed before you can decide how to proceed.
- Examples:
- There is _**not**_** an** **immediate** **need** to fill the prescription and there is **not sufficient time** to follow-up on the reject. (i.e., Unable to contact provider, payer)
- If local policy states an e-Pharmacy Site Manager or alternate is responsible for resolving all rejects and the prescription processing RPhs are not involved.
- Remember, a label **will not be printed** for this prescription and it **cannot be filled/dispensed** until this reject is resolved.

## Prescription ReleaseNDC Validation

## Importance of Medication Release

- Releasing an Rx is the Final sign off in Outpatient Pharmacy
- Indicates an Rx was checked and filled
**Critical** from a revenue generation standpoint:
- For ePharmacy claims:
- NDCs are verified at medication release
- Additional DUR or RTS reject resolution may occur here
- ePharmacy Claims for filled Rxs will reverse if not released
- Not releasing an Rx can be used to avoid processing to third party, e.g. for Rxs given in clinic
- Release triggers First Party Rx Copay charge for eligible patients
- Copay will not be assigned if Rx is not released

**Notes:**
With automated systems using OPAI with auto-release activated, the release is automated

## Release Medication Option

** ****OP Medications(ACTIVE)     ** Aug 6, 2007@11:10:38      Page:  1 of    1
-  TEST,ECMEPATIENT
-    PID: 000-00-0000       **                   **  Ht(cm): _______ (______)
-    DOB: JAN 1,1901 (XX)   **                   **  Wt(kg): _______ (______)
- ---------------------------------------------------------------------------------
-  (9)      Days Supply: 30                     (10)  QTY (  ): 1
-  (11)    # of Refills: 5                           Remaining: 4
-  (12)        Provider: PROVIDER,PSOTEST
-  (13)         Routing: WINDOW                (14)     Copies: 1
-      Method of Pickup:
-  (15)          Clinic: Not on File
-  (16)        Division: TEST CBOC (XXX)
-  (17)      Pharmacist:
-  (18)         Remarks:
-  (19)      Counseling: NO
-  (20)     Refill Data
-  (21)        DAW Code: 0 - NO PRODUCT SELECTION INDICATED
-           Finished By: PHARMACIST,PSOTEST
-     Entry By: ECME,PHARMACIST             Entry Date: 08/06/07 10:16:47
_**Enter ?? for more actions                                                    **__**s**__**                                        **_
-  DC   Discontinue          PR   Partial              **RL   Release**
-  ED   Edit                 RF   Refill               RN   Renew Select
-  Select Action: Next Screen// **RL   Release**

## Validate NDC

- Enter PHARMACIST:
**NDC:**

**NDC displayed is number sent on e-Pharmacy Claim **

**Logic system uses to select NDC sent on e-Pharmacy claim:**
**Uses NDC stored in appropriate multiple field called,**
**	****NDC BY OUTPATIENT SITE (File #50, field #32)**
**	****  ****.01  OUTPATIENT SITE**
**	****     ****	****1  LAST LOCAL NDC**
**	****	****2  LAST CMOP NDC**
**If no “LAST” NDC exists, uses data from NDC field (File #50, field #31)**

## Validate NDC (continued)

- Enter PHARMACIST:
**NDC: 50474-0001-48// ****?**
- Select one of the following valid NDC code(s) below:
**           ****1 - 50474-0001-48**
**           ****2 - 50474-0001-33**
- NDC: 50474-0001-48// **2    50474-0001-33**
- Prescription 2222222 successfully submitted to ECME for claim generation.
- Claim Status:
- Reversing and Rebilling a previously submitted claim...
**Reversing...**
- IN PROGRESS-Waiting to start
- IN PROGRESS-Waiting for transmit
- IN PROGRESS-Transmitting
- IN PROGRESS-Waiting to process response
**Resubmitting...**
- IN PROGRESS-Waiting to start
- IN PROGRESS-Waiting for packet build
- IN PROGRESS-Waiting for transmit
- IN PROGRESS-Transmitting
- IN PROGRESS-Waiting to process response
**E PAYABLE**
- Prescription Number 2222222 Release

**The Releasing Pharmacist selects the correct NDC for the drug dispensed.**

**If the NDC is changed, ePharmacy reverses the original claim and resubmits a new claim with the new NDC.  **
**The messaging displays on the screen.**

## NDC / DAWPrior AuthorizationsSignature Logs

- Pharmacy Data that impacts ePharmacy

## NDC Requirements

- Pharmacy needs to ensure the NDC transmitted to the third party is the one used to **fill the Rx**
- NDC needs to be available as a selection
- NDCs should be added through Drug Accountability
- If new NDC needs to be added, whoever is responsible for Drug File maintenance or their designee should add
- Use Drug Enter/Edit or other special local options to add the NDC

**Notes:**
We mentioned earlier how third parties use the NDC to ID drugs.  Pharmacy needs to ensure the NDC transmitted to the third party and the NDC of the product used to fill the prescription are the same.
The choice of NDC needs to be available in the software, and
Should be added through Drug Accountability whenever possible.
If the NDC is not one of the choices seen at Medication Release, it indicates it is not in the drug file and needs to be added.  If that is the case then in order to maintain product accuracy the Drug File maintenance person should be responsible.
This can be done through Drug Enter/Edit or other special local options you might have.

## Manually Entering NDC into Drug File

- Select Pharmacy Data Management Option: **Drug Enter/Edit**
- Select DRUG GENERIC NAME:    AMOXICILLIN 250MG CAP              AM052
-               ...OK? Yes//   (Yes)
- ***************************************************************************
- This entry is marked for the following PHARMACY packages:
-  Outpatient
-  Non-VA Med
- GENERIC NAME: AMOXICILLIN 250MG CAP  Replace  **^SYNONYM**
- Select SYNONYM: 00003010160// **?**
-     Answer with SYNONYM
-    Choose from:
-    1            AMOXIL
-    2            000015727860
-    21           00093310701
-    22           00003010160
**Select SYNONYM**: 00003010160// **55370088408**  **< Manually enter a new NDC INTENDED USE**: **D**  DRUG ACCOUNTABILITY    **< Use is Drug Accountability  NDC CODE**: **55370-0884-08**                 **< Define each sub-field   **

- The newly added NDC synonym will display and be selectable by the RPh during Rx release.

**Notes:**
1. This mainly a reference slide, and shows how to manually enter a new NDC into File #50 (Drug file) when the NDC is not in the selection list displayed to the RPh at the time of release. 

## Editing the NDC for an Rx

- Most NDCs for local fills are validated at prescription release so will not reject
- Sometimes you realize after Rx release that the wrong NDC was transmitted
- Pharmacy users sometimes need to work with the OPECC to resolve rejected NDCs they get
- The NDC of an ePharmacy prescription that has been released can be edited from the Patient Prescription Processing or Rx Edit screens
- NDC of Original Rxs are edited from field 2
- NDC of Refills are edited through field 20
- Editing an NDC triggers a claim resubmission
- Only edit the **last fill** of a prescription

**Notes:**
If properly running the process then NDCs for local fills are validated at prescription release and will not reject.
We have found times however when this is not done and you realize after Rx release that the wrong NDC was transmitted.
The OPECC will probably be the one that notices those because the claim may reject,  so Pharmacy users sometimes need to work with the OPECC to resolve rejected NDCs they get.
The NDC of an ePharmacy prescription can be edited from the Patient Prescription Processing or Rx Edit screens as long as the Rx has been released.
Originals are edited from field 2 and refills through field 20
When the NDC is edited it will resubmit the claim with the new information
Only the last fill of a prescription will result in a claims resubmission.  Cannot go back any further.

## Edit NDC from PPP Screen

_**OP Medications (ACTIVE)**__       Jul 09, 2007@19:54:44      Page:    1 of    2 _
- Test, Patient One                                                <A>
-   PID: 000-00-0001                              Ht(cm): 182.88 (06/15/2006)
-   DOB: JAN 01,1700 (XX)                         Wt(kg): 97.27 (06/15/2006)
-                 Rx #: 1234567F$e
-  (1) *Orderable Item: HYDROCODONE/ACETAMINOPHEN TAB
-  (2)       CMOP Drug: HYDROCODONE 5/ACETAMINOPHEN 500MG TAB
**                 ****NDC: 00603-3881-22**
-                 Verb: TAKE
-  (3)         *Dosage: 2 TABLETS
-               *Route: ORAL
-            *Schedule: Q4H PRN
-  (4)Pat Instructions:
-                  SIG: TAKE 2 TABLETS BY MOUTH EVERY 4 HOURS AS NEEDED
-  (5)  Patient Status: OPT NSC
-  (6)      Issue Date: 02/28/07               (7)  Fill Date: 02/28/07
-       Last Fill Date: 07/06/07 (Mail, Transmitted)
-    Last Release Date: 05/08/07               (8)      Lot #:
**+         Enter ?? for more actions**
- DC   Discontinue          PR   Partial              RL   Release
- ED   Edit                 RF   (Refill)             RN   Renew
- Select Action: Next Screen//

**Notes:**
1. This is an example of how you would edit the NDC of a first fill of a prescription.  You would edit field 2.  Refills would be edited through field 20.

## DAW Codes

**List of Dispense as Written (DAW) Codes**
**0****	****NO PRODUCT SELECTION INDICATED**
**1****	****SUBSTITUTION NOT ALLOWED BY PRESCRIBER**
**2****	****SUBSTITUTION ALLOWED-PATIENT REQUESTED PRODUCT DISPENSED**
**3****	****SUBSTITUTION ALLOWED-PHARMACIST SELECTED PRODUCT DISPENSED**
**4****	****SUBSTITUTION ALLOWED-GENERIC DRUG NOT IN STOCK**
**5****	****SUBSTITUTION ALLOWED-BRAND DRUG DISPENSED AS A GENERIC**
**6****	****OVERRIDE**
**7****	****SUBSTITUTION NOT ALLOWED-BRAND DRUG MANDATED BY LAW**
**8****	****SUBSTITUTION ALLOWED-GENERIC DRUG NOT AVAILABLE IN MARKETPLACE**
**9****	****OTHER**

**Notes:**
DAW codes are standard NCPDP codes.  NCPDP – National Council for Prescription Drug Programs
They convey special circumstances that may affect pricing or copay calculation.
All of our claims default to 0, or ‘no product selection indicated’.
The major impact of these has been with our negative formulary items.  For example sometimes brand name Coumadin rejects for DAW reasons, and we have to resubmit with a DAW of 5.  This does not happen very often.
The functionality exists to change the value at the drug file level if most claims are rejecting, but this has not needed to be done that much.

## Prescription Edit of a DAW code

_**OP Medications**__ (ACTIVE)       Jul 09, 2007@19:59:43      Page:    2 of    2 _
- ECME,Patient One                                                <A>
-   PID: 000-00-0000                              Ht(cm): 182.88 (06/15/2007)
-   DOB: JAN 1,1700 (XX)                          Wt(kg): 97.27 (06/15/2007)
- +
-              Expires: 08/31/07                          MFG:
- (9)      Days Supply: 30                    (10)  QTY (TAB): 120
- (11)    # of Refills: 3                           Remaining: 0
- (12)        Provider: VHAProvider,ONE
- (13)         Routing: MAIL                  (14)     Copies: 1
- (15)          Clinic: TO-ADMINISTRATIVE N/C
- (16)        Division: ECME DIV (XXXA5)
- (17)      Pharmacist:
- (18)         Remarks: RENEWED FROM RX # 52517998E
- (19)      Counseling: NO
- (20)     Refill Data
**(21)        DAW Code: 0 - NO PRODUCT SELECTION INDICATED**
-          Finished By: VHAPharmacist,One
-    Entry By: VHAProvider,ONE        Entry Date: 02/28/07 15:49:42        **Enter ?? for more actions**
- DC   Discontinue          PR   Partial              RL   Release
- ED   Edit                 RF   (Refill)             RN   Renew
- Select Action: Quit//

**Notes:**
This screen shows how a prescription can be edited to change the DAW.
The DAW value for an original prescription is edited through field 21 of the PPP screen.
Refills are edited through field 20.

## Prior Authorizations

- Rxs requiring Prior Authorization will reject for Code 75 (or Code 88 - DUR).
- Usually result of Third Party's Restricted/Non-Formulary Drug Request.
- Key words in payer message.
- Call Prior Auth Center or PA Required.
- Drug Is Non-Compliant with Step Therapy.
- Max Dose is ___ .
- Limit ___ Dose per Day.
- Max Age is ___.
- Establish local process for obtaining approval.
- Most Billing Offices have Prior Auth process in place
- Need to expand to include ePharmacy process

**Notes:**
While 75 is the official rejection code associated with prior authorizations, many of ours have been rejected as code 88 (DUR). You might think of the requirement for a prior authorization as being similar to our requirement in VA pharmacy for a Restricted Drug or Non-Formulary Drug Request. Certain language in the payer response is helpful in identifying DURs that are actually PA issues.

Pharmacy, Billing and UM have teamed up to address PA's at our facility. We make use of VistA MailMan to communicate back-and-forth. We also created a MailMan Mail Group for that purpose.

## Signature Log

- Third Parties require documentation that Rxs were received by patient
- The trailing document of the laser labels display signature lines for all prescriptions
- e-Pharmacy prescriptions also print the third party name
- Signatures only needed for **window Rxs**
- Many sites require **all** patients sign for meds received
- Manual signature logs can be pasted into a notebook once signed

**Notes:**
Third Parties require documentation that Rxs were received by patient.
The trailing document of the laser labels will display signature lines for all prescriptions filled within an outpatient  batch
If it is an e-Pharmacy prescriptions the third party name will also print.
Once signature is obtained it can be pasted into a notebook to be used as a log

## Signature Log (continued)

- Logs need to be readily available for 3rd party audits for 3 years, then filed for another 3 years
- Electronic signature devices can be used in lieu of paper signature logs
- Eventual goal is to have VA-wide electronic signature log process

**Notes:**
Signature Logs need to be readily available for 3rd party audits basically for 6 years.
Electronic signature devices can be used in lieu of paper signature logs
The eventual goal is to have a VA-wide electronic signature log process
Signatures are only needed for window Rxs.  The standard tracking methods we have for mail-out prescriptions should meet the mail-out standards  
Signature Logs may be reprinted if lost or not available when the Rx is picked up.    

## Signature Log Sample  - Verify Samples

-           	VAMC ECME TEST, ST 00011
- 	XXXA5 Ph. 555-555-5555          APR 7,2007
**By signing below**
**you acknowledge receipt of the following Rx’s**
- 51360591 (0) 04/07/07 AMOXICILLIN 500MG CA
- 51360592 (0) 04/07/07 NAPROXEN 250MG TAB
- Pt. Sig. ____________________________________________
- Caremark
- Relation________________ Counseling Refused __ Accepted__
**ECMEpatient, One  0000**

**Notes:**
If all prescriptions in a batch are local mail, sig log will not print 

## Electronic Signature Log

- Some sites have electronic signature with automation systems e.g. ScriptPro.  These meet current requirements.
- The iMed Consent product provides a Patient Signature Form for Pharmacy.
- VA Medical Center Pharmacy in Fargo is using iMed Consent to capture and store patient signatures stating they have received prescriptions.
- The digital image of the patient’s Medication Receipt is saved to the patient’s chart and can be viewed via VistA Imaging and CPRS.

**Notes:**
The iMed Consent product provides a Patient Signature Form for Pharmacy.
Most VAs have the basic iMed product but have not utilized it for signatures
The VA Medical Center Pharmacy in Fargo is one that is using iMed Consent to capture and store patient signatures stating they have received prescriptions.
The digital image of the patient’s Medication Receipt is saved to the patient’s chart and can be viewed via VistA Imaging and CPRS.
If you have an electronic signature component with an automation systems e.g. ScriptPro, these meet current requirements.

## 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 sometimes call Pharmacy about third party processing questions
- 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

**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
- Live Meeting Sessions
- e-Pharmacy Checklists
- Show-Me videos
- ePharmacy Simulation Training located on VA Employee Education System On-Line Learning Website
- https://vaww.ees.aac.va.gov/librix/loginhtml.asp?v=librix
- OI&T Project Website
- 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?