Claims. Pharmacy Update. Summer Summer 2016 Page 1

Transcription

1 Claims Pharmacy Update Summer 2016 Summer 2016 Page 1

2 Is TELUS Health the insurance company? TELUS Health plays a key role within the benefits management system but is an adjudicator and not an insurance company. Key stakeholders include: The employer or plan sponsor called the group. The insurance company called the carrier. The insurance company uses TELUS Health to adjudicate the claim. Plan Sponsor Insurance Company Adjudicator Patient Group Carrier TELUS Health Where can I find the following information? Diabetic Pseudo-DIN List Compound Submission and Eligibility Guidelines Pharmacy Manual (i.e. intervention codes, relationship codes, carrier codes) All can be found at: Summer 2016 Page 1

3 Common Claim Rejections and Resolution Tips No. Reject Message Common Causes and Resolutions 1 Invalid Cardholder ID Verify the card numbers that appear on the drug card. Ensure the claim is submitted with the correct issue number. Each cardholder is issued a unique 20-digit ID number that appears on their TELUS Assure claims cards and contains the following information: the first two digits identify the cardholder s insurance carrier, also referred to as the carrier number the next six digits identify the group or policy number the next ten digits identify the certificate number the last two digits identify the issue number 2 Card Terminated When this message appears, it indicates that coverage has been cancelled. This message is most often generated for one of the following reasons: a dependant reaches the maximum age (18, 19, or 21 for example) and must register as an over-age dependent if a new card was re-issued, the issue number of the card may have changed the plan or card may no longer be active, or may not be registered for online billing Ask the cardholder for their most recent drug card and verify the card numbers that appear on the drug card. If the information entered is correct, the cardholder must contact their plan administrator to correct the problem. 3 Date of Birth Error Confirm the date of birth with your patient and the relationship of the patient to the main cardholder. The name on the TELUS Assure card may be the name of the employee, a spouse or dependent child. Ensure the correct relationship code is selected when submitting claims. Relationship codes*: employee (primary cardholder) 01 spouse 02 dependent child 03 over-age dependent child 04 over-age disabled dependent child 05 * Relationship codes may vary depending on pharmacy software If this doesn t resolve the error, try reversing the date of birth month and day. The cardholder must contact their plan administrator to update their date of birth on file. TELUS Health cannot provide or update the patient date of birth due to privacy reasons. Summer 2016 Page 2

4 4 DIN not Covered This reject message indicates that the DIN/PIN is not a benefit under the plan. Please confirm that the claim is being transmitted with the correct DIN indicated on the stock bottle or package, and is being billed to TELUS Health. If the drug was previously covered, the plan coverage may have changed. The cardholder can contact their plan administrator for plan coverage questions. For WSIB members receiving this message, they need to contact their plan administrator. Once the DIN is added, please use the UG intervention code to override the early refill message when you resubmit the claim; no approval is required to use this code in this scenario. 5 Refill too Soon General You can process a new supply without pre-approval from TELUS Health for the following common scenarios: when you ve confirmed at least two-thirds of the days supply of the dispensed medication has been used when you ve validated a change in required dosage with the patient s physician Please use the UG intervention code to override the reject code. Simply ensure you document your rationale in these two situations for auditing purposes. Vacation Supplies Most plans administered by TELUS Health will allow 100 days supply for maintenance drugs. When a cardholder or dependent requests a supply greater than 100 days, they need to contact their insurance carrier for an exception to allow the submission of the larger days supply. Alternatively, the pharmacy can transmit the claim with the correct days supply, TELUS Health will cut back the cost to the allowed days supply and the pharmacy can have the cardholder pay for the difference. The cardholder must pay for this extra supply and submit a manual claim to their insurance carrier with an explanation. 6 Duplicate DUR Rx Number 7 Covered by Other You will receive this message if an incorrect intervention code, or no intervention code, was entered following an initial Refill too Soon, Drug Interaction or Duplicate Therapy message. If the pharmacist, doctor and patient are aware of the interaction, please use the UG intervention code to override this message. No additional approval is required from TELUS Health. The member has other coverage showing on their file with the carrier. If the member is a senior submit the claim to the provincial plan first. For a non-senior member submit the claim to their primary coverage first. If the member has no other primary plan, refer the member to their plan administrator to update their file and add this plan as their primary coverage. 8 Prior Auth Required If you receive this reject message, the cardholder is required to obtain the appropriate Prior Authorization Program request form from either their employer or their insurer s website. Summer 2016 Page 3

5 Do I need to inform TELUS Health if my pharmacy is closing? Yes, it is important that every provider notifies TELUS Health in writing at least 30 days prior to the closure of the pharmacy. Notifying us in advance of your pharmacy closure is a contractual requirement and ensures that you will not have any issues rejoining our network in the future. Simply the closing date with your pharmacy information to provider.registry@telus.com and we will update your profile accordingly and deactivate your provider number. How do I notify TELUS Health if I am making a change to my provider information? A provider must notify TELUS Health in writing of any changes to their pharmacy information by completing the Pharmacy Provider Change Request Form posted on our website. Keeping your information up-to-date allows for timely payment and ensures your store will receive all pharmacy communications sent out by TELUS Health. Please submit a change form for the following requests: Change of address Change of operating name Change of usual and customary (U&C) fee Change of banking information Change of manager/signing authority Change of address, fax or phone number Change of pharmacy software Closing of pharmacy To access the change form, please go to supportdoc_pharmacy-provider-change.pdf. Send the completed form by fax to or by to provider.registry@telus.com. Summer 2016 Page 4

6 READ past Pharmacy Updates on the TELUS Health website. Comments and Questions TELUS Health Pharmacy Support Centre Monday - Friday Weekends Public Holidays Civic Holidays 8:00 a.m. to 12:00 midnight (EST) 9:00 a.m. to 8:00 p.m. (EST) 12:00 noon to 8:00 p.m. (EST) 9:00 a.m. to 8:00 p.m. (EST) AST Summer 2016 Page 5