D. 0. C H A N G E S & U P D A T E S. Released December 12, 2011 perform your PROscript updates today
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1 D. 0. C H A N G E S & U P D A T E S Released December 12, 2011 perform your PROscript updates today 1
2 D.0. Field Changes [Patient Segment] Patient Address (350-HN). Place of Service (307-C7). Will always default to 01 Pharmacy. Patient Residence Code (384-4X) / was Patient Location (307-C7) in v5. PROscript will automatically map the patient residence code based upon the facility type field. 2
3 D.0. Field Changes [Insurance Segment] Medicaid ID Number (115-N5). PROscript will automatically send the Medicaid Number if the patient has an active Medicaid coverage record AND Medicaid third party is flagged as a Medicaid Carrier (Third Party Setup / Options Tab). Provider Accept Assignment Indicator (361-2D). Value populated is based upon Accept Assignment indicator in Third Party Setup. CMS Part D Qualified Facility (997-G2). New field available in Facility Setup. 3
4 D.0. Field Changes [Claim Segment] Prescription Origin Code (419-DJ). Value of 5 Pharmacy added. NCPDP Description: This value is used to cover any situation where a new Rx number needs to be created from an existing valid prescription such as traditional transfers, intrachain transfers, file buys, software upgrades/migrations, and any reason necessary to give it a new number. PROscript will NOT be automatically populating an origin code of 5 on ANY prescription. Submission Clarification Code (420-DK). Has been increased to a maximum of 3 occurrences. Other Coverage Code (308-C8). Definition of 08 now = Claim is billing for patient financial responsibility only. Definition of 03 = Other coverage billed, claim not covered. Values of 05, 06, and 07 have been removed. Delay Reason Code (357-NV). Required when needed to specify the reason that submission of the transaction has been delayed. 4
5 D.0. Field Changes [Claim Segment] Route of Admission (995-E2). Based off of drug file setup, the corresponding SNOMED code will be sent. Example: The SNOMED code for Oral is Compound Type (996-G1). Each compound can now have a compound type associated to it. Possible values are 01-Anti- Infective, 02-Lonotropic, 03-Chemotherapy, 04-Pain Management, 05-TPN/PPN, 06-Hydration, 07-Ophthalmic, 99- Other. This field can be set at the Drug/Compound template level and/or the prescription level. Pharmacy Service Type (147-U7). Required when the submitter must clarify the type of services being performed as a condition for proper reimbursement. This field is set in your facility 999 setup (your pharmacy). Possible values are 01- Community/Retail Pharmacy Services, 02-Compounding Pharmacy Services, 03=Home Infusion Therapy Provider Services, 04=Institutional Pharmacy Services, 05=Long Term Care Pharmacy Services, 06=Mail Order Pharmacy Services, 07=Managed Care Organization Pharmacy Services, 08=Specialty Care Pharmacy Services, 09=Other than above. 5
6 D.0. Field Changes [Prescriber Segment] Provider ID Qualifier (465-EY). PROscript will default all D.0. plans to sending the NPI Number. This can be overridden in the F3 Claim Field Setup screens. Prescriber First Name (364-2J). Added. Prescriber Address (365-2K). Added. Prescriber City (366-2M). Added. Prescriber State/Province (367-2N). Added. Prescriber Zip/Postal (368-2P). Added. 6
7 D.0. Field Changes [Compound Segment] ALL D.0. COMPOUND CLAIMS REQUIRE A COMPOUND SEGMENT. A compound segment will be sent when the third party option of Bill Multiple Ingredients is checked (Third Party Setup -> D.0./5.1 General Options Tab). PROscript will default to this option automatically when adding/changing to a D.0. plan. Maximum number of ingredients has been increased to 25. All PROscript compounding screens will now accept 25 ingredients. 7
8 D.0. Field Changes [Facility Segment] New Facility Segment Introduced. PROscript will ONLY populate the facility segment if the Facility Type field is NOT a R and/or Facility# NOT 999. Facility Name (385-3Q). Added. Facility Address (386-3U). Added. Facility City (388-5J). Added. Facility State (387-3V). Added. Facility Zip (389-6D). Added. 8
9 D.0. Field Changes [COB Segment] 3 Distinct Coordination of Benefits (COB) Scenarios. Scenario #1 Other Payer Amount Paid (OPAP). This scenario will send the Other Payer Amount Paid (from the previous payer(s)) in the COB segment. Other Coverage code of 02 is sent. Scenario #2 Other Payer-Patient Responsibility Amount (OPPRA). This scenario will send the pieces that make up the Patient Responsibility Amounts Breakdown. Other Coverage code of 08 (billing for patient responsibility) will be sent. Note: If the Patient Resp. Amounts DON T total the Patient Pay Amount returned from the prior payer, ONLY the Patient Pay Amount will be sent. Scenario #3 OPAP/OPRA (MIX). This scenario will send both the Other Payer Amount Paid + any Patient Responsibility amounts returned from the previous payers. Note: Only 1 Scenario per payer sheet is allowed. 9
10 D.0. Field Changes [COB Segment] OPAP Example (Scenario #1) 10
11 D.0. Field Changes [COB Segment] OPPRA Example (Scenario #2) 11
12 D.0. Field Changes [COB Segment] Selecting the COB scenario. 12
13 D.0. Field Changes [Other Payer Info] 13
14 D.0. Field Changes [Other Payer Info] 14
15 D.0. Field Changes Pharmacy Testing Changing an existing plan to D.0. / Adding new D.0. Plan. 15
16 D.0. Field Changes Pharmacy Testing 16
17 D.0. Field Changes Pharmacy Testing What to expect on Jan 1, 2012? Doing your part. Staying informed: 4Rx Matching (Importance of E1 Checks). 17
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