District of Columbia Pharmacy Benefit Management (PBM) Implementation Details
District of Columbia Pharmacy Benefit
Management (PBM)
Provider Training
Implementation Information
District of Columbia Pharmacy Benefit Management
(PBM)
•
On December 19, 2015, Magellan Medicaid Administration, Inc. (part of the
Magellan Rx Management Division of Magellan Health, Inc.) will assume the
responsibility for the District of Columbia Pharmacy Benefit Management (PBM).
The PBM will perform the following functions:
‒
Claims Processing
‒
Operations support for the Pharmacy Benefit Management (PBM) system
‒
Call Center Operations for Providers and Members
‒
Clinical Consultation Services
‒
Education and Outreach for Providers
3
Effective Date for Transition Implementation
•
On December 18, 2015, the current PBM vendor, Xerox State Healthcare, will
shutdown claims processing at 11:59 p.m.
•
On December 19, 2015,
Magellan Medicaid Administration
will begin claims
processing at 6:00 a.m.
‒
Providers should hold ALL claims from 11:59 p.m.
–
6:00 a.m.
4
Availability
•
The point-of-sale (POS) system will be available for submitting claims 24/7
•
When needed, routine maintenance may occur:
Saturday at 11:00 p.m. – 6:00 a.m.
5
Readiness Documents and Resources
•
Provider Manual
•
Payer Specification Sheet
•
Forms
•
Frequently Asked Questions
•
User Administration Console (UAC) and Web Prior Authorization (WebPA)
information for the prescriber community will be forthcoming
All documents and resources are located on the
District of Columbia Pharmacy Benefit
Management (PBM)
Website:
www.dc-pbm.com
6
POS Technical Readiness
Technical POS Submission Readiness
Transaction Header Segment
•
All transactions require the following values:
•
NEW -
BIN Number:
018407
for all District pharmacy programs
•
Version/Release Number:
D0
•
NEW -
Processor Control Number (PCN):
District Medicaid:
DCMC018407
District
Alliance:
DCAL018407
District
ADAP:
TROOP
•
Group ID:
District
Medicaid:
DCMEDICAID
District
Alliance:
ALLI
District
ADAP:
DCADAP
8
Technical POS Submission Readiness
NEW
•
Unit of Measure is required.
‒
Values:
o
EA = Each
o
GM = Grams
o
ML = Milliliters
9
POS Operational Readiness
POS Operational Readiness
The following transactions will be processed:
•
Claim Type
‒
Original
Claims B1
‒
Reversals B2
‒
Re-bills B3
11
POS Operational Readiness
HIPAA Compliance
There are requirements for privacy regulations regarding the use of claim data
elements.
Data element conditions are detailed in the Payer Specification Sheet including:
•
Mandatory (NCPDP designation – required at all times); or
•
Required; and
•
District Program requirements
•
Qualified Requirement
•
“Required when”
•
All submitted fields will be edited for valid format.
•
All submitted fields will be edited for valid values.
•
If optional data is sent, the values must be valid and any supporting and associated
fields must be sent as well.
12
Co-Pay Structure
District Medicaid Fee-for-Service (FFS) co-pay is $1.00 per prescription.
•
Exceptions include the following :
‒
Pregnant women (when pregnancy indicator is submitted)
‒
Long-Term Care (LTC) resident
‒
Beneficiary under 21 years of age
‒
All contraceptives
DC Healthcare Alliance and DOH ADAP have no co-pay
13
Coordination of Benefits
•
Providers are required to fully pursue all third-party coverage before billing
Medicaid.
•
Providers must comply with all policies of a beneficiary's insurance coverage
including, but not limited to prior authorization (PA), quantity, and days’ supply
limits.
•
Reimbursement will be calculated to pay the lesser of the Medicaid allowed
amount or the Other Payer Patient Responsibility as reported by the primary
carrier, less than the third-party payment.
•
Medicaid co-payments will also be deducted for beneficiaries subject to Medicaid
co-pay.
‒
In some cases, this may result in the claim billed to Medicaid being paid at
$0.00.
•
Co-pay Only Claims, Other Coverage Code (OCC) = ‘8’, are not allowed.
14
Early Refills
•
Early refill tolerance periods:
‒
80 percent of the previous fill must be used for all drugs
•
NCPDP Response code for early refill error = “88”
•
For non-controlled drugs, the system will automatically check for an increase in
dose and if found, based on the current and historical claims for the same GSN, the
system will not deny the current claim for early refill.
15
Remittance Advices and Payment
•
Payments and remittance advice (RA) will still come from Xerox State Healthcare.
16
POS Claim Processing
District of Columbia Pharmacy Benefit Management
(PBM)
Contact Information
•
Clinical Contact Center Phone: 1-800-273-4962
•
Clinical Contact Center Fax: 1-866-535-7622
•
Pharmacy Contact Center Phone: 1-800-272-9679
•
ADAP Beneficiaries and Physicians Phone: 1-202-671-4900
18
www.dc-pbm.com
•
The
District of Columbia Pharmacy Benefit Management (PBM)
Website will
become active on November 19, 2015.
•
Primary sources for Pharmacy Program information and resources are:
‒
Provider communication (letters, notices, etc.)
‒
Forms
‒
Provider Manual
‒
Payer Specification Sheet
‒
Contact Information
‒
Links
Note:
User Administration Console (UAC) and Web Prior Authorization (WebPA)
information for the prescriber community will be forthcoming.
19
ADAP
20
Key program elements remain the same:
•
Closed formulary available in the Provider Manual found at
www.doh.dc.gov/node/299012
•
Co-pays and deductibles are covered when other insurance payments apply
•
Prior authorization may be required for :
•
Certain CII drugs
•
A single drug claim exceeding $1,200
•
Claims in excess of $10,000 annual cumulative amount per client
DC Healthcare Alliance
21
Key program elements remain the same:
•
Closed formulary can be found at
www.dc-pbm.com
•
Antiretrovirals are not part of the DC Healthcare Alliance formulary. These
are covered through the Department of Health’s AIDS Drug Assistance
Program (ADAP).
•
Other non-formulary drugs must be submitted to the beneficiary’s Managed
Care Organization for consideration and authorization
Medicaid FFS
22
Key program elements remains the same:
•
A preferred drug list is utilized and can be found at
www.dc-pbm.com
•
Claims submitted for drugs that are not on the preferred drug list will
require prior authorization
•
Non-PDL PA Request Form can be found at
www.dc-pbm.com
•
$1.00 co-pay applies
Prior Authorizations
23
New in all programs
A beneficiary’s medical claim history is examined for diagnosis codes or procedure
codes that will allow the system to automatically override a prior authorization
requirement. For example:
•
The prior authorization requirement for a CII medication intended for
long-term use will be systematically waived when a diagnosis of ADD,
ADHD, narcolepsy, or cancer is found within the past six months in the
beneficiary’s medical history.
Questions and Answers
24
Thank You
District of Columbia Pharmacy Benefit Management (PBM) will transition to Magellan Medicaid Administration, Inc. on December 19, 2015. This transition includes functions like claims processing, call center operations, and clinical consultation services. The effective date for the transition is on December 18, 2015. Providers should note the availability of the point-of-sale system for claims submission 24/7, with routine maintenance occurring on Saturdays. Necessary readiness documents and resources are available on the PBM website. Additionally, the Technical POS Submission Readiness outlines transaction header segment requirements for all transactions.
Download Presentation
Please find below an Image/Link to download the presentation.
The content on the website is provided AS IS for your information and personal use only. It may not be sold, licensed, or shared on other websites without obtaining consent from the author. Download presentation by click this link. If you encounter any issues during the download, it is possible that the publisher has removed the file from their server.
E N D
Presentation Transcript
District of Columbia Pharmacy Benefit Management (PBM) Provider Training
District of Columbia Pharmacy Benefit Management (PBM) On December 19, 2015, Magellan Medicaid Administration, Inc. (part of the Magellan Rx Management Division of Magellan Health, Inc.) will assume the responsibility for the District of Columbia Pharmacy Benefit Management (PBM). The PBM will perform the following functions: Claims Processing Operations support for the Pharmacy Benefit Management (PBM) system Call Center Operations for Providers and Members Clinical Consultation Services Education and Outreach for Providers 3
Effective Date for Transition Implementation On December 18, 2015, the current PBM vendor, Xerox State Healthcare, will shutdown claims processing at 11:59 p.m. On December 19, 2015, Magellan Medicaid Administration will begin claims processing at 6:00 a.m. Providers should hold ALL claims from 11:59 p.m. 6:00 a.m. 4
Availability The point-of-sale (POS) system will be available for submitting claims 24/7 When needed, routine maintenance may occur: Saturday at 11:00 p.m. 6:00 a.m. 5
Readiness Documents and Resources Provider Manual Payer Specification Sheet Forms Frequently Asked Questions User Administration Console (UAC) and Web Prior Authorization (WebPA) information for the prescriber community will be forthcoming All documents and resources are located on the District of Columbia Pharmacy Benefit Management (PBM) Website: www.dc-pbm.com 6
Technical POS Submission Readiness Transaction Header Segment All transactions require the following values: NEW - BIN Number: 018407 for all District pharmacy programs Version/Release Number: D0 NEW - Processor Control Number (PCN): District Medicaid: DCMC018407 District Alliance: DCAL018407 District ADAP: TROOP Group ID: District Medicaid: DCMEDICAID District Alliance: ALLI District ADAP: DCADAP 8
Technical POS Submission Readiness NEW Unit of Measure is required. Values: o EA = Each o GM = Grams o ML = Milliliters 9
POS Operational Readiness The following transactions will be processed: Claim Type Original Claims B1 Reversals B2 Re-bills B3 11
POS Operational Readiness HIPAA Compliance There are requirements for privacy regulations regarding the use of claim data elements. Data element conditions are detailed in the Payer Specification Sheet including: Mandatory (NCPDP designation required at all times); or Required; and District Program requirements Qualified Requirement Required when All submitted fields will be edited for valid format. All submitted fields will be edited for valid values. If optional data is sent, the values must be valid and any supporting and associated fields must be sent as well. 12
Co-Pay Structure District Medicaid Fee-for-Service (FFS) co-pay is $1.00 per prescription. Exceptions include the following : Pregnant women (when pregnancy indicator is submitted) Long-Term Care (LTC) resident Beneficiary under 21 years of age All contraceptives DC Healthcare Alliance and DOH ADAP have no co-pay 13
Coordination of Benefits Providers are required to fully pursue all third-party coverage before billing Medicaid. Providers must comply with all policies of a beneficiary's insurance coverage including, but not limited to prior authorization (PA), quantity, and days supply limits. Reimbursement will be calculated to pay the lesser of the Medicaid allowed amount or the Other Payer Patient Responsibility as reported by the primary carrier, less than the third-party payment. Medicaid co-payments will also be deducted for beneficiaries subject to Medicaid co-pay. In some cases, this may result in the claim billed to Medicaid being paid at $0.00. Co-pay Only Claims, Other Coverage Code (OCC) = 8 , are not allowed. 14
Early Refills Early refill tolerance periods: 80 percent of the previous fill must be used for all drugs NCPDP Response code for early refill error = 88 For non-controlled drugs, the system will automatically check for an increase in dose and if found, based on the current and historical claims for the same GSN, the system will not deny the current claim for early refill. 15
Remittance Advices and Payment Payments and remittance advice (RA) will still come from Xerox State Healthcare. 16
District of Columbia Pharmacy Benefit Management (PBM) Contact Information Clinical Contact Center Phone: 1-800-273-4962 Clinical Contact Center Fax: 1-866-535-7622 Pharmacy Contact Center Phone: 1-800-272-9679 ADAP Beneficiaries and Physicians Phone: 1-202-671-4900 18
www.dc-pbm.com The District of Columbia Pharmacy Benefit Management (PBM) Website will become active on November 19, 2015. Primary sources for Pharmacy Program information and resources are: Provider communication (letters, notices, etc.) Forms Provider Manual Payer Specification Sheet Contact Information Links Note: User Administration Console (UAC) and Web Prior Authorization (WebPA) information for the prescriber community will be forthcoming. 19
ADAP Key program elements remain the same: Closed formulary available in the Provider Manual found at www.doh.dc.gov/node/299012 Co-pays and deductibles are covered when other insurance payments apply Prior authorization may be required for : Certain CII drugs A single drug claim exceeding $1,200 Claims in excess of $10,000 annual cumulative amount per client 20
DC Healthcare Alliance Key program elements remain the same: Closed formulary can be found at www.dc-pbm.com Antiretrovirals are not part of the DC Healthcare Alliance formulary. These are covered through the Department of Health s AIDS Drug Assistance Program (ADAP). Other non-formulary drugs must be submitted to the beneficiary s Managed Care Organization for consideration and authorization 21
Medicaid FFS Key program elements remains the same: A preferred drug list is utilized and can be found at www.dc-pbm.com Claims submitted for drugs that are not on the preferred drug list will require prior authorization Non-PDL PA Request Form can be found at www.dc-pbm.com $1.00 co-pay applies 22
Prior Authorizations New in all programs A beneficiary s medical claim history is examined for diagnosis codes or procedure codes that will allow the system to automatically override a prior authorization requirement. For example: The prior authorization requirement for a CII medication intended for long-term use will be systematically waived when a diagnosis of ADD, ADHD, narcolepsy, or cancer is found within the past six months in the beneficiary s medical history. 23
![Enhancing Patient Blood Management in Pregnancy at [INSERT LOCAL HOSPITAL NAME]](/thumb/143207/enhancing-patient-blood-management-in-pregnancy-at-insert-local-hospital-name.jpg)
